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Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/80368, first published .
Cocreation of Integrated Interventions Addressing Noncommunicable Diseases and Environmental Degradation: Protocol for a Participatory Qualitative Study

Cocreation of Integrated Interventions Addressing Noncommunicable Diseases and Environmental Degradation: Protocol for a Participatory Qualitative Study

Cocreation of Integrated Interventions Addressing Noncommunicable Diseases and Environmental Degradation: Protocol for a Participatory Qualitative Study

Authors of this article:

Nushrat Khan1 Author Orcid Image ;   Paraskevi Seferidi1 Author Orcid Image ;   Kristine Belesova1 Author Orcid Image ;   Nantu Chakma2 Author Orcid Image ;   Laura Downey1, 3 Author Orcid Image ;   Noshin Farzana2 Author Orcid Image ;   Sarada Satyamoorthy Garg4 Author Orcid Image ;   Suparna Ghosh-Jerath5 Author Orcid Image ;   Renu John5 Author Orcid Image ;   Maroof Khan5 Author Orcid Image ;   PK Latha4 Author Orcid Image ;   Asri Maharani6 Author Orcid Image ;   Sabhya Pritwani5 Author Orcid Image ;   Sekar Aqila Salsabilla7 Author Orcid Image ;   Haryani Saptaningtyas8, 9 Author Orcid Image ;   Vidisha Sharma5 Author Orcid Image ;   Sujarwoto Sujarwoto7 Author Orcid Image ;   Aliya Naheed2 Author Orcid Image ;   Vidhya Venugopal4 Author Orcid Image ;   Christopher Millett1 Author Orcid Image ;   Vivekanand Jha1, 3, 5, 10 Author Orcid Image ;   Devarsetty Praveen3, 5, 10 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    Protocol

    1Primary Care and Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom

    2Non Communicable Diseases, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh

    3University of New South Wales, The George Institute for Global Health, Sydney, Australia

    4Department of Environmental Health Engineering, Faculty of Public Health, Sri Ramachandra Institute of Higher Education and Research, Chennai, India

    5George Institute for Global Health, New Delhi, India

    6School of Health Sciences, Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, United Kingdom

    7Department of Public Administration, University of Brawijaya, Malang, Indonesia

    8Percik Institute, Surakarta, Indonesia

    9Sebelas Maret University, Surakarta, Indonesia

    10Manipal Academy of Higher Education, Manipal, Karnataka, India

    Corresponding Author:

    Nushrat Khan, PhD

    Primary Care and Public Health

    Faculty of Medicine

    Imperial College London

    90 Wood Lane

    London, W12 0BZ

    United Kingdom

    Phone: 44 020 7589 5111

    Email: nushrat.khan@imperial.ac.uk


    Background: Addressing the adverse impacts of climate change on human health requires a global effort across multiple sectors. People living in low- and middle-income countries are particularly vulnerable to the health crises induced by climate change. Therefore, context specific solutions to tackle such challenges are essential to ensure preventive measures are in place for mitigating such risks.

    Objective: This protocol aims to outline an integrated, participatory approach to cocreate multisectoral interventions tailored to specific environmental and health challenges in Bangladesh, India, and Indonesia. This work is done as part of the Global Health Research Centre for Non-Communicable Diseases and Environmental Change, funded by the National Institute for Health and Care Research. The overall aim is to collaboratively design and assess interventions that deliver dual benefits for planetary and human health.

    Methods: To address the multisectoral nature of the challenges, this study will adopt a cocreation methodology that blends co-design and coproduction approaches. While the problem areas are specific to each context—tackling air pollution due to plastic burning in Indonesia, improving dietary diversity of public food procurement systems and managing extreme heat in India, and mitigating drinking water salinity in Bangladesh—the underlying cocreation framework is consistent and can be adapted to the needs of each study setting. The workflow consists of 4 key stages guided by an existing cocreation framework: planning, developing, evaluation, and reporting, with the 6 core elements of the Medical Research Council’s complex intervention development framework embedded throughout the process. Drawing on the Double Diamond design process, the cocreation stage involves the following phases: codevelopment of a theory of change to explore potential context-specific interventions, short-listing of intervention components through gap analysis and prioritization, co-designing and coproducing selected intervention components, and assessing appropriateness and feasibility of intervention implementation. The cocreation process will be evaluated using the Research Quality Plus for Co‑Production framework to ensure methodological rigor and quality.

    Results: Cocreation will take place over 6 months. Sampling and recruitment of cocreators (key stakeholders across sectors) have been completed in all 3 countries, with each cocreator group consisting of 20-30 members. We have developed the tools for the cocreation phase, informed by the findings from formative research, and received the necessary ethics approval to conduct these activities. We will generate a series of academic and nonacademic outputs on the cocreation process to disseminate the findings, as well as training materials for implementers to facilitate future adoption in similar settings.

    Conclusions: The cocreation of multisectoral interventions to tackle both environmental change and health is a comparatively new domain of implementation research. This protocol addresses the complex, multidimensional, and unique nature of such interventions by developing a structured and scientifically sound approach to be implemented in real-life settings.

