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A framework for stakeholder identification in concept mapping and health research: a novel process and its application to older adult mobility and the built environment

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A framework for stakeholder identification in concept mapping and health research: a novel process and its application to older adult mobility and the built environment
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  RESEARCH ARTICLE Open Access A framework for stakeholder identification inconcept mapping and health research: a novelprocess and its application to older adult mobilityand the built environment Claire Schiller 1,2,3* , Meghan Winters 1,3 , Heather M Hanson 1,2 and Maureen C Ashe 1,2 Abstract Background:  Stakeholders, as srcinally defined in theory, are groups or individual who can affect or are affectedby an issue. Stakeholders are an important source of information in health research, providing critical perspectivesand new insights on the complex determinants of health. The intersection of built and social environments witholder adult mobility is an area of research that is fundamentally interdisciplinary and would benefit from a betterunderstanding of stakeholder perspectives. Although a rich body of literature surrounds stakeholder theory, asystematic process for identifying health stakeholders in practice does not exist. This paper presents a framework of stakeholders related to older adult mobility and the built environment, and further outlines a process forsystematically identifying stakeholders that can be applied in other health contexts, with a particular emphasis onconcept mapping research. Methods:  Informed by gaps in the relevant literature we developed a framework for identifying and categorizinghealth stakeholders. The framework was created through a novel iterative process of stakeholder identification andcategorization. The development entailed a literature search to identify stakeholder categories, representation of identified stakeholders in a visual chart, and correspondence with expert informants to obtain practice-based insight. Results:  The three-step, iterative creation process progressed from identifying stakeholder categories, to identifyingspecific stakeholder groups and soliciting feedback from expert informants. The result was a stakeholder framework comprised of seven categories with detailed sub-groups. The main categories of stakeholders were, (1) the Public,(2) Policy makers and governments, (3) Research community, (4) Practitioners and professionals, (5) Health and socialservice providers, (6) Civil society organizations, and (7) Private business. Conclusions:  Stakeholders related to older adult mobility and the built environment span many disciplines and realmsof practice. Researchers studying this issue may use the detailed stakeholder framework process we present to identifyparticipants for future projects. Health researchers pursuing stakeholder-based projects in other contexts areencouraged to incorporate this process of stakeholder identification and categorization to ensure systematicconsideration of relevant perspectives in their work. Keywords:  Stakeholders, Concept mapping, Older adults ’  mobility, Built environment, Health * Correspondence: claire.schiller@hiphealth.ca 1 Centre for Hip Health and Mobility, 6F-2635 Laurel Street, Vancouver, BCV5Z 1M9, Canada 2 Department of Family Practice, University of British Columbia (UBC),Vancouver, BC V6T 1Z4, CanadaFull list of author information is available at the end of the article © 2013 Schiller et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the srcinal work is properly cited. Schiller  et al. BMC Public Health  2013,  13 :428http://www.biomedcentral.com/1471-2458/13/428  Background Public health problems are inherently complex, spanningacross realms of practice and impacting a variety of stakeholders. The importance of involving stakeholders inhealth research is increasingly recognized [1-3]. Groups and individuals affected by an issue (such as public healthpractitioners and community members) possess criticalinsight that may inform all aspects of the research process,providing valuable input in all stages from setting researchpriorities, to disseminating and implementing results [4].The diversity of perspectives that stakeholders possessmay be particularly relevant to understanding the complexdeterminants of health which figure centrally in publichealth research and practice.Concept mapping is a mixed-methods technique thatfacilitates the analysis of stakeholder perspectives. Assuch, it is a useful tool for understanding complex phe-nomena in public health [5]. A detailed explanation of the methodology is outlined in Trochim ’ s seminal work[6] and subsequent publication by Kane and Trochim[7]. In brief, concept mapping integrates group brain-storming and sorting of ideas with quantitative analysisto generate visual representations of concepts. Conceptmaps reflect the relative importance and relationshipsbetween intersecting ideas [7]. A recent review of con-cept mapping attests to the quality and rigor of themethodology  [8]. The review also highlights the increas-ingly widespread use of concept mapping in healthresearch; of the 69 articles reviewed, over 59% had apublic health orientation [8].In order to implement concept mapping projects, in- vestigators must first identify which stakeholders arerelevant to their topic of inquiry. However, this provesto be a challenging task as the literature lacks systematic,practical techniques for identifying stakeholder groupsand individuals [9]. In practice, the process is more oftenguided by intuition and feasibility than structured sys-tematic frameworks [10]. Broad, heterogeneous partici-pation