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The importance of symbolic and engaged participation in evidence-based quality improvement in a complex integrated healthcare system: response to “The science of stakeholder engagement in research”

  • Commentary
  • Published:
Translational Behavioral Medicine


In this commentary, we respond to the commentary provided by Goodman and Sanders Thompson regarding our paper on multilevel stakeholder engagement in a VA implementation trial of evidence-based quality improvement (EBQI) in women’s health primary care. We clarify our overall approach to engagement (comprised of both symbolic and engaged participation, according to the authors’ classification rubric), highlighting that symbolic participation is of more import and value than the authors suggest, especially in the context of a hierarchical healthcare system. We contend that the issue of power—and how power matters in stakeholder engagement—needs to be considered in this context rather than in global “community” terms. In response to the authors’ call for greater detail, we clarify our planning processes as well as our approach to veteran engagement. We concur with Goodman and Sanders Thompson that the science of stakeholder engagement necessitates a broader understanding of best practices as well as the impact of engagement on implementation outcomes.

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We would like to thank Ms. Angela Cohen for her overall management of the Women’s Health CREATE and our Executive Steering Committee members and Women Veteran Council members for their valuable contributions to this project.

Study funding sources

Support for this research was provided by VA HSR&D Service, Veterans Health Administration through the CREATE initiative (CRE 12-026) and the VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy (CIN 13-417). Dr. Yano’s effort was funded by a VA HSR&D Senior Research Career Scientist Award (Project #RCS 05-195).

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Corresponding author

Correspondence to Alison B. Hamilton PhD, MPH.

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Conflict of interest

The views expressed within this study are solely those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US Government. None of the authors has any actual or potential conflicts of interest.

Reporting and control of data

The reported findings have not been previously published and the manuscript is not being simultaneously submitted elsewhere.

The data has not been previously reported.

The authors have full control of all primary data and agree to allow the journal to review their data if requested.

Ethics approval and consent to participate

This study protocol has been approved by the VA Greater Los Angeles Healthcare System IRB-B Subcommittee (IRB Chair, Paul Shekelle, MD, PhD) (Approval Number 2013-040589). Individual study components, including key stakeholder interviews, were reviewed and approved by IRB-B as serial project modifications to an umbrella IRB application under the study title. For each study component, we obtained IRB approval for waivers of documentation of consent for all data collections. Consent was provided verbally and recorded in the case of interviews.

The VA Central IRB (Washington, DC) also determined that the participating VA medical centers (n = 12) were not engaged in research and that the intervention (or implementation strategy, evidence-based quality improvement [EBQI]) was QI. Documentation of IRB approval (and in VA settings, Research and Development Committee approval as well) and Central IRB determination of non-research for the implementation strategy are available on request.

Statement on welfare of animals

No animals are or will be involved in this study protocol. Similarly, use of animal or human data or tissue is not applicable to this study protocol.

HELSINKI statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Hamilton, A.B., Yano, E.M. The importance of symbolic and engaged participation in evidence-based quality improvement in a complex integrated healthcare system: response to “The science of stakeholder engagement in research”. Behav. Med. Pract. Policy Res. 7, 492–494 (2017).

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