    International Registered Report Identifier (IRRID): DERR1-10.2196/80368

    JMIR Res Protoc 2025;14:e80368

    doi:10.2196/80368

    Keywords

    multisectoral intervention; planetary health; cocreation; noncommunicable diseases; implementation research 


    Environmental change and its impacts on human lives and livelihoods are a major global concern [1]. The adverse effects of rising global temperatures and extreme weather events are evident in increasing physical and economic losses as well as a surge in noncommunicable diseases (NCDs) [2,3]. Those living in low- and middle-income countries (LMICs) are often among the most vulnerable and disproportionately affected due to their high exposure and sensitivity to the impacts on ecosystems, human habitat, and infrastructure [4,5]. Health systems in many of these countries also have the lowest climate readiness scores, meaning that they are poorly prepared to adapt their available resources to climate vulnerabilities [6]. Given the complexity and scale of such climate change–induced health issues, there is a critical need to develop and implement context-specific solutions through collaboration across different sectors and disciplines, also known as multisectoral interventions [7]. Suited to local needs, these multisectoral interventions can help with early mitigation of risks and reduce the extent of human activities that lead to adverse environmental and health outcomes.

    The National Institute for Health and Care Research (NIHR) Global Health Research Centre (GHRC) for NCDs and Environmental Change is a collaborative effort among researchers from 4 countries that aims to achieve dual benefits for health and the environment by developing such multisectoral interventions [8]. NIHR GHRC focuses on a context-specific environmental issue in each geographic region that is important both locally and globally. The first problem area is tackling air pollution from plastic burning in Indonesia, where increasing plastic pollution is a major threat because of both the production and import of large quantities of plastics [9]. The second problem area is managing extreme weather events such as heat waves and improving dietary diversity within public food procurement systems in rural India. Heat waves have been associated with increased risks of dehydration, heat stroke, cardiovascular complications, and mortality, especially among vulnerable populations such as older adults and those with preexisting NCDs [10]. Climate change can negatively impact agriculture and dietary diversity of rural and indigenous populations in such settings, which can worsen malnutrition in all its forms and diet-related NCDs [1,11]. The third problem area is mitigating drinking water salinity in coastal areas in Bangladesh, where surface water and groundwater bodies are becoming increasingly salinized because of rising sea levels and tropical storm surges. Regular intake of such saline water can result in a range of health issues, including hypertension and cardiovascular disease [12,13].

    Multisectoral interventions designed to address these interconnected challenges must be grounded in local needs and priorities to be effective across diverse contexts. Guided by the Medical Research Council (MRC) framework [14] for developing and evaluating complex interventions, NIHR GHRC adopted cocreation as a collaborative participatory approach for developing and implementing complex multisectoral solutions [15]. Cocreation is an overarching term that includes both coproduction and co-design [16]. This involves engaging diverse stakeholders across multiple disciplines throughout the process of understanding the issue at hand as well as designing and evaluating contextually relevant solutions [15,16]. While a range of frameworks have been developed to assist with co-design [17-20], including policy co-design [21,22], coproduction [23], and cocreation of interventions [24], there is a lack of evidence that demonstrates how these could be integrated in the MRC guidance to develop a complex multisectoral intervention. Furthermore, given the dual focus on the environment and health in this study, it is important to incorporate planetary health perspectives in the design and evaluation of interventions in a structured way [25,26], following recently published guidance [27]. In addition, engagement and involvement with a range of stakeholders across multiple sectors and settings requires a culturally sensitive and setting-specific cocreation process. Therefore, this protocol outlines a practical, context-sensitive framework for cocreating solutions with the communities and partners involved in NIHR GHRC to guide the development of dual-benefit multisectoral interventions that address NCDs and environmental change.


    Study Setting

    This study is being implemented in designated intervention and control areas within each participating country. Cocreation activities are limited to the intervention areas, where stakeholders are actively engaged in developing multisectoral interventions. Table 1 presents an overview of the country-specific projects.

    Table 1. Study setting and problem areas of the National Institute for Health and Care Research Global Health Research Center for Non-Communicable Diseases (NCDs) and Environmental Change.
    CountryStudy locationsProblemNCD riskPotential solutions
    IndonesiaMalang districtAir pollution due to plastic burningCardiovascular and chronic obstructive pulmonary diseasesImproved waste management to reduce plastic burning
    IndiaSarguja district, ChhattisgarhLack of dietary diversity in public food procurement systems (Integrated Child Development Services program [28] and Pradhan Mantri Poshan Shakti Nirman [29])Nutrition and dietary health issuesAdaptation of school food menus and procurement processes to enhance dietary diversity
    IndiaSrikakulam district, Andhra PradeshExtreme weather events due to heatCardiometabolic diseasesStrengthening health systems and community preparedness for heat-related health impacts
    BangladeshKhulna districtIncreased drinking water salinityChronic kidney diseases and cardiovascular diseasesProviding access to safe, nonsaline drinking water

    Study Design

    Overview

    We will use a participatory qualitative study design to cocreate the interventions. Throughout the intervention cocreation process, we will follow the MRC framework for developing and evaluating complex interventions. The intervention identification, development, and feasibility assessment will be guided by the six core elements of the MRC framework: (1) consider context; (2) develop, refine, and retest program theory; (3) engage stakeholders; (4) identify key uncertainties; (5) refine intervention; and (6) economic considerations [14].