from  “ relevant people ”  is generally encouraged inconcept mapping projects [7, p.36]. Techniques such asfocus groups, semi-structured interviews and snowballsampling (described in more detail below) broadly cap-ture methods of identifying stakeholders, but fail to pro- vide a detailed process required to ensure systematicidentification. A challenge, and apparent gap in the lit-erature thus exists with regards to knowing who  “ rele- vant people ”  are in practice.We encountered the challenge of identifying stake-holders in a concept mapping project on the intersectionbetween older adult mobility with built and social envi-ronments [11]. This is an important and emerging areaof research; as mobility contributes significantly to thehealth of older adults, and early evidence suggests thatbuilt and social environments interact to impact theability for older adults to engage in community partici-pation [12]. In this context, we defined: mobility as  “ theability of a person to move about and complete physicalactivities in their community setting ”  [12]; the built en- vironment as the composite of   “ urban design, land useand the transportation system ” [13]; and the social envir-onment as  “ social relationships and cultural milieuswithin which defined groups of people function andinteract ”  [14]. Diverse stakeholder engagement is likely critical to advancing our understanding of this issue, forit has already contributed to other aspects of built envir-onment and physical activity research [15-17]. Yet the literature provides little guidance on how to identify stakeholders in practice and there are no detailed frame-works of stakeholders related to older adult mobility andthe built environment. Therefore, in this paper, wepresent a framework to address this gap and outline astakeholder identification process that can be appliedacross public health research, policy and community en-gagement projects. By discussing the applicability of ourframework in the growing practice of concept mapping,we hope to further demonstrate the utility of our work.A brief review of stakeholder theory figures at the fore-front of our analysis as it lends clarity to the term  “ stake-holder ”  and provides theoretical underpinnings of ourframework. Stakeholder theory Freeman is credited with the classic definition of a stake-holder, articulated in his seminal work as  “ any group orindividual who can affect or is affected by the achieve-ments of the organization ’ s objective ”  [18, p.46]. Thisdefinition reflects the business management context inwhich the term srcinated. As a concept, stakeholder ex-tend  s  the responsibilities of business beyond financial in- vestors to other entities that may be affected by a firm ’ sactions. Most pertinent to other disciplines is the  “ affector is affected by  ”  clause which may serve as a criterionto designate individuals or groups as stakeholders.Nuanced variations on the stakeholder definition exist,however Freeman ’ s is still considered the most broadand balanced [18]. Friedman and Miles identify fifty-fivedefinitions of stakeholder spanning forty years andseventy-five texts; for a more comprehensive comparisonof the term, their work should be referenced [18].In addition to defining the term  “ stakeholder ” ,Freeman ’ s seminal work contributes two other tools forstakeholder identification that may be applied to healthresearch projects. The first is the now common  ‘ hub-and-spoke ’  picture, where stakeholder groups aredepicted at the end of spokes emanating from a centralfirm [19] (See Additional file 1: Figure S1). This figure isan acknowledged oversimplification, as each stakeholdercategory can be further broken down into more specific Schiller  et al. BMC Public Health  2013,  13 :428 Page 2 of 9http://www.biomedcentral.com/1471-2458/13/428  groups, however, this visual map is a useful tool foridentifying stakeholders [18]. The other contribution is abroader stakeholder analysis process, of which stake-holder identification is only the first step [18]. Subse-quent components of stakeholder analysis focus onunderstanding the interests and stance of various stake-holder groups, and on devising a business managementstrategy in response. Stakeholder analysis theories offerinteresting techniques for prioritizing stakeholders andunderstanding relationships, but they do not providepractical guidance on how to  identify   stakeholders.Some additional insight on the practice of stakeholderidentification is gleaned from the discussion of stake-holder management issues within  Stakeholders: Theory and Practice  [18]. Notably, the challenge of constructingstakeholder maps is acknowledged, particularly in lightof the heterogeneity of interests within stakeholdergroups, and the possibility of a single stakeholder be-longing to multiple categories [18].The use of stakeholder analysis has broadened consid-erably beyond its srcinal application in business man-agement [10]. Environmental resource management, inparticular, has embraced this study design, as demon-strated by Reed et al. [20]. The authors build on thetheoretical contributions of business management litera-ture, and notably categorize methods employed to iden-tify stakeholders, differentiate between stakeholders, andinvestigate relationships between stakeholders in prac-tice [20]. Three specific methods of identifying stake-holders are listed, mainly; focus groups, semi-structuredinterviews, and snowball sampling. These techniques arelikely familiar to health researchers, however their appli-cation in the explicit context of stakeholder identifica-tion is perhaps more novel. In focus groups, a smallnumber of participants brainstorm lists of stakeholders.This method is notably less structured than others, andmay be supplemented with interviews of