partnership approach case study

Improving the management of complex business partnerships

Partnerships never go out of style. Companies regularly seek partners with complementary capabilities to gain access to new markets and channels, share intellectual property or infrastructure, or reduce risk. The more complex the business environment becomes—for instance, as new technologies emerge or as innovation cycles get faster—the more such relationships make sense. And the better companies get at managing individual relationships, the more likely it is that they will become “partners of choice” and able to build entire portfolios of practical and value-creating partnerships.

Of course, the perennial problems associated with managing business partnerships don’t go away either—particularly as companies increasingly strike relationships with partners in different sectors and geographies. The last time we polled executives on their perceived risks for strategic partnerships, 1 Observations collected in McKinsey’s 2015 survey of more than 1,250 executives. Sixty-eight percent said they expect their organizations to increase the number of joint ventures or large partnerships they participate in over the next five years. A separate, follow-up survey in 2018 showed that 73 percent of participants expect their companies to increase the number of large partnerships they engage in. the main ones were: partners’ disagreements on the central objectives for the relationship, poor communication practices among partners, poor governance processes, and, when market or other circumstances change, partners’ inability to identify and quickly make the changes needed for the relationship to succeed (exhibit).

In our work helping executive teams set up and navigate complex partnerships, we have witnessed firsthand how these problems crop up, and we have observed the different ways companies deal with them . The reality is: successful partnerships don’t just happen. Strong partners set a clear foundation for business relationships and nurture them. They emphasize accountability within and across partner companies, and they use metrics to gauge success. And they are willing to change things up if needed. Focusing on these priorities can help partnerships thrive and create more value than they would otherwise.

Establish a clear foundation

It seems obvious that partner companies would strive to find common ground from the start—particularly in the case of large joint ventures in which each side has a big financial stake, or in partnerships in which there are extreme differences in cultures, communications, and expectations.

Yet, in a rush to complete the deal, discussions about common goals often get overlooked. This is especially true in strategic alliances within an industry, where everyone assumes that because they are operating in the same sector they are already on the same page. By skipping this step, companies increase the stress and tension placed on the partnership and reduce the odds of its success. For instance, the day-to-day operators end up receiving confusing guidance or conflicting priorities from partner organizations.

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How can the partners combat it? The individuals expected to lead day-to-day operations of the partnership, whether business-unit executives or alliance managers, should be part of negotiations at the outset. This happens less often than you think because business-development teams and lawyers are typically charged with hammering out the terms of the deal—the objectives, scope, and governance structure—while the operations piece often gets sorted out after the fact.

Transparency during negotiations is the only way to ensure that everyone understands the partners’ goals (whether their primary focus is on improving operations or launching a new strategy) and that everyone is using the same measures of success. Even more important, transparency encourages trust and collaboration among partners, which is especially important when you consider the number of executives across the organizations who will likely rotate in and out of leadership roles during the life of the relationship.

Inevitably, points of tension will emerge. For instance, companies often disagree on financial flows or decision rights. But we have seen partners articulate such differences during the negotiation period, find agreement on priorities, and reset timelines and milestones. They defused much of the tension up front, so when new wrinkles—such as market shifts and changes in partners’ strategies—did emerge, the companies were more easily able to avoid costly setbacks and delays in the business activities they were pursuing together.

Nurture the relationship

Even business relationships that start off solidly can erode, given individual biases and common communication and collaboration issues. There are several measures partners can take to avoid these traps.

Connect socially

If executives in the partner organizations actively look for opportunities to understand one another, good collaboration and communication at the operations level are likely to follow. Given time and geographic constraints, it can be hard for them to do so, but as one energy-sector executive who has negotiated and managed dozens of partnerships noted, “It’s important to spend as much time as you can on their turf.” He says about 30 to 40 percent of partnership meetings are about business; the rest of the time is spent building friendships and trust.

Keep everyone in the loop

Skipping the step of keeping everyone informed can create unnecessary confusion and rework for partner organizations. That is what happened in the case of an industrial joint venture: the first partner in the joint venture included a key business-unit leader in all venture-related discussions. The second partner apprised a key business-unit leader about major developments, but this individual did not actually join the discussions until late in the joint-venture negotiation. At that point, as he learned more about the agreement, he flagged several issues, including inconsistencies in the partners’ access to vendors and related data. He immediately recognized these issues because they directly affected operations in his division. Because he hadn’t been included in early discussions, however, the partners wasted time designing an operating model for the joint venture that would likely not work for one of them. They had to go back to the drawing board.