    Stakeholder recruitment for the cocreator groups will be conducted through a nonrandomized purposive sampling to ensure diverse representation across characteristics of interest such as gender, role, socioeconomic status, and stakeholder influence, which are commonly adopted by cocreation studies [24]. The cocreator groups will be involved throughout all stages of the iterative process outlined subsequently. At the end of this process, the key outputs will include a set of contextually appropriate intervention components and corresponding implementation strategies to support effective and efficient delivery.

    In addition, the cocreation workflow is informed by the framework and principles developed by Leask et al [24], which emphasize participatory engagement across 4 key stages: planning, developing, evaluation, and reporting. Figure 1 illustrates the iterative cocreation workflow adapted for this study.

    Table 2 presents the frameworks used in guiding different phases of the cocreation process. While many implementation frameworks exist, these frameworks have been chosen based on their use in existing literature and appropriateness for our desired intervention output.

    ‎
    Figure 1. The iterative cocreation workflow for multisectoral intervention development. NGO: nongovernmental organization; ToC: theory of change.
    Table 2. Frameworks used throughout different cocreation phases and their purposes.
    Cocreation phasePurposeFramework used
    Overall cocreation process
    • Guide the overall cocreation process
    • Medical Research Council intervention development framework [14] and cocreation workflow by Leask et al [24]
    Planning
    • Contextual analysis
    • Context and implementation of complex interventions framework [30]
    Development of the intervention
    • Guide the intervention design process
    • Pre-evaluate the cocreated intervention through a planetary health lens before implementation
    • Double Diamond design model [31]
    • Planetary health framework [26]
    Evaluation
    • Evaluate the cocreation process
    • Research Quality Plus for Co-Production framework [32]
    Reporting
    • Report cocreation outcomes using a structured checklist
    • Leask et al [24]
    Planning

    The planning stage incorporates preparatory activities to inform the intervention development. The key objectives of this stage are to (1) develop a comprehensive understanding of the context based on the findings from previous formative research, (2) establish a core study team composed of researchers and community engagement members, and (3) recruit cocreators from relevant stakeholder communities to form a cocreation group. The core study team will define the cocreation process, provide necessary training and guidance, and support the recruitment of cocreator group members. The cocreator group will provide active input in the intervention development process and help with the development of implementation strategies.

    As emphasized by the MRC framework, the success and outcome of an intervention are strongly influenced by the context in which it is implemented. Contextual understanding can enable, modify, constrain, or facilitate the intervention design and delivery [14,30]. Therefore, an in-depth understanding of the context is crucial for developing an intervention suited to that specific setting. To inform this context, we conducted formative research, including literature and policy reviews, as well as qualitative and quantitative research in each setting. These findings will be synthesized to describe the existing landscape of the issue, local community practices, availability of resources, and stakeholders’ perceptions. We will use the context and implementation of the complex interventions framework to map these findings against relevant contextual domains: geographical, epidemiological, sociocultural, socioeconomic, ethical, legal, and political [30]. We will also consider other independent interventions implemented in the same setting and targeting the same population group, as these may influence the outcomes of the proposed intervention.

    To ensure meaningful engagement with relevant stakeholders, core study teams composed of researchers and community engagement members will be formed in each country. These groups will support the preparation of information packages based on synthesized contextual information and training materials, aid in the recruitment of cocreator group members, and advise on specific stakeholder engagement methods.

    Guided by these core study teams, stakeholders from the cocreator groups will be purposefully selected, with members across different groups equally represented, including those from vulnerable groups. This will be guided by the stakeholder mapping conducted as part of formative research and community engagement activities. The core study teams will collaborate with the cocreator group members to coproduce rules of participation and facilitate necessary training and knowledge-sharing opportunities.

    Developing
    Overview

    The development stage includes a series of iterative phases, guided by the Double Diamond design process [31]. The key objectives of this stage are (1) codevelopment of a theory of change to identify potential interventions [33,34] (discover), (2) prioritization and short-listing of existing solutions (define), (3) assessment of suitability and implementation feasibility of proposed solutions through a planetary health lens (develop), and (4) development of implementation strategies to deliver the final intervention (deliver). A series of iterative workshops and interviews will be conducted with the cocreator groups to achieve these objectives. There may be several iterations of intervention refinement and implementation strategies based on stakeholder feedback before piloting and delivering the intervention.

    Codevelop a Theory of Change Model

    A theory of change describes why and how an intervention or program works. Depicted as a causal diagram, the theory of change can be an effective tool to design and evaluate interventions by outlining pathways to achieve intended outcomes, underlying assumptions, and indicators to measure change [34]. We will codevelop our theory of change in 2 stages by involving the core study teams and cocreator groups to ensure it is context specific and culturally responsive [35]. As the first step, the core study team will participate in an exploratory workshop to discuss the problem we are addressing and the scale and ambition of the solutions to aim for. On this basis, they will develop a preliminary theory of change, setting the overarching aim of intervention, identifying its intermediate goals, and outlining potential activities (intervention components) linked to these goals.

    In the second workshop, the cocreator group will review and modify the proposed long- and short-term goals outlined in the theory of change to reflect community realities and needs. Similar to the first round, they will then identify a list of possible activities that align with these goals, taking into consideration context, scale, and feasibility. Any additional outcomes proposed will be integrated into the preliminary theory of change model to develop an updated theory of change. This will remain a living document and may be revised as necessary throughout the course of cocreation.

