Introduction: The 2021 European floods in Germany, Belgium, and the Netherlands significantly impacted healthcare. With climate change increasing flood risks, healthcare preparedness is essential. Floods affect healthcare directly and indirectly by disrupting patient access, damaging infrastructure and impeding care continuity. Our interdisciplinary research in the Netherlands systematically assesses flood impacts on healthcare, optimises disaster preparedness, patient logistics, and continuity and explores crisis governance, incorporating lessons from coronavirus disease-2019 (COVID-19). Methods: Our multi-sited, interdisciplinary project titled “Pandemic lessons for flood disaster preparedness” includes literature reviews on: (i) the (in) direct impacts of floods on healthcare, (ii) disaster decision-making strategies and (iii) patient logistics during crises. Empirically, ethnographic methods (interviews, focus groups, document analyses, and observations) will: (a) assess hospital flood preparedness, (b) explore decision-making and crisis management strategies and (c) analyse the dynamics of health system governance during floods. Data from these sources and flood scenarios will inform models on healthcare impacts and decision-making, culminating in a simulation game for research and training. Discussion: This study offers a comprehensive, interdisciplinary approach to understanding and improving healthcare system preparedness for floods. By integrating diverse fields such as healthcare governance, disaster risk management, logistics and hydraulic engineering, we provide a unique lens on resilience. A key strength is the incorporation of lessons from the COVID-19 pandemic, allowing us to draw parallels between pandemic response and flood preparedness. In addition, our simulation game serves as a robust tool for translating knowledge into practice. However, the study’s reliance on collaboration with busy healthcare and disaster response professionals may limit engagement. Moreover, the absence of direct public and patient involvement in the research design, though partially mitigated by engaging representative organizations, presents a potential limitation. Lastly, the challenge of obtaining real-time data from flood events could introduce recall bias, but triangulation of various data sources aims to address this issue. Despite these challenges, the study’s integration of long-term data from recent floods and focus on healthcare-specific crisis governance provides valuable insights for improving disaster preparedness.

Background: Telemedicine in neonatal care (TeleNeonatology) has the potential to improve neonatal outcomes, address capacity challenges and influence the emotional burden on parents. TeleNeonatology allows for real-time audiovisual communication between healthcare providers at different neonatal intensive care units (NICUs). Despite the high potential for multiple neonatal use-cases, TeleNeonatology is primarily being used for neonatal resuscitation and has yet to be widely implemented in Europe. Our study aims to evaluate both implementation strategies and effectiveness of TeleNeonatology in a pilot study in The Netherlands.

Methods: A pre-post implementation study with hybrid type III design will be conducted from 1 January 2023 to 31 December 2024. The year 2023 will serve as a baseline period pre-implementation. From 1 January 2024, a TeleNeonatology device will be integrated within all communication between the NICU-level IV of the Erasmus MC hospital and the NICU-level II at Amphia Hospital. Outcomes of the implementation of the TeleNeo programme will be evaluated using a mixed-methods approach evaluating implementation outcomes, service outcomes and client outcomes. Feasibility, the primary implementation outcome, will be evaluated via a validated questionnaire for parents and personnel. Secondary implementation outcomes will be barriers and facilitators of implementation, based on semi-structured interviews and focus groups. A cost minimisation analysis, using decision trees, will be evaluated as service outcomes. Client outcomes will be assessed via parent-reported transfer experience questionnaires and interviews and the clinical outcomes NICU-level III transfer rate and length of stay.

Ethics and dissemination: This study was reviewed by the Medical Ethical Committee of the Erasmus Medical Centre, who confirmed that the rules laid down in the Medical Research Involving Human Subjects Act do not apply (identification number: MEC-2023–0561). Results will be published in peer-reviewed journals in two separate scientific articles: the primary evaluation and the cost evaluation.

Purpose
Properly functioning health systems globally require medical devices and equipment for vital care. Despite promising innovations, many medical devices face adoption barriers such as regulatory issues, interoperability and data exchange challenges. In low-resource settings, contextual factors influencing adoption and diffusion have not been synthesized into an overview to guide future medical device and equipment suppliers. Our study provides a scientific inventory of frameworks, theories, models, and guidelines describing the adoption and diffusion of medical devices and equipment in low-resource settings.