Recognize each other’s capabilities, cultures, and motivations

Partners come together to take advantage of complementary geographies, corresponding sales and marketing strengths, or compatibilities in other functional areas. But it is important to understand which partner is best at what . This process must start before the deal is completed—but cannot stop at signing. In the case of one consumer-goods joint venture, for instance, the two partner organizations felt confident in their plan to combine the manufacturing strength of one company with the sales and marketing strengths of the other. During their discussions on how to handle financial reporting, however, it became clear that the partner with sales and marketing strengths had a spike in forecasting, budgeting, and reporting expertise. The product team for the first partner had originally expected to manage these finance tasks, but both partner teams ultimately agreed that the second partner should take them on. In this way, they were able to enhance the joint venture’s ongoing operations and ensure its viability.

Equally important is understanding each partner’s motivation behind the deal. This is a common point of focus during early negotiations; it should continue to be discussed as part of day-to-day operations—particularly if there are secondary motivators, such as access to suppliers or transfer of capabilities, that are important to each partner. Within one energy-sector partnership, for instance, the nonoperating partner was keen to understand how its local workforce would receive training over the course of the partnership. This company wanted to enhance the skills of the local workforce to create more opportunities for long-term employment in the region. The operating partner incorporated training and skill-evaluation metrics in the venture’s quarterly updates, thus improving the companies’ communication on the topic and explicitly acknowledging the importance of this point to its partner.

Invest in tools, processes, and personnel

Bringing different business cultures together can be challenging, given partners’ varying communication styles and expectations. The good news is that there are a range of tools—among them, financial models, key performance indicators, playbooks, and portfolio reviews—companies can use to help bridge any gaps. And not all these interventions are technology dependent. Some companies simply standardize the format of partnership meetings and agendas so that teams know what to expect. Others follow stringent reporting requirements.

Another good move is to convene an alliance-management team. This group tracks and reviews the partnership’s progress against defined metrics and helps to spot potential areas of concern—ideally with enough time to change course. Such teams take different forms. One pharmaceutical company with dozens of commercial and research partnerships has a nine-member alliance-management team charged mostly with monitoring and flagging potential issues for business-unit leaders, so it consists of primarily junior members and one senior leader who interacts directly with partners. An energy company with four large-scale joint ventures has taken a different approach: its alliance-management team comprises four people, but each is an experienced business leader who can serve as a resource for the respective joint-venture-leadership teams.

Sometimes partnerships need a structural shake-up—and not just as an act of last resort.

How companies structure these teams depends on concrete factors—the number and complexity of the partnerships, for instance—as well as intangibles like executive support for alliances and joint ventures and the experiences and capabilities of the individuals who would make up the alliance-management team.

Emphasize accountability and metrics

Good governance is the linchpin for successful partnerships; as such, it is critical that senior executives from the partner organizations remain involved in oversight of the partnership. At the very least, each partner should assign a senior line executive from the company to be “deal sponsor”—someone who can keep operations leaders and alliance managers focused on priorities, advocate for resources when needed, and generally create an environment in which everyone can act with more confidence and coordination.

Additionally, the partners must define “success” for their operations teams: What metrics will they use to determine whether they have hit their goals, and how will they track them? Some companies have built responsibility matrices; others have used detailed process maps or project stage gates to clarify expectations, timelines, and critical performance measures. When partnerships are initially formed, it is usually the business-development teams that are responsible for building the case for the deal and identifying the value that may be created for both sides. As the partnership evolves, the operations teams must take over this task, but they will need ongoing guidance from senior leaders in the partner organizations.

Build a dynamic partnership

Sometimes partnerships need a structural shake-up—and not just as an act of last resort. For instance, it might be less critical to revisit the structure of a partnership in which both sides are focused on joint commercialization of complementary products than it would be for a partnership focused on the joint development of a set of new technologies. But there are some basic rules of thumb for considering changes in partnership structure.