    Short-Listing of Potential Interventions

    Following the development of the theory of change, all identified interventions (activities), both those codeveloped and those identified through literature and evidence mapping, will be compiled. A gap analysis and prioritization exercise will be conducted with cocreator groups in smaller breakout sessions. These sessions will assess the strengths, limitations, and relevance of each option. The key discussion points will then be shared with the whole group to coproduce a short list of interventions, using a relevant prioritization technique. For example, these can include the impact-effort matrix, which prioritizes solutions based on their relative value to end users versus the resources needed to deliver the solution [36], or the must have, should have, could have, will not have (MoSCoW) method, which emphasizes end user requirements to classify solutions into respective groups [36,37].

    Assessing the Suitability and Feasibility of Short-Listed Interventions

    Short-listed interventions will be packaged based on alignment with the theory of change and assessed for suitability and feasibility in 2 steps—first, with community members and health care professionals and second, with policy-level stakeholders and planetary health experts.

    In the first step, a workshop will be held to explore the cultural acceptability, perceived effectiveness, and implementation feasibility of each intervention. A decision matrix will be used to guide discussions around each of the following criteria [38]: social validity (cultural relevance, satisfaction, and equity), intervention coherence, and dual health-environmental impact [39,40]. The cocreator group will judge whether each intervention meets the outlined criteria or requires modification. Ideas for alternative solutions will also be sought in case the intervention does not meet the criteria. At the end of this workshop, the working group will incorporate the feedback and refine the proposed intervention package.

    In the second step, we will evaluate the co-designed multisectoral intervention through a planetary health lens, informed by the planetary health framework for preimplementation assessment, which we tailored for the purposes of our codevelopment process based on previous theories [25,26] and guidance for assessing acceptability and feasibility [39-41]. This will involve in-depth discussions around health and environmental cobenefits and feasibility of intervention implementation, considering practicality, perceived fit with the infrastructure, cost to organizations and policy bodies, as well as aspects of governance. The final intervention package will be refined based on these assessments.

    Development of an Implementation Plan

    The final step in this stage is to develop a detailed implementation plan. Building on the theory of change, an implementation theory will be articulated, outlining how the desired changes should take effect in the setting for the implementation effort to be successful and how the implementation process will be operationalized. We will map the implementation strategies, that is, a set of methods and activities designed for the specific context, as well as identify the implementation agents, that is, the individuals and organizations engaged in the process [42].

    Evaluation

    The cocreation process will be evaluated continuously to ensure the outcomes generated through the process are representative of cocreators’ opinions as well as suitable, tailored, and valid for end users [23,40]. Short anonymous feedback will be used after each workshop to incorporate participant needs and views while not overburdening them. A structured questionnaire for collecting participant feedback at the end of the final cocreation workshop will be developed using the Research Quality Plus for Co-Production framework [32]. The format will include focus group discussions, individual interviews, and surveys. These tools will be adapted to the needs of each setting, depending on the context, nature of the intervention, and how different groups of stakeholders will be involved in different stages of the cocreation process.

    Reporting

    The outputs from the cocreation process will be reported using a structured checklist such as the one proposed by Leask et al [24], to ensure transparency and consistency. Outputs will include artifacts directly derived from the workshops, such as the theory of change model and prioritized list of interventions, as well as qualitative data from the discussions during cocreation workshops and evaluation. Other outputs include a logic model and implementation strategies that will be developed for the final multisectoral intervention based on the cocreation workshop outputs.

    Qualitative data collected during the workshops and evaluation process will be analyzed using hybrid thematic analysis [43] in NVivo (Lumivero) software. Inductive analysis will be used for coding the exploratory discussions from the theory of change building workshop, whereas deductive analysis will be used for the later stages, as those workshops should follow a more structured discussion supported by specific tools and frameworks. Any emerging themes will be captured using iterative inductive coding [44]. All findings will be triangulated with observations and field notes recorded by team members during cocreation activities. These combined data sources will inform the final reporting of the cocreation process and outcomes, providing a rich, contextualized account of the intervention development journey.

    Ethical Considerations

    Ethics approvals have been obtained from the research and ethics committee at Imperial College London and ethics committees of the George Institute of Global Health, India; the International Centre for Diarrhoeal Disease Research, Bangladesh; and Brawijaya University, Indonesia (Imperial College Research Ethics Committee reference: 6565249 [India], 6694705 [Indonesia], and 6700946 [Bangladesh]). Informed consent will be collected for all participants before their involvement in the cocreation workshops, and all identifiable data will be removed before dissemination. Where appropriate, participants will be compensated according to local guidelines in the study countries.