Methods
We searched both the PubMed and Scopus databases to identify studies within the health and broader non-health domains. Our search yielded 2.124 results after de-duplication. Extended attributes on the type of the paper, adoption and diffusion focus, medical devices and equipment use cases, and country settings revealed patterns of underpinning and emerging frameworks for adoption and diffusion.

Results
We included 28 studies in our review. The most researched device types were telemedicine, telehealth, m-health, and e-health. Among a larger variety, the most utilized underpinning frameworks were the Diffusion of Innovation Framework, and the Technology Acceptance Model. These frameworks led to the development of emerging models, such as a modified version based on Kifle’s Adoption Model or the Intervention-Context-Actors-Mechanism-Outcome Model.

Conclusions
Our findings offer initial insights for further research in identifying mechanisms for improving access to and utilization of medical devices and equipment in low-resource settings. Researchers can use this comprehensive review to guide continued research, addressing gaps in theoretical understanding and empirical evidence on medical device adoption and diffusion in low-resource settings.

Background: Health systems worldwide struggled to obtain sufficient personal protective equipment (PPE) and ventilators during the COVID-19 pandemic due to global supply chain disruptions. Our study’s aim was to create a proof-of-concept model that would simulate the effects of supply strategies under various scenarios, to ultimately help decision-makers decide on alternative supply strategies for future similar health system related crises. Methods: We developed a system dynamics model that linked a disease transmission model structure (susceptible, exposed, infectious, recovered (SEIR)) with a model for the availability of critical supplies in hospitals; thereby connecting care demand (patients’ critical care in hospitals), with care supply (available critical equipment and supplies). To inform the model structure, we used data on critical decisions and events taking place surrounding purchase, supply, and availability of PPE and ventilators during the first phase of the COVID-19 pandemic within the English national health system. We used exploratory modelling and analysis to assess the effects of uncertainties on different supply strategies in the English health system under different scenarios. Strategies analysed were: (i) purchasing from the world market or (ii) through direct tender, (iii) stockpiling, (iv) domestic production, (v) supporting innovative supply strategies, or (vi) loaning ventilators from the private sector. Results: We found through our exploratory analysis that a long-lasting shortage in PPE and ventilators is likely to be apparent in various scenarios. When considering the worst-case scenario, our proof-of-concept model shows that purchasing PPE and ventilators from the world market or through direct tender have the greatest influence on reducing supply shortages, compared to producing domestically or through supporting innovative supply strategies. However, these supply strategies are affected most by delays in their shipment time or set-up. Conclusion: We demonstrated that using a system dynamics and exploratory modelling approach can be helpful in identifying the purchasing and supply chain strategies that contribute to the preparedness and responsiveness of health systems during crises. Our results suggest that to improve health systems’ resilience during pandemics or similar resource-constrained situations, purchasing and supply chain decision-makers can develop crisis frameworks that propose a plan of action and consequently accelerate and improve procurement processes and other governance processes during health-related crises; implement diverse supplier frameworks; and (re)consider stockpiling. This proof-of-concept model demonstrates the importance of including critical supply chain strategies as part of the preparedness and response activities to contribute to health system resilience.

BACKGROUND: Prompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature. METHODS: We searched the Pubmed database for concepts related to 'resilience' and 'health systems'. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation. RESULTS: The intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, 'resilience engineering' is the most prominent one, followed by 'community resilience' and 'organisational resilience'. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature. CONCLUSIONS: Our review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