Partner organizations must acknowledge that the scope of the relationship is likely to shift over time. This will be the case whether the partners are in a single- or multiasset venture, expect that services will be shared, anticipate expansion, or have any geographic, regulatory, or structural complexities. Accepting the inevitable will encourage partners to plan more carefully at the outset. For example, during negotiations, the partners in a pharmaceutical partnership determined that they had different views on future demand for drugs in development. This wasn’t a deal breaker, however. Instead, the partners designated a formula by which financial flows would be evaluated at specific intervals to address any changes in expected performance. This allowed the partners to adjust the partnership based on changes in market demand or the emergence of new products. All changes could be incorporated fairly into the financial splits of the partnership.

Avoiding blind spots in your next joint venture

Partners should also consider the potential for restructuring during the negotiation process—ideally framing the potential endgame for the relationship. What market shifts might occur, how might that affect both sides’ interests and incentives, and what mechanisms would allow for orderly restructuring? When one oil and gas joint venture began struggling, the joint-venture leader realized he was being pulled in opposing directions by the two partner companies because of the companies’ conflicting incentives. “It made the alliance completely unstable,” he told us. He brought the partners back to the negotiation table to determine how to reconcile these conflicting incentives, restructure their agreement, and continue the relationship, thus avoiding deep resentment and frustration on both sides of the deal.

Such dialogues about the partnership’s future, while potentially stressful, should be conducted regularly—at least annually.

The implementation of these four principles requires some forethought and care. Every relationship comes with its own idiosyncrasies, after all, depending on industry, geography, previous experience, and strategy. Managing relationships outside of developed markets, for instance, can present additional challenges involving local cultures, integration norms, and regulatory complexities. Even in these emerging-market deals, however, the principles can serve as effective prerequisites for initiating discussions about how to change long-standing practices and mind-sets.

An emphasis on clarity, proactive management, accountability, and agility can not only extend the life span of a partnership or joint venture but also help companies build the capability to establish more of them—and, in the process, create outsize value and productivity in their organizations.

Ruth De Backer is a partner in McKinsey’s New York office, where Eileen Kelly Rinaudo is a senior expert.

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Article Contents

Introduction, methodology.

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A partnership approach to health promotion: a case study from Northern Ireland

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Deirdre Heenan, A partnership approach to health promotion: a case study from Northern Ireland, Health Promotion International , Volume 19, Issue 1, March 2004, Pages 105–113, https://doi.org/10.1093/heapro/dah111

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In recent years there has been a renewal of interest in community development and partnership approaches in the delivery of health and social services in Northern Ireland. The general thrust of these approaches is that local communities can be organized to address health and social needs and to work with government agencies, voluntary bodies and local authorities in delivering services and local solutions to problems. Since the Ottawa Charter was launched in 1986, government in Northern Ireland has stressed that community development should no longer simply be added on to key aspects of Health and Social Services, but should instead be at the core of their work. There is increasing consensus that traditional approaches to improving health and well-being, which have focused on the individual, are paternalistic and have failed to tackle inequalities effectively. Partnerships within a community development setting have been heralded as a means to facilitate participation and empowerment. This paper outlines the policy background to community development approaches in health promotion and delivery in Northern Ireland. Drawing on evidence from a case study of a community health project it highlights the benefits and difficulties with this approach. The findings suggest that partnerships can positively influence a community's health status, but in order to be effective they require effective planning and long-term commitment from both the state and the local community.

Since the early 1990s, community development has been reinvented and is now depicted as having the potential to play a key role in welfare intervention policies. At the heart of this resurgence is the belief that if social intervention of any form is to have a chance of success, it must take into account the views and opinions of the communities in which the intervention is taking place. Traditional, individualistic methods of delivery of health care have failed to tackle inequalities effectively. It is now widely accepted that strategies that are imposed on reluctant communities are doomed to failure ( Davies, 1999 ). The Alma Ata declaration of ‘Health for All’ ( WHO, 1978 ) claimed that new approaches were needed to achieve complete health globally by the year 2000. It was suggested that these approaches should be based on a re-orientation of the health services towards primary care and the development of collaboration between statutory, voluntary and community sectors. Since these principles were reiterated in the Ottawa Charter for Health Promotion ( WHO, 1986 ), there has been increasing emphasis on developing approaches to health promotion that tackle the broader social, economic and environmental determinants of health ( Gillies, 1998 ). Approaches that aim to empower communities to identify their own health needs and facilitate ways to address those needs have gained broad acceptance ( Drennan, 1988 ; Webb, 1994 ; Davies, 1999 ). This paper begins with a brief outline of the structure of health care delivery in Northern Ireland and then sets out the policy culture that has led to the re-emergence of community development approaches. It then reports the findings from a case study of a community health project based in the Creggan area of Derry City in Northern Ireland. The main aim of the study reported was to identify the key issues that emerged during the establishment of a partnership between statutory health providers and the community and voluntary sectors, and to assess how they could inform future initiatives.