    Formative phase research activities started after NIHR GHRC was funded in October 2022. Cocreation workshops as part of this formative research phase will take place over a 6-month period, and the multisectoral interventions are expected to be implemented in each country by the end of December 2025. As part of the planning phase described earlier, core study teams have been established in each country to oversee and coordinate the overall intervention development process. Sampling and recruitment of cocreation group members, informed by research partnerships established with relevant organizations during the formative phase, have been completed in all geographic regions. Each cocreation group consists of 20-30 members depending on the project needs and study location. Due to the iterative nature of the process, findings from each stage may necessitate the involvement of new stakeholders. For example, community members and health care professionals are being recruited first for the cocreation workshops, and the selection of policy and planetary health experts will be based on the initial workshop outcomes. Community engagement activities have helped build trust with the community members and foster a deeper understanding of the local context. On the basis of emerging findings from formative phase research, we prepared tools for each stage of the cocreation process and obtained ethics approvals to conduct these activities.

    We plan to produce a series of outputs on the cocreation process to ensure knowledge mobilization. First, we will publish scientific papers for academic audiences as well as present our findings at relevant conferences. The publications will describe the outputs of the cocreation process, outcomes of cocreation evaluation, and how planetary health perspectives were incorporated in the intervention design. Other outputs such as blog posts and videos will be developed for public and policy-level stakeholders and disseminated via NIHR GHRC’s website, social media channels, and other relevant platforms. These outputs are intended to have a broader societal impact by reaching nonacademic audiences. Second, as part of our implementation plan, we will develop training materials for implementers of the codeveloped interventions to facilitate future adoption of these cocreation methods in similar settings. Finally, a formative evaluation report outlining key insights into the cocreation process will be produced for NIHR. This will include an assessment of how effectively the cocreation process supported the development of multisectoral interventions that are reflective of locally articulated priorities.


    Cocreation of Planetary Health Interventions

    This protocol outlines the cocreation process for developing complex multisectoral interventions for addressing NCD burden due to environmental change in Bangladesh, India, and Indonesia. While participatory approaches are being increasingly adopted for developing and adapting a range of public health interventions [45,46], very few of these studies have been conducted in LMICs [47] or have incorporated a planetary health lens. The cocreation process described here builds on existing theories and frameworks and brings together a robust set of tools that can be adapted to a range of settings for developing complex multisectoral interventions with dual health and environmental objectives.

    While the MRC framework provides general guidance for developing complex interventions and highlights the importance of theory-driven approaches [14], there is limited evidence and guidance on how to translate and transfer such approaches for cocreating complex interventions in low-resource settings [21,34]. Our protocol describes how such interventions can be cocreated in collaboration with the community and other relevant stakeholders, grounded in locally defined priorities and context-specific needs. In addition, most examples of complex intervention development processes tend to have a narrow focus, such as specific health care settings [48], focusing on a certain health care service or model [20,49] or aimed at developing tailored systems or programs [17,50-53]. This protocol provides an overview of developing multisectoral interventions that target both environmental and health domains and thus necessitate the integration of multiple components and sectors.

    To accommodate this complexity, the cocreation workflow uniquely combines a range of tools and frameworks. We integrated the Double Diamond model into an adapted cocreation framework, guided by the core components of the MRC framework. By codeveloping a theory of change that helps identify shared solutions together and applying a structured prioritization process, the cocreation approach empowers communities to voice and address their needs and priorities. A key strength of this process is the systematic integration of environmental and health cobenefits while maintaining a balance between top-down and bottom-up approaches in assessing appropriateness and feasibility of implementation. By aligning the interventions with community needs and incorporating feedback from policy and system-level stakeholders, we seek to enhance both feasibility and system integration.

    Limitations

    While the cocreation process described in this study is adaptable to different contexts, challenges and limitations remain. The structure of participatory activities and modes of collaboration among stakeholders may depend on local dynamics and culture as well as the climate change issue at hand. For example, frequent flooding in study areas in Bangladesh may limit accessibility and frequency of cocreation activities during the rainy season; therefore, the plans will need to accommodate such factors beyond our control. In case of weak buy-in from local partners, adaptations will need to be made to the intervention development and delivery plans. Geographic distance of intervention areas and travel time may also affect participation, necessitating careful selection of workshop locations to ensure equitable access. Therefore, the suggested process may need to be further adapted to facilitate the maximum level of participation and uphold equity and power balance among all stakeholders throughout the process. The cocreation process described in this study does not include details of the co-design process of any educational and training materials. Given the diverse nature of these multisectoral interventions, we will develop targeted guidance for each setting, depending on available resources and identified needs for additional content.

    Conclusions

    This cocreation protocol describes a structured process to guide the development of multisectoral interventions that incorporate dual benefits to health and the environment in LMICs. Given the unavoidable effect of climate change on human health, it is increasingly important to consider planetary health aspects when codeveloping new or adapting existing multisectoral interventions that are integrated within the health system. By cocreating context-specific, community-driven solutions, we recognize and build upon the strengths of local actors, working collaboratively to support their leadership in sustaining these efforts. The cocreation process developed as part of NIHR GHRC can act as a blueprint for developing complex multisectoral interventions and be adapted to diverse settings beyond the work of NIHR GHRC.

    Acknowledgments

    The authors acknowledge all members of the study teams at the George Institute for Global Health, India; Sri Ramachandra Institute of Higher Education and Research; the International Centre for Diarrhoeal Disease Research, Bangladesh; and Brawijaya University, Indonesia, for their support with these research projects in their specific settings.