Despite its fundamental role in diagnostic and curative care, radiology has been described as a neglected essential service in many low and middle-income countries (LMICs). Previous studies have demonstrated basic equipment and infrastructure shortages in LMIC settings, but no studies to date have gone further in understanding the perceptions and experiences of staff delivering radiology services, as a way of identifying their perspectives on barriers and facilitators for delivering services, and the potential for where improvements can be made. Our qualitative study aimed to: (a) identify barriers for delivering radiology services, and (b) suggest potential facilitators for improvement of radiology service delivery in the Zimbabwean context; from the perspective of radiology staff. We conducted semi-structured interviews (n = 13) and three focus groups (n = 24 radiographers), followed by four half- to full- days of field observations to validate insights from the interviews and focus groups in all three public hospitals and one private hospital in the Harare metropolitan area. Our study identified four main barriers for delivering radiology services: (i) poor basic infrastructure, equipment, and consumables; (ii) suboptimal equipment maintenance; (iii) shortage of radiology staff and skills development; and (iv) lack of wider integration and support for radiology services. We also identified a strong sense of motivation among staff to keep radiology services, pointing to what may be an enabler and facilitator for improving radiology services. These findings point to potential risks to patient safety and quality of delivering radiology services. More importantly, we found a strong sense of personal motivation displayed by the staff, suggesting there is the potential to maintain and improve existing practices, but this would require investments to train and remunerate more radiology staff, as well as investing in continuing professional development.

Objectives To systematically review academic literature for studies on any processes, procedures, methods or approaches to purchasing high-cost medical devices and equipment within hospitals in high-income countries. Methods On 13 August 2020, we searched the following from inception: Cost-Effectiveness Analysis Registry, EconLit and ProQuest Dissertations & Theses A&I via ProQuest, Embase, MEDLINE, and MEDLINE in Process via Ovid SP, Google and Google Scholar, Health Management and Policy Database via Ovid SP, IEEE Xplore Digital Library, International HTA Database, NHS EED via CRD Web, Science Citation Index-Expanded, Conference Proceedings Citation Index-Science, and Emerging Sources Citation Index via Web of Science, Scopus, and Zetoc conference search. Studies were included if they described the approach to purchasing (also known as procurement or acquisition) of high-cost medical devices and/or equipment conducted within hospitals in high-income countries between 2000 and 2020. Studies were screened, data extracted and results summarised in tables under themes identified. Results Of 9437 records, 24 were included, based in 12 different countries and covering equipment types including surgical robots, medical imaging equipment, defibrillators and orthopaedic implants. We found heterogeneity in methods and approaches; including descriptions of processes taking place within or across hospitals (n=14), out of which three reported cost savings; empirical studies in which hospital records or participant data were analysed (n=8), and evaluations or pilots of proposed purchasing processes (n=2). Studies emphasise the importance of balancing technical, financial, safety and clinical requirements for device selection through multidisciplinary involvement (especially clinical engineers and clinicians) in decision-making, and the potential of increasing evidence-based purchasing decisions using approaches such as hospital-based health technology assessments, ergonomics and device 'user trials'. Conclusions We highlight the need for more empirical work that evaluates purchasing approaches or interventions, and greater specificity in study reporting (eg, equipment type, evaluation outcomes) to build the evidence base required to influence policy and practice for medical equipment purchasing. Protocol registration This review was registered in Open Science Framework: Shokraneh F, Hinrichs-Krapels S, Chalkidou A et al. Purchasing high-cost medical equipment in hospitals in OECD countries: A systematic review. Open Science Framework 2021; doi:10.17605/OSF.IO/GTXN8. Available at: https://osf.io/gtxn8/ (accessed 12 February 2022).

Objectives ASSET (Health System Strengthening in sub-Saharan Africa) is a health system strengthening (HSS) programme involving eight work-packages (ie, a research study that addresses a specific need for HSS) that aims to develop solutions that support high-quality care. Here we present the protocol for the implementation science (IS) theme within ASSET (ASSET-ImplmentER) that aims to understand what HSS interventions work, for whom and how, and how IS methodologies can be adapted to improve the HSS interventions within resource-poor contexts. Settings Publicly funded health facilities in rural and urban areas in in Ethiopia, South Africa, Sierra Leone, and Zimbabwe. Participants Research staff including principal investigators, coinvestigators, field staff, PhD students, and research assistants. Interventions Work-packages use a mixed-methods effectiveness-effectiveness hybrid designs. At the end of the pre-implementation phase, a workshop is held whereby the IS theme, jointly with ASSET work-packages apply IS determinant frameworks to research findings to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work-packages also theorise selective mechanisms. In the piloting and rolling implementation phase, work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, reflection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers/enablers to implementation. Selective mechanisms of action are also investigated. Implementation outcomes are evaluated using qualitative and quantitative methods. The psychometric properties of outcome measures including acceptability, appropriateness and feasibility are also evaluated. In a final workshop, work-packages come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use. Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data are analysed using means and proportions. Conclusions We use a novel combination of IS methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study also contributes conceptual development and clarification at the underdeveloped interface of IS, HSS and global health. The ASSET-ImplementER theme is considered minimal risk as we only interview researchers involved in the different work-packages. To this effect we have received approval from King's College London Ethics Committee for research that is considered minimal risk (Reference number: MRA-20/21-21772).