a cross-sectionof stakeholders [20]. Semi-structured interviews withselected stakeholders are akin to consulting key infor-mants, which is recommended for the analysis of stake-holders by Varvasovsky and Brugha [21]. The snowballsampling technique consists of individuals from initialstakeholder categories identifying new stakeholders andcontacts. Possible bias towards the social networks of the first stakeholders should be noted [20], howeversnowball sampling is nonetheless commonly employedin health management stakeholder analysis [10]. Al-though these techniques broadly capture methods of identifying some stakeholder group, they do not providea systematic method for identification in practice.As discussed in the context of concept mapping above,a challenge and gap in the literature exists in regards toknowing who  “ relevant people ”  are. A systematic processfor determining which perspectives or stakeholders arerelevant is not described in health research method-ology. In part this is due to the diversity of contexts andthe need to tailor approaches to specific projects. How-ever it also reflects an observation made by Reed et al.,[20] that stakeholders are often presumed to be  “ self-evi-dent ”  in the literature. In practice it seems intuition andfamiliarity with a given topic tend to guide identificationof stakeholder categories; whether for specific health re-search projects or broader stakeholder analysis.A more documented, systematic methodology forstakeholder identification stands to benefit public healthresearch and concept mapping projects by increasingtransparency in participant selection and minimizing re-searcher bias towards familiar groups. Frameworks of stakeholder categories may serve as a starting point forsystematic identification of stakeholders, however suchframeworks are not commonly cited in the literature.Therefore our aim was to develop a framework of healthstakeholder categories and outline its application toolder adults ’  mobility and built and social environmentsto identify specific stakeholder groups. Methods To inform the development of our framework weconducted a strategic, focused literature search with par-ticular attention to categories of health stakeholdersemployed in concept mapping research, so as to informa separate project conducted by the authors of this paper[11]. The texts  Stakeholders: Theory and Practice  [18]and  Concept Mapping for Planning and Evaluation  [7]served as comprehensive, resources on stakeholder the-ory and concept mapping methodology. After reviewingrelevant citations from these texts, we identified  “ stake-holder analysis ”  and  “ concept mapping ”  as appropriatesearch terms. In order to focus our search on health, welimited our search to the health database of OvidMedline (years 1950  –  present). A search in April 2012,identified 68 and 245 citations using our keywords “ stakeholder analysis ”  and  “ concept mapping ”  respect-ively. An additional search of the Cochrane Database for “ stakeholders ”  returned no completed reviews. We thenreviewed retrieved articles for relevance to older adultmobility and the built environment in search of applic-able stakeholder frameworks.Identified categories of health stakeholders informedthe organization of our framework, however they didnot provide sufficient guidance on how to adapt theclassification to specific public health contexts, such asthe intersection of older adults ’  mobility with the builtand social environments. To address this gap in theliterature and facilitate stakeholder identification, wepresent a detailed description of the steps employed inthis project in addition to the final framework. Schiller  et al. BMC Public Health  2013,  13 :428 Page 3 of 9http://www.biomedcentral.com/1471-2458/13/428  Broadly speaking, our stakeholder framework was cre-ated through an iterative process of revising stakeholdercategories to encompass individual stakeholders deemedimportant by literature and experienced informants. Theframework is presented as a visual representation andclassification of groups and individuals related to theintersection of older adult mobility with the built andsocial environments.Varvasovszky and Brugha recommend a mixed teamof internal and external analysts to conduct stakehodleranalysis [21]. Our initial chart was thus created by oneauthor (CS) who had little  a priori  knowledge of the re-lation between older adult mobility and the built and so-cial environment, to increase objectivity and benefitfrom an external, theory driven identification of stake-holders. The scope and methods of analysis were derivedin consultation with all authors (experienced in thisarea), and the final stakeholder framework reflects col-lective expertise.To enhance the project with practice-based insight,four expert informants reviewed and provided feedbackon an initial draft of the stakeholder framework. Expertinformants were professionals with knowledge of thefield and represented policy makers, researchers, practi-tioners and service providers, and were chosen based onthe individuals ’  expertise and prior collaboration. Allworked across disciplines but had primary training orworked professionally in the fields of health or socialservices. Expert informants were asked to review thestakeholder framework and provide open-ended feed-back on the organization of stakeholder groups andidentification of missing stakeholders. We collectedcomments via email in accordance with a consent proto-col approved by the Simon Fraser University Depart-ment of Research Ethics (File #:2012s0331). The finalstakeholder framework incorporated recommendationsfrom the expert informants. Results Creation process An account of the systematic process employed in thisproject precedes the final framework (Figures 1 and 2),providing