Lessons learnt from the process of designing care coordination interventions through participatory action research in public healthcare networks of six Latin American countries
Authors: Vargas Ingrid , Mogollón-Pérez Amparo-Susana , Eguiguren Pamela , Samico Isabella , Bertolotto Fernando , López-Vázquez Julieta , Amarilla Delia-Inés , De Paepe Pierre , Vázquez María-Luisa ,   for Equity-LA II, Puzzolo Julia , Colautti Marisel , Aronna Alicia , Luppi Irene , Muruaga Cecilia , Leone Francisco , Rovere Mario , Huerta Adriana , Alonso Claudio , Hoet Héctor , Porpatto María , Hernández Elba , Stapaj María Inés , Vignone Fernando , Caruana Leonardo , Mendes Marina , Oliveira Cecylia , Almeida Hylany , Freitas Renata , Resque Cynthia , Silva Geison , Dubeux Luciana , Guzmán Isabel , Alvarez Patricio , Oyarce Ana-María , Alvarez Andrea , Pastén Nimsi , Rojas Viviana , González Paola , Caro Jorge , Abarca Isabel , Chadwick Maria Eugenia , Espejo Patricia , Araya Mauricio , Rojas Wilma Hidalgo ySergio , Garcia Virginia , Pinzón Angela-María , León Heisel-Gloria , Gallego Andrés , Cardoso Carol , Bejarano Laura , Chávez Josefina , Ballesteros Silvia , Gómez Leonardo , Santamaría Cesar , Villamizar Carmen , Salinas Amanda , Cortés Cristian , Larrañaga Carolina , Rivera Haidy Carolina , Sanabria Edgar Fabián , Velandia Omar , Solórzano Carlos , Cisneros Angélica-Ivonne , Rodríguez Edit , Pérez Damián-Eduardo , González Vianey , Cabrera Néstor-Iván , Córdoba Daniel , Gadea Sebastián , Estiben Camila , Piccardo Luciana , García Graciela , Acosta Cecilia , Ballarini María-Noel 
Published: June 2023

Abstract
Background
The participation of health professionals in designing interventions is considered vital to effective implementation, yet in areas such as clinical coordination is rarely promoted and evaluated. This study, part of Equity-LA II, aims to analyse the design process of interventions to improve clinical coordination, taking a participatory-action-research (PAR) approach, in healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. This participatory process was planned in four phases, led by a local steering committee (LSC): (1) dissemination of problem analysis results and creation of professionals’ platform, (2) selection of problems and intervention (3) intervention design and planning (4) adjustments after evaluation of first implementation stage.

Methods
A descriptive qualitative study based on documentary analysis, using a topic guide, was conducted in each intervention network. Documents produced regarding the intervention design process were selected. Thematic content analysis was conducted, generating mixed categories taken from the topic guide and identified from data. Main categories were LSC characteristics, type of design process (phases, participants’ roles, methods) and associated difficulties, coordination problems and interventions selected.

Results
LSCs of similar composition (managers, professionals and researchers) were established, with increasing membership in Chile and high turnover in Argentina, Colombia and Mexico. Following results dissemination and selection of problems and interventions (more participatory in Chile and Colombia: 200–479 participants), the interventions were designed and planned, resulting in three different types of processes: (1) short initial design with adjustments after first implementation stage, in Colombia, Brazil and Mexico; (2) longer, more participatory process, with multiple cycles of action/reflection and pilot tests, in Chile; (3) open-ended design for ongoing adaptation, in Argentina and Uruguay. Professionals’ time and the political cycle were the main barriers to participation. The clinical coordination problem selected was limited communication between primary and secondary care doctors. To address it, through discussions guided by context and feasibility criteria, interventions based on mutual feedback were selected.

Conclusions
As expected in a flexible PAR process, its rollout differed across countries in participation and PAR cycles. Results show that PAR can help to design interventions adapted to context and offers lessons that can be applied in other contexts.