The purchaser–provider co-operation model is a way of increasing efficiency and quality in healthcare services. Risks associated with this model, including goal misalignment and information asymmetry, are managed through control mechanisms. Based on data from 12 clinical commissioning groups (purchasers of cancer care) in the English National Health Service, this paper describes the control mechanisms used to facilitate purchaser–provider co-operation and identifies good practices in using different control mechanisms. Effective control mechanisms were found to include stakeholder involvement (social control); co-operation and partnerships with providers (process control); and monitoring and service outcome measures for provider (outcome control). The paper fills an important gap in the literature—little scholarly attention has to date been paid about how purchaser and provider relationships are managed ex post and how performance is affected.

Background: In 2016 the UK Department of Health and Social Care published the results of a comprehensive review of efficiency in hospitals, identifying “unwarranted variation” in procurement (or purchasing) practices for materials, supplies and devices. Addressing this variation in materials and supplies procurement practice has been identified as particularly important for creating efficiencies in health service delivery. However, little is known about the behaviour and experiences of front-line individuals who make these procurement decisions, which has implications for the development of strategies to improve efficiency. The objective of this study is to improve understanding of the factors influencing procurement behaviour and decisions among requisitioners who use an internal electronic procurement portal for medical supplies and equipment, and identify areas where efficiency could be improved. Methods: Qualitative semi-structured individual interview study, following approximately 70 h of exploratory observations on site. The study context was a large London National Health Service (NHS) healthcare provider (the Trust), where we focussed primarily on purchases managed by a large hospital. Participants were drawn from requisitioners from multiple directorates across the Trust (n = 15; of these n = 2 clinical staff members, n = 13 non-clinical). Results: Four factors stood out in our analysis as directly affecting procurement decisions: (1) a high level of variation in electronic purchasing and inventory management procedures throughout the Trust, (ii) an inaccurate and cumbersome search facility on the internal electronic procurement platform, exacerbated by poor IT skills training and support (iii) an inefficient purchase approvals system and (iv) multiple working sites and cluttered environments. We observed that these factors led requisitioners to employ a variety of strategies or so-called ‘workarounds’ to overcome the challenges they encountered, including stockpiling, relying on internal and supplier relationships, by-passing procedures to save time, purchasing outside existing agreements to save cost, and (re) delegating purchasing responsibilities among requisitioner staff - which both addressed and created difficulties. Conclusions: Working with the assumption that staff ‘workarounds’ indicate where main issues lie, we offer four possible explanations to why they occur: (a) to maintain services and prepare for future care requirements, (b) to save on costs for the organisation, (c) to develop skills and development in purchasing and (d) to break silos and work collaboratively. These four explanations help provide initial starting points for improving efficiencies in health supplies’ procurement processes.

The healthcare sector is facing significant challenges that require a systems approach, resulting in a rapid growth in the application of systems approaches in healthcare since the beginning of the 21st century. Consequently, healthcare practitioners and policymakers now desire to understand the evidence-base for the approach, but little evidence of the kind desired exists. This paper is a first step in conducting a narrative review of the application of systems approaches in healthcare based on a systematic review of the academic and grey literature. First, the emergence of the approach in healthcare is explored. Second, specific examples of applications of systems approaches in healthcare are examined to identify any missing elements in current practice. Third, fourteen reviews of the approach in healthcare published in the last ten years are analysed. The results suggest that the use of the approach in healthcare will most likely continue to increase, however, significant work remains for the design and systems community to demonstrate the effectiveness of systems approaches, specifically in providing convincing measures of impact on patient and service outcomes.