justification for the stakeholders identifiedand, of particular value, guidance for others undertakinga similar task. The iterative process was articulated asthe following series of three main steps: 1. Identify a relevant framework of stakeholder categoriesBased on an iterative search of the literature, noframeworks of stakeholder categories specific toolder adult mobility, the built environment, orsocial environments were identified. Threeclassifications of health stakeholders were found[22-24]. The most concise and explicit articulations of health stakeholders for concept mapping waslisted by Trochim and Kane [23]. Although not presented as a formal framework for stakeholdercategorization, Trochim and Kane identifiedrelevant health stakeholders including the public,health professionals, health administrators, policy makers and politicians, and the researchcommunity. A second concept mapping project onchronic disease prevention in Canada used thebroad categories of researchers, practitioners, andpolicy specialists to classify health stakeholders [22].In a third example of stakeholder analysis in healthresearch, a comprehensive list of stakeholders ispresented by Future Health Systems: Innovationsfor Equity [24]. Within the context of healthsystems research in developing countries, theauthors recommend systematic consideration of thefollowing eleven stakeholder categories;beneficiaries, central government agencies, ministry of health, local governments, financiers, civil society organizations, health governing boards, provider Older adults’ mobility and built and social environments POLICY MAKERS AND GOVERNMENTSRESEARCH COMMUNITYPRACTITIONERS AND PROFESSIONALSHEALTH AND SOCIAL SERVICE PROVIDERSPUBLICCIVIL SOCIETY ORGANIZATIONSPRIVATE BUSINESS Figure 1  Framework of stakeholder categories related to the intersection of older adults ’  mobility with built and social environments. Schiller  et al. BMC Public Health  2013,  13 :428 Page 4 of 9http://www.biomedcentral.com/1471-2458/13/428  organizations, professional organizations and healthworkers, unions, and suppliers [24]. The categories of health stakeholders identified by Trochim and Kane [23] were adapted in this project as they encompassed most other categorieswhile maintaining an element of simplicity. Thesecategories included the public, health professionals,health administrators, policy makers and politicians,and the research community. As our stakeholderframework evolved, new categories of stakeholderswere added and some were renamed. For example, ‘ Health providers ’  (identified by Hyder et al., [24])replaced health administrators as a main category of stakeholders and  ‘ Health professionals ’  wasbroadened to  ‘ Professionals and practitioners ’ .2. Identify specific stakeholder groups:(i) Begin with relevant research disciplinesWe first discerned relevant research disciplinesto initiate the identification of specific groupsof stakeholders within each category. This stepwas greatly informed by an evidence review published by co-authors [12]. For the purposeof stakeholder identification, a list of relevantresearch disciplines was generated based on Older adults Families and caregivers Taxpayers (community members) Research Centres and networks Post-secondary institutionsHealth ProfessionsMedicine NursingPhysiotherapyOccupational TherapyKinesiologyPublic HealthSocial WorkPsychologyGerontology and ageing studies Health services Social inequities in health ArchitecturePlanningUrban design EngineeringTechnology and society studiesTransportation Health geography Environmental geographySocial and economic policy Inter-professional networks and advisory groups Health ProfessionsMedicine NursingPhysiotherapyOccupational TherapyKinesiologyPublic HealthSocial WorkPsychologyPharmacologyGerontology and ageing studies Health services Social inequities in health ArchitecturePlanningUrban design Building tradesEngineeringTechnology and society studiesTransportation Health geography Environmental geographySocial and economic policy Chambers of commerce Health and social service suppliersMobility aidsAlternative transportation Land Use DevelopersReal estateInfrastructureMaterial manufacturersConstruction companiesHousing and accommodations Assisted livingResidential care Sustainable housingMortgage corporations Health insurance providers Occupational health and safetyProvincial medical service plansDisability Services Safety and crime preventionTransportationMaintenance of public spaces POLICY MAKERS AND GOVERNMENTSPRIVATE BUSINESSRESEARCH COMMUNITYPUBLICCIVIL SOCIETY ORGANIZATIONSPRACTITIONERS AND PROFESSIONALSHEALTH AND SOCIAL SERVICE PROVIDERS Non-governmental organizationsInterest groupsThink tanksCharitable organizationsDisease specificDisability orientedCommunity oriented Sustainability orientedFaith-based organizationsIndigenous / ethnic groups Policy networks and advisory groupsMunicipal Governments Unions of municipalitiesMunicipal insurance associations City councilsElected officialsCitizen’s Advisory Committees Departments of: Legal servicesCommunity servicesEngineering and transportation Human resource servicesSustainabilityParks and recreationProvincial GovernmentsElected officials Ministry of:Children and family Community and culture HealthSocial DevelopmentTransportation / infrastructureEnergy and mines Health Authorities Federal Government Elected officialsMinistry of:Health State (Seniors)Human resources development Industry (Building codes) Figure 2  Detailed chart of stakeholders, expanding framework of stakeholder categories related to the intersection of older adultmobility with built and social environments. Schiller  et al. BMC Public Health  2013,  13 :428 Page 5 of 9http://www.biomedcentral.com/1471-2458/13/428
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