Delivery of health care in Northern Ireland

In 1972, 4 years after the beginning of the most recent period of ‘troubles’ in Northern Ireland, the British government removed power from local politicians and imposed direct rule from Westminster. Control over social services such as health, housing and education was taken from local government and placed in the hands of centralized administrative bodies. The Department of Health and Social Services (Northern Ireland) is responsible for the provision of health, personal social services and social security. Four area health and social services boards are responsible for the administration of both health and personal social services, unlike the system in Britain where local authorities are responsible for personal social services. These boards were designed to distance statutory health and personal social services from violence and sectarianism, and to ensure that services were delivered in an impartial, fair manner ( Pinkerton, 1998 ). Hospital and community services are provided by 19 health care trusts and five health care agencies (see Figure 1 ).

The structure of the national health service in Northern Ireland.

The centralized and bureaucratic organization of statutory social services in Northern Ireland has led to health care work within communities becoming an extremely marginalized activity, afforded a very low priority. This administrative system has been widely condemned as technocratic, remote and divorced from local communities ( Caul and Herron, 1992 ; Campbell et al ., 1995 ; Traynor, 1998 ). In the last decade, however, there has been a resurgence of community development approaches within statutory health and social services, and a focus on partnerships with voluntary and community groups. The impetus for this change has come from a range of influences and these are briefly discussed in the next section.

The policy context

Within the UK, partnerships have been heralded as a new model for local governance as they reflect the changing relationship between the state, the market and civil society ( Geddes, 1997 ). In the context of Health and Social Services, government in Northern Ireland has explicitly stated its desire to see community development, through partnerships, encouraged and supported. In 1993, the Voluntary Activity Unit was established with the Department of Health of Social Services to promote community development. At the launch of this unit, government stated that community development had the potential to make a major impact on a wide range of policies and programmes delivered by both statutory and voluntary agencies.

Attempts to mainstream community development approaches in the core work of the Department of Health and Social Services (DHSS) derive from policy changes in the late 1990s. In 1997, the DHSS regional strategy included a policy and plans to include community development methods in the remit of Health and Social Services. It stated that, where possible, the Health and Social Services Boards should promote and employ community development approaches to target social and health needs. It emphasized the importance of partnerships with local people in the planning, development, delivery and evaluation of social services. This report stressed that community development should be mainstreamed into health programmes and not added on as an afterthought ( DHSS, 1996 ).

This commitment to community development approaches was reiterated in the DHSS document entitled Mainstreaming Community Development in the Health and Social Services ( DHSS, 1999 ), which stressed the government's commitment to see community development ‘extended, strengthened and promoted’ throughout Northern Ireland. It was claimed that a rigorous application of a community development approach would advance social justice goals and social inclusion. This document highlights the importance of a culture change to ensure that community development is embedded into mainstream health and personal social services planning and the service delivery process. It stresses the need for a reorientation in senior management away from a process of ‘providing for’ towards a process of ‘working with’ local communities.

Given that the statutory and community sectors working in partnership in the area of health promotion is unusual in Northern Ireland, the main aim of this study was to assess the dynamics of this method of working and identify issues that may inform future projects. In order to set the study in context, a wide range of secondary sources (see Table 1 ) was consulted. As the research was largely exploratory in nature, a qualitative research method was considered to be most appropriate as it enabled the researcher to ascertain the views and perceptions of those who had been directly involved with the project ( Janesick, 1994 ). Semi-structured interviews were undertaken with 16 key players in the project, from a range of statutory, voluntary and community backgrounds. These individuals were contacted by the researcher and all agreed to participate in the study. All of the interviews were undertaken by the researcher, and were tape-recorded and transcribed immediately afterwards. The interviews lasted on average 45 min. The participants were asked to reflect on their involvement in the project and to discuss the main advantages and disadvantages of the model, and to identify lessons for future projects. The respondents included the Director of Social and Health Care in the Western Area Board, the Director of Social Care in the Foyle Trust, the Programme Manager of Health Care in the Trust, the health visitor who was the driving force behind the project, two other health visitors, the manager of the Creggan Health Information Project (CHIP), two nurses working part-time in CHIP, and seven community and voluntary workers. The data were analysed using thematic analysis, which involved identification of themes and categories from the interviews ( Lincoln and Guba, 1985 ). Findings are reported through summaries of themes illustrated by direct quotations.