Implementation research is a multidisciplinary field that addresses the complex phenomenon of how context influences our ability to deliver evidence-informed healthcare. There is increasing realisation of the importance of applying robust implementation research to scale-up life-saving interventions that meet health-related sustainable development goals. However, the lack of high-quality implementation research is impeding our ability to meet these targets, globally. Within implementation research, theory refers to the proposed hypothesis and/or explanation of how an intervention is expected to interact with the local context and actors to bring about change. Although there is increasing interest in applying theory to understand how and why implementation programmes work in real-world settings, global health actors still tend to favour impact evaluations conducted in controlled environments. This may, in part, be due to the relative novelty as well as methodological complexity of implementation research and the need to draw on divergent disciplines, including epidemiology, implementation science and social sciences. Because of this, implementation research is faced with a particular set of challenges about how to reconcile different ways of thinking and constructing knowledge about healthcare interventions. To help translate some of the ambiguity surrounding how divergent theoretical approaches and methods contribute to implementation research, we draw on our multidisciplinary expertise in the field, particularly in global health. We offer an overview of the different theoretical approaches and describe how they are applied to continuously select, monitor and evaluate implementation strategies throughout the different phases of implementation research. In doing so, we offer a relatively brief, user-focused guide to help global health actors implement and report on evaluation of evidence-based and scalable interventions, programmes and practices.

There are a variety of structural and systems frameworks for describing the building blocks of country’s public health and health systems. In this paper, we propose a conceptual framework for a holistic view of a country’s health service providers in order to inform the plan for Defence Health Engagement activities with partner countries. This includes all potential government ministries involved in healthcare provision, the independent, private sector and the non-government organisation/charity sector. The framework provides a visualisation to support the analysis of a country’s health services providers. We propose that recognising and analysing the different contributions of all these national health providers is essential for understanding the wider political economy of a nation’s health systems. This can inform a plan of Defence Health Engagement for capacity building in crisis response, development and health systems strengthening.

It is widely acknowledged across the global health sector that research programmes need to be designed and implemented in a way that maximise opportunities for strengthening local capacity. This paper examines how the United Kingdom Research and Innovation (UKRI) Grand Challenges Research Fund (GCRF) funded PRECISE (PREgnancy Care Integrating translational Science, Everywhere) Network has been established as a platform to strengthen global capacity for research focused on the improvement of maternal, fetal and newborn health in sub-Saharan Africa. Best practice principles outlined in an ESSENCE on Health Research report have been considered in relation to the PRECISE Network capacity-building activities described in this paper. These activities are described at the individual, programmatic and institutional levels, and successes, challenges and recommendations for future work are outlined. The paper concludes that the PRECISE leadership have an opportunity to review and refresh activity plans for capacity building at this stage in the project to build on achievements to date.

While robust evidence is one ingredient in the policymaking process, it is by no means the only one. Engaging with policymakers and the policymaking process requires collaborative working models, navigating through the experiences, values and perspectives of policymakers and other stakeholders, as well as communicating evidence in an accessible manner. As a response to these requirements, over recent years there has been proliferation of activities that engage producers of evidence (specifically, academics), policymakers, practitioners, and the public in policy formulation, implementation and evaluation. In this article, we describe one engagement approach for facilitating research evidence uptake into policy and practice—an activity called a ‘Policy Lab’—as conducted by the team at The Policy Institute at King’s College London on numerous policy challenges over the past four years. Drawing on our experience in running 15 Policy Labs between January 2015 and September 2019, we (a) provide a guide to how we have run Policy Labs, while sharing our learning on what has worked best in conducting them and (b) demonstrate how these labs can contribute to bringing evidence closer to policymaking, by comparing their characteristics to enablers for doing so identified in the literature. While this approach to Policy Labs is not the only one of its kind, we suggest that these types of Labs manifest characteristics identified in previous studies for influencing the policymaking process; namely: providing a forum for open, honest conversations around a policy topic; creating new networks, collaborations and partnerships between academics and policymakers; synthesising available evidence on a policy topic in a robust and accessible format; and providing timely access to evidence relevant to a policy issue. We recognise the limitations of measuring and evaluating how these Labs change policy in the long-term and recommend viewing the Policy Lab as part of a process for engaging evidence and policymaking and not an isolated activity. This process serves to build a coalition through participation of diverse communities (thereby establishing ‘trust’), work on the language and presentation of evidence (thereby enabling effective ‘translation’ of evidence) and engage policymakers early to respond when policy windows emerge (thereby taking into account ‘timing’ for creating policy action).