    This research was funded by the National Institute for Health and Care Research (NIHR) Global Health Research Centre award scheme for Non-Communicable Diseases and Environmental Change (grant NIHR203247) using UK international development funding from the UK government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK government. NIHR had no role in the study design of this protocol.

    Data Availability

    Data sharing is not applicable to this paper as no datasets were generated or analyzed during this study.

    Authors' Contributions

    NK conceptualized the study methodology under the supervision of PS, with contributions from all coauthors. CM, VJ, DP, LD, AN, VV, and SS contributed to funding acquisition for the National Institute for Health and Care Research and Global Health Research Centre. NK drafted the original manuscript, and PS and DP provided critical review and editorial inputs. All authors reviewed and approved the final version of the manuscript.

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    Peer review report from the NIHR Global Health Research Centre on NCDs and Environmental Change, National Institute for Health Research (NIHR), UK.

    PDF File (Adobe PDF File), 92 KB
    1. Romanello M, Walawender M, Hsu SC, Moskeland A, Palmeiro-Silva Y, Scamman D, et al. The 2024 report of the Lancet countdown on health and climate change: facing record-breaking threats from delayed action. Lancet. Nov 09, 2024;404(10465):1847-1896. [CrossRef] [Medline]
    2. Vicedo-Cabrera AM, Scovronick N, Sera F, Royé D, Schneider R, Tobias A, et al. The burden of heat-related mortality attributable to recent human-induced climate change. Nat Clim Chang. Jun 31, 2021;11(6):492-500. [CrossRef] [Medline]
    3. Rocque RJ, Beaudoin C, Ndjaboue R, Cameron L, Poirier-Bergeron L, Poulin-Rheault RA, et al. Health effects of climate change: an overview of systematic reviews. BMJ Open. Jun 09, 2021;11(6):e046333. [FREE Full text] [CrossRef] [Medline]
    4. Abbass K, Qasim MZ, Song H, Murshed M, Mahmood H, Younis I. A review of the global climate change impacts, adaptation, and sustainable mitigation measures. Environ Sci Pollut Res Int. Jun 04, 2022;29(28):42539-42559. [FREE Full text] [CrossRef] [Medline]
    5. Green H, Bailey J, Schwarz L, Vanos J, Ebi K, Benmarhnia T. Impact of heat on mortality and morbidity in low and middle income countries: a review of the epidemiological evidence and considerations for future research. Environ Res. Apr 2019;171:80-91. [CrossRef] [Medline]
    6. Bianco G, Espinoza-Chávez RM, Ashigbie PG, Junio H, Borhani C, Miles-Richardson S, et al. Projected impact of climate change on human health in low- and middle-income countries: a systematic review. BMJ Glob Health. Oct 02, 2024;8(Suppl 3):e015550. [FREE Full text] [CrossRef] [Medline]
    7. Sutarsa IN, Campbell L, Ariawan IM, Kasim R, Marten R, Rajan D, et al. Multisectoral interventions and health system performance: a systematic review. Bull World Health Organ. Jul 01, 2024;102(7):521-32F. [FREE Full text] [CrossRef] [Medline]
    8. NIHR global health research centre for non-communicable diseases (NCDs) and environmental change. NIHR Global Health Research Centre for Non-Communicable Diseases. URL: https://ghrcentre-ncdec.nihr.ac.uk/ [accessed 2025-04-17]
    9. Pathak G, Nichter M, Hardon A, Moyer E, Latkar A, Simbaya J, et al. Plastic pollution and the open burning of plastic wastes. Glob Environ Change. May 2023;80:102648. [CrossRef]
    10. Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Belesova K, Berry H, et al. The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come. Lancet. Dec 08, 2018;392(10163):2479-2514. [CrossRef] [Medline]
    11. Ghosh-Jerath S, Kapoor R, Ghosh U, Singh A, Downs S, Fanzo J. Pathways of climate change impact on agroforestry, food consumption pattern, and dietary diversity among indigenous subsistence farmers of Sauria Paharia tribal community of India: a mixed methods study. Front Sustain Food Syst. Jun 17, 2021;5:667297. [FREE Full text] [CrossRef] [Medline]
    12. Ashrafuzzaman M, Gomes C, Guerra J. The changing climate is changing safe drinking water, impacting health: a case in the southwestern coastal region of Bangladesh (SWCRB). Climate. Jul 12, 2023;11(7):146. [CrossRef]
    13. Tsai C, Hoque MA, Vineis P, Ahmed KM, Butler AP. Salinisation of drinking water ponds and groundwater in coastal Bangladesh linked to tropical cyclones. Sci Rep. Mar 03, 2024;14(1):5211. [FREE Full text] [CrossRef] [Medline]
    14. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. Sep 30, 2021;374:n2061. [FREE Full text] [CrossRef] [Medline]
    15. Vargas C, Whelan J, Brimblecombe J, Allender S. Co-creation, co-design, co-production for public health - a perspective on definition and distinctions. Public Health Res Pract. Jun 15, 2022;32(2):3222211. [FREE Full text] [CrossRef] [Medline]