Main secondary sources

Background to community development approaches in the Foyle Trust

Foyle Health and Social Services Trust provides health and social services to a population of 160 000 in the Western Area Health Board. Neither the Health Board nor the Trust has a written commitment to advancing community development approaches. The majority of references to community development are in the context of health promotion, yet work in this area has been described as largely based on the medical model, focusing on individual issues such as immunization, smoking and tackling ill health. Notwithstanding this lack of a formal policy, the board has a long-established history of work with community and voluntary groups [ Community Development Health Network (CDHN), 2000 ]. Following the World Health Organization identifying the movement of health care into the community as a key objective, in 1993 the then Director of Health Care decided to re-designate responsibilities for a number of the Trust's health visitor posts. Five of the Trust's 40 health visitors were moved out of their traditional health visiting roles and became community-based. This was a move designed to represent a shift away from a traditional mother and child focus, which had dominated health visiting, towards a more participatory view of health promotion ( CDWG, 1999 ). One of these health visitors was allocated to the city side of Derry, where she was given responsibility for a number of deprived inner city areas. Her main focus, however, was on the Creggan area as this was where she had contacts and felt that she could make the biggest impact.

The Creggan area of Derry has been identified as one of the three poorest wards in Northern Ireland ( Townsend et al ., 1988 ). It is one of the largest and oldest public housing estates, with a population of ∼11 000 people. The three main electoral wards of St Peters, Creggan Central and Creggan South are ranked the first, second and third of the most deprived areas, respectively, with respect to extent of deprivation out of a total of 5666 wards in Northern Ireland. Male unemployment ranges from 44% to 58% across the electoral wards for the area ( Lazenbatt, 1997 ). Similar to many other areas in Northern Ireland marked by severe levels of deprivation and poverty, a vibrant community development ethos exists. The number and variety of community groups that exist in the area evidence this tradition of self-help [ Murtagh and McGinn, 1995 ; Creggan Neighbourhood Partnership (CNP), 1996 ]. Following several public meetings to address health concerns, a cross-sectoral partnership, which became known as the Creggan Health Information Project, was formed in 1993. At these initial meetings it was very apparent that there was much hostility amongst the local population to the idea of a partnership with the statutory health authorities. They were sceptical about the health authorities' motives or their commitment to working at a local level. Interestingly, the local community perceived their problems to be social and economical, but had not really considered how they could be addressed from a health perspective ( CDHN, 2000 ).

Despite this inauspicious beginning, ∼30 people agreed to form a working group to take the project forward. The overall aim of the project was ‘to put health on the agenda for the community’. The following key principles were identified by the community as central to the project: CHIP was designed to create a core group of local people with knowledge or expertise in health issues. Skills are acquired through capacity building and training programmes, and rather than simply provide their skills, experts trained and supported others ( McShane, 2000 ). The project was based on a partnership between the health and social service professionals, and community and voluntary workers. There are currently ∼150 core members with expertise in a wide range of health issues. The project has stressed the need for the community to take ownership of their own health needs; individuals are no longer passive recipients in their health care, but can actively direct and influence the delivery of services.

active community involvement in the giving and receiving of information;

empowerment of local people through capacity building;

a commitment to training and the sharing of skills;

community management and ownership of the project; and

partnerships between statutory services and the community.

Over 1000 people have attended CHIP information sessions, conference health festivals and courses. Many of the courses have been described as stepping stones to enable further development as they have enabled the community to identify their health needs ( CDWG, 1999 ).

From the interviews and examination of secondary sources, three key themes emerged: the need for strategic planning, the contested nature of partnerships and sustainability.

Strategic planning

The health visitors were freed up from their traditional roles to explore the possibilities of developing health projects within the community. It was a bold move that demonstrated a willingness to change.

We were just told to go out and be innovative. There was no strategic thinking and during our first year in the community we realized that we knew nothing. What was clear was that we would have to tap into other networks already working in this area.