Background: Public research funding agencies and research organisations are increasingly accountable for the wider impacts of the research they support. While research impact assessment (RIA) frameworks and tools exist, little is known and shared of how these organisations implement RIA activities in practice. Methods: We conducted a review of academic literature to search for research organisations' published experiences of RIAs. We followed this with semi-structured interviews from a convenience sample (n = 7) of representatives of four research organisations deploying strategies to support and assess research impact. Results: We found only five studies reporting empirical evidence on how research organisations put RIA principles into practice. From our interviews, we observed a disconnect between published RIA frameworks and tools, and the realities of organisational practices, which tended not to be reported. We observed varying maturity and readiness with respect to organisations' structural set ups for conducting RIAs, particularly relating to leadership, skills for evaluation and automating RIA data collection. Key processes for RIA included efforts to engage researcher communities to articulate and plan for impact, using a diversity of methods, frameworks and indicators, and supporting a learning approach. We observed outcomes of RIAs as having supported a dialogue to orient research to impact, underpinned shared learning from analyses of research, and provided evidence of the value of research in different domains and to different audiences. Conclusions: Putting RIA principles and frameworks into practice is still in early stages for research organisations. We recommend that organisations (1) get set up by considering upfront the resources, time and leadership required to embed impact strategies throughout the organisation and wider research 'ecosystem', and develop methodical approaches to assessing impact; (2) work together by engaging researcher communities and wider stakeholders as a core part of impact pathway planning and subsequent assessment; and (3) recognise the benefits that RIA can bring about as a means to improve mutual understanding of the research process between different actors with an interest in research.

BACKGROUND: The mechanisms and pathways to impacts from public health research in the UK have not been widely studied. Through the lens of one funder (NIHR), our aims are to map the diversity of public health research, in terms of funding mechanisms, disciplinary contributions, and public health impacts, identify examples of impacts, and pathways to impact that existing reporting mechanisms may not otherwise have captured, and provide illustrations of how public health researchers perceive the generation of non-academic impact from their work. METHODS: A total of 1386 projects were identified as 'public health research' by the NIHR and listed in the NIHR Public Health Overview database (2000-2016). From these, a subset of 857 projects were matched as potentially having begun reporting impacts via an external data-gathering platform (Researchfish). Data on the 857 projects were analyzed quantitatively, and nine projects were selected to investigate further through semi-structured interviews with principal investigators. Two workshops took place to validate emerging and final findings and facilitate analysis. RESULTS: In addition to the NIHR School for Public Health Research and the NIHR Public Health Research Programme, 89% of projects contained in the NIHR Public Health Overview portfolio as 'public health research' are funded via other NIHR research programmes, suggesting significant diversity in disciplines contributing to public health research and outcomes. The pathways to impact observed in our in-depth case studies include contributing to debates on what constitutes appropriate evidence for national policy change, acknowledging local 'unintended' impacts, building trusted relationships with stakeholders across health and non-health sectors and actors, collaborating with local authorities, and using non-academic dissemination channels. CONCLUSIONS: Public health as a discipline contributes substantially to impact beyond academia. To support the diversity of these impacts, we need to recognise localized smaller-scale impacts, and the difference in types of evidence required for community and local authority-based impacts. This will also require building capacity and resources to enable impact to take place from public health research. Finally, support is required for engagement with local authorities and working with non-health sectors that contribute to health outcomes.