    16. Sanders EB, Stappers PJ. Co-creation and the new landscapes of design. CoDesign. Mar 2008;4(1):5-18. [CrossRef]
    17. Tay BS, Edney SM, Brinkworth GD, Cox DN, Wiggins B, Davis A, et al. Co-design of a digital dietary intervention for adults at risk of type 2 diabetes. BMC Public Health. Nov 11, 2021;21(1):2071. [FREE Full text] [CrossRef] [Medline]
    18. Banbury A, Pedell S, Parkinson L, Byrne L. Using the Double Diamond model to co-design a dementia caregivers telehealth peer support program. J Telemed Telecare. Nov 02, 2021;27(10):667-673. [CrossRef]
    19. Donetto S, Pierri P, Tsianakas V, Robert G. Experience-based co-design and healthcare improvement: realizing participatory design in the public sector. Des J. May 07, 2015;18(2):227-248. [CrossRef]
    20. Bird M, McGillion M, Chambers EM, Dix J, Fajardo CJ, Gilmour M, et al. A generative co-design framework for healthcare innovation: development and application of an end-user engagement framework. Res Involv Engagem. Mar 01, 2021;7(1):12. [FREE Full text] [CrossRef] [Medline]
    21. Walker SC, Baquero B, Bekemeier B, Parnes M, Arora K. Strategies for enacting health policy codesign: a scoping review and direction for research. Implement Sci. Sep 21, 2023;18(1):44. [FREE Full text] [CrossRef] [Medline]
    22. Walker SC, Ahrens KR, Owens MD, Parnes M, Langley J, Ackerley C, et al. Using policy codesign to achieve multi-sector alignment in adolescent behavioral health: a study protocol. Implement Sci Commun. May 08, 2024;5(1):54. [FREE Full text] [CrossRef] [Medline]
    23. Hawkins J, Madden K, Fletcher A, Midgley L, Grant A, Cox G, et al. Development of a framework for the co-production and prototyping of public health interventions. BMC Public Health. Sep 04, 2017;17(1):689. [FREE Full text] [CrossRef] [Medline]
    24. Leask CF, Sandlund M, Skelton DA, Altenburg TM, Cardon G, Chinapaw MJ, et al. GrandStand‚ Safe StepTeenage Girls on the Move Research Groups. Framework, principles and recommendations for utilising participatory methodologies in the co-creation and evaluation of public health interventions. Res Involv Engagem. Jan 9, 2019;5(1):2. [FREE Full text] [CrossRef] [Medline]
    25. Brousselle A, McDavid J. Evaluation for planetary health. Evaluation. Nov 05, 2020;27(2):168-183. [CrossRef]
    26. Brousselle A, McDavid J, Curren M, Logtenberg R, Dunbar B, Ney T. A theory-based approach to designing interventions for Planetary Health. Evaluation. Jul 14, 2022;28(3):330-355. [CrossRef]
    27. Benton L, Brousselle A, McDavid J, Whitmee S, Haines A. Need for planetary health perspective in guidance for complex interventions for climate and health. BMJ. Jun 03, 2025;389:e083337. [FREE Full text] [CrossRef] [Medline]
    28. Integrated Child Development Services Scheme Maharashtra State. URL: https://icds.gov.in/en/about-us [accessed 2025-03-04]
    29. PM POshan SHAkti Nirman (PM-POSHAN). Ministry of Education. URL: https://dsel.education.gov.in/scheme/pm-poshan-scheme [accessed 2025-03-04]
    30. Pfadenhauer LM, Gerhardus A, Mozygemba K, Lysdahl KB, Booth A, Hofmann B, et al. Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework. Implement Sci. Feb 15, 2017;12(1):21. [FREE Full text] [CrossRef] [Medline]
    31. The double diamond. Design Council. URL: https://www.designcouncil.org.uk/our-resources/the-double-diamond/ [accessed 2025-02-28]
    32. McLean RK, Carden F, Aiken AB, Armstrong R, Bray J, Cassidy CE, et al. Evaluating the quality of research co-production: Research Quality Plus for Co-Production (RQ + 4 Co-Pro). Health Res Policy Syst. Jun 13, 2023;21(1):51. [FREE Full text] [CrossRef] [Medline]
    33. What is theory of change? Theory of Change Community. URL: https://www.theoryofchange.org/what-is-theory-of-change/ [accessed 2025-03-11]
    34. De Silva MJ, Breuer E, Lee L, Asher L, Chowdhary N, Lund C, et al. Theory of Change: a theory-driven approach to enhance the Medical Research Council's framework for complex interventions. Trials. Jul 05, 2014;15(1):267. [FREE Full text] [CrossRef] [Medline]
    35. Meyer ML, Louder CN, Nicolas G. Creating with, not for people: theory of change and logic models for culturally responsive community-based intervention. Am J Eval. Jun 29, 2021;43(3):378-393. [CrossRef]
    36. Trieflinger S, Münch J, Bogazköy E, Eißler P, Schneider J, Roling B. How to prioritize your product roadmap when everything feels important: a grey literature review. In: Proceedings of the 2021 IEEE International Conference on Engineering, Technology and Innovation. 2021. Presented at: ICE/ITMC '21; June 21-23, 2021:1-9; Cardiff, United Kingdom. URL: https://ieeexplore.ieee.org/document/9570243 [CrossRef]
    37. Hatton S. Choosing the right prioritisation method. In: Proceedings of the 9th Australian Conference on Software Engineering. 2008. Presented at: ASWEC '08; March 26-28, 2008:517-526; Perth, Australia. URL: https://ieeexplore.ieee.org/document/4483241 [CrossRef]