Initially there had been some scepticism amongst the local community; many were reluctant to be seen as a testing ground for the latest idea. There was real resistance to the idea they were simply passive and dependency orientated, waiting to be drip-fed the latest idea from the State.

There was a feeling that enabling the community to identify their own health needs was just pie in the sky. They had no aims, no objectives; they didn't have a strategy, they just parachuted in a health visitor and hoped for the best.

Whilst senior management in the health and social care sector had supported staff to refocus their activities on community work, there was some degree of scepticism within the community that they were fully committed to this approach. There was inevitable tension between the two groups and whilst those in the statutory sector claimed that the existence of this project was proof of their commitment within the community and voluntary sector, it was suggested that there was a lack of visible support for a change in direction. As one voluntary worker quipped ‘They can talk the talk but won't walk the walk’.

The contested nature of partnerships

There was a belief in the community that we had entered into a partnership, there was a real feeling of ownership, but no real sense of having control or power.

For the first time there was a sense of actually achieving something, you know making a difference. But it was also frustrating, you are answerable to the management of the Trust and to the local community, and it is not possible to please everybody. I just ended up as piggy in the middle.

Sometimes it was a no-win situation. I was either a traitor in the community or my colleagues in the health service were accusing me of having gone native.

The way they handled the whole issue made it clear that there was a lack of mutual respect. All of our plans for the needs assessment had been based on the belief that we would be able to access the data; we had been assured by the Trust that it was no problem.

So much for all the talk of joint planning, we were informed without consultation over the phone.

The practical difficulties surrounding the issue of identifying families with children under 5 years of age were resolved when those undertaking the research decided to knock on every door and ask about family structure so that the sample could be identified. This issue was highlighted by many of those who were involved with CHIP as a way of comparing the commitment at community level with the commitment at Trust level. Within the management of the Trust it was suggested that some of those within the community had unrealistic expectations and would inevitably be frustrated and disappointed. It was clear that many of the difficulties encountered in the partnership were the result of different understandings of what the term ‘partnership’ actually meant.

Unsurprisingly, there was tension between the theory of working in partnership and the practice of power sharing. The partnership was not something that could simply be set in motion; it required a significant amount of work and negotiation between all the parties involved. In this project there was a commitment to investing a considerable amount of time into building the relationships required for a productive consultation process. Whilst the community and voluntary groups were extremely wary of becoming involved in a token consultation process, the Trust could not delegate authority to an extent that it would encroach on their statutory responsibilities.

Sustainability

When we were getting the project off the ground, I seemed to there night and day. Eventually I had to let go; I just could not maintain that level of commitment. The irony was I was working so hard on the project, my own health began to suffer.

We had done all we could. We identified needs and we wanted action and there was none. I began to wonder why we bothered.

I suppose on reflection there was an expectation of some clear strategy to address the needs we had identified, but nothing really happened.

You can't really expect people to just keep on going, it is human nature to want some outcomes. The project was never going to be a quick fix, but some positive feedback would have been welcomed.

It is significant that this partnership took place against a backdrop of cost cutting and financial constraints; it was therefore inevitable that it would be seen by many as health promotion ‘on the cheap’. Popple has warned previously that community work could be used by some to offer low-cost solutions to tackle problems that require significant resources ( Popple, 1995 ). The participation of disadvantaged community members is fundamentally different to that of privileged community members, who have resources at their disposal ( Boyce, 2002 ). Financial and support mechanisms are prerequisites to community participation by excluded individuals. Given that few resources were available to support this move towards partnership, goodwill was at times stretched to breaking point. As Mayo ( Mayo, 1994 ) noted, community initiatives have the potential to have a huge impact on health and well-being, but the limits of this type of work must be clearly acknowledged. In community health projects, it is essential to renew the pool of activists and avoid becoming a self-perpetuating clique. The transformation of the delivery of health services is not possible if it is not accompanied by resources and training.