    38. Kueppers LM, Baer P, Harte J, Haya B, Koteen LE, Smith ME. A decision matrix approach to evaluating the impacts of land-use activities undertaken to mitigate climate change. Clim Change. Apr 2004;63(3):247-257. [CrossRef]
    39. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. Jan 26, 2017;17(1):88. [FREE Full text] [CrossRef] [Medline]
    40. Gadke DL, Kratochwill TR, Gettinger M. Incorporating feasibility protocols in intervention research. J Sch Psychol. Feb 2021;84:1-18. [CrossRef] [Medline]
    41. Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, et al. How we design feasibility studies. Am J Prev Med. May 2009;36(5):452-457. [FREE Full text] [CrossRef] [Medline]
    42. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implement Sci. Dec 01, 2013;8:139. [FREE Full text] [CrossRef] [Medline]
    43. Proudfoot K. Inductive/deductive hybrid thematic analysis in mixed methods research. J Mix Methods Res. Sep 20, 2022;17(3):308-326. [CrossRef]
    44. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. Mar 01, 2006;5(1):80-92. [CrossRef]
    45. Greenhalgh T, Jackson C, Shaw S, Janamian T. Achieving research impact through co-creation in community-based health services: literature review and case study. Milbank Q. Jun 06, 2016;94(2):392-429. [FREE Full text] [CrossRef] [Medline]
    46. Halvorsrud K, Kucharska J, Adlington K, Rüdell K, Brown Hajdukova E, Nazroo J, et al. Identifying evidence of effectiveness in the co-creation of research: a systematic review and meta-analysis of the international healthcare literature. J Public Health (Oxf). Apr 12, 2021;43(1):197-208. [FREE Full text] [CrossRef] [Medline]
    47. Longworth GR, Erikowa-Orighoye O, Anieto EM, Agnello DM, Zapata-Restrepo JR, Masquillier C, et al. Conducting co-creation for public health in low and middle-income countries: a systematic review and key informant perspectives on implementation barriers and facilitators. Global Health. Jan 17, 2024;20(1):9. [FREE Full text] [CrossRef] [Medline]
    48. Lazo-Porras M, Perez-Leon S, Cardenas MK, Pesantes MA, Miranda JJ, Suggs LS, et al. Lessons learned about co-creation: developing a complex intervention in rural Peru. Glob Health Action. Dec 31, 2020;13(1):1754016. [FREE Full text] [CrossRef] [Medline]
    49. Savaria V, Queenton J, Carrier A. Decentralized management of home care services for seniors: protocol for a participatory action research. JMIR Res Protoc. Jan 17, 2025;14:e58271. [FREE Full text] [CrossRef] [Medline]
    50. Johnson GU, Towell-Barnard A, McLean C, Robert G, Ewens B. Co-designing a digital family-led intervention for delirium prevention and management in adult critically ill patients: an application of the double diamond design process. Int J Nurs Stud. Dec 2024;160:104888. [FREE Full text] [CrossRef] [Medline]
    51. Hall K, Evans J, Roberts R, Brown R, Duggan L, Williamson M, et al. Co-designing a nature-based intervention to promote postnatal mental health for mothers and their infants: a complex intervention development study in England. BMJ Open. Dec 28, 2023;13(12):e075366. [FREE Full text] [CrossRef] [Medline]
    52. Rubio MA, Mosquera D, Blanco M, Montes F, Finck C, Duval M, et al. Cross-sector co-creation of a community-based physical activity program for breast cancer survivors in Colombia. Health Promot Int. Jun 01, 2022;37(3):daac073. [FREE Full text] [CrossRef] [Medline]
    53. Eyles H, Jull A, Dobson R, Firestone R, Whittaker R, Te Morenga L, et al. Co-design of mHealth delivered interventions: a systematic review to assess key methods and processes. Curr Nutr Rep. Jul 4, 2016;5(3):160-167. [CrossRef]

    ‎
    GHRC: Global Health Research Centre
    LMIC: low- and middle-income country
    MoSCoW: must have, should have, could have, will not have
    MRC: Medical Research Council
    NCD: noncommunicable disease
    NIHR: National Institute for Health and Care Research

    Edited by J Sarvestan; The proposal for this study was peer-reviewed by: NIHR Global Health Research Centre on NCDs and Environmental Change, National Institute for Health Research (NIHR), UK. See the Multimedia Appendix for the peer-review report; submitted 09.Jul.2025; accepted 31.Oct.2025; published 25.Nov.2025.

    Copyright

    ©Nushrat Khan, Paraskevi Seferidi, Kristine Belesova, Nantu Chakma, Laura Downey, Noshin Farzana, Sarada Satyamoorthy Garg, Suparna Ghosh-Jerath, Renu John, Maroof Khan, PK Latha, Asri Maharani, Sabhya Pritwani, Sekar Aqila Salsabilla, Haryani Saptaningtyas, Vidisha Sharma, Sujarwoto Sujarwoto, Aliya Naheed, Vidhya Venugopal, Christopher Millett, Vivekanand Jha, Devarsetty Praveen. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 25.Nov.2025.

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