What this case study reveals is that local commu-nities can be empowered by community-based health promotion projects. The major success of this project has been the continuing and increasing involvement of local people in the partnership. Training local people to facilitate courses and programmes is an integral part of the project and has led to increased levels of self-confidence and self-belief. The sense of ownership of the process of health promotion has encouraged and promoted a belief that health awareness can positively influence communities. This project provides evidence of how local people can actually be encouraged to take control of their lives. It demonstrates that professional boundaries can be transgressed, and a more open and flexible approach to health and social needs can be adopted. What is clear though, is that those working in this type of collaboration must ensure that aims and objectives have been clearly articulated by all parties involved. Unrealistic expectations of what can be achieved can lead to demoralization and disillusionment. Health promoters in the community must recognize that the community's greatest resources for health are its members ( Kemm and Close, 1995 ). The process of building a partnership can be time-consuming, demanding high levels of commitment, therefore it crucial that those involved feel that their input is acknowledged and valued. The government's commitment to community development is meaningless rhetoric unless it is supported by education programmes, research, training, resources and long-term commitments. If it is to be an effective, vibrant, creative method of engagement, community development must be embedded in the planning and delivery of services, and not an isolated marginal activity driven by committed individuals.

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WHO ( 1986 ) Ottawa Charter for Health Promotion . WHO, Geneva.

Author notes

Faculty of Social Sciences, University of Ulster, Derry, Northern Ireland

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Case studies in partnerships.

Here you will find a series of case studies of partnerships in action within a range of Cochrane Groups. These talk about the background to the partnership, its development, the benefit to both sides and tips for Groups. 

If you have examples of partnership work that you would like to share, please contact Cochrane KT Department .

Cancer Review Group Network identifies potential stakeholders across the network in a mapping exercise

Cochrane Airways and a UK based charity, Asthma UK

Cochrane oral health and their global alliance of partners, cochrane rehabilitation and various national societies of rehabilitation medicine, cochrane rehabilitation and the international society of physical and rehabilitation medicine, cochrane child health and trekk (translating emergency knowledge for kids).

Partner(s): TREKK, a Canadian organisation committed to improving emergency care for children and families across Canada.  Partnership activities: identification of high quality evidence and development of KT tools for healthcare practitioners and parents, made available through the TREKK website.  Type of partnership agreement: formal Date: 2018 Read more 

Further examples

Here you can find links to a range of further examples of partnerships taking place across Cochrane.

Partnership for priority setting

• Neuro-Oncology Group Priority Setting Partnership
• Developing a research agenda for ENT, Hearing and Balance Care

Partnership for review dissemination

• BMJ partners with Cochrane Clinical Answers to boost knowledge at the point of care 
• Cochrane UK partnership with Mediwikis
• Cochrane Airways working with Sense about Science

Partnership for guideline development

• Cochrane Eyes and Vision partnering with American Academy of Ophthalmology
• South African Guidelines Excellence project
• Cochrane Incontinence: working with guideline developers

Partnership for consumer engagement

• Consumers United for Evidence-Based Healthcare (CUE)
• PartecipaSalute : Involving patients, citizens and their association in research 
• Consumer/patient engagement Cochrane Child Health

A partnership approach to health promotion: a case study from Northern Ireland

Affiliation.

• 1 Faculty of Social Sciences, University of Ulster, Derry, Northern Ireland. [email protected]
• PMID: 14976178
• DOI: 10.1093/heapro/dah111

In recent years there has been a renewal of interest in community development and partnership approaches in the delivery of health and social services in Northern Ireland. The general thrust of these approaches is that local communities can be organized to address health and social needs and to work with government agencies, voluntary bodies and local authorities in delivering services and local solutions to problems. Since the Ottawa Charter was launched in 1986, government in Northern Ireland has stressed that community development should no longer simply be added on to key aspects of Health and Social Services, but should instead be at the core of their work. There is increasing consensus that traditional approaches to improving health and well-being, which have focused on the individual, are paternalistic and have failed to tackle inequalities effectively. Partnerships within a community development setting have been heralded as a means to facilitate participation and empowerment. This paper outlines the policy background to community development approaches in health promotion and delivery in Northern Ireland. Drawing on evidence from a case study of a community health project it highlights the benefits and difficulties with this approach. The findings suggest that partnerships can positively influence a community's health status, but in order to be effective they require effective planning and long-term commitment from both the state and the local community.

• Community Health Planning / organization & administration*
• Community Networks*
• Community Participation / methods*
• Community-Institutional Relations
• Government Agencies / organization & administration
• Health Policy
• Health Promotion / organization & administration*
• Northern Ireland

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Social Capital in Higher Education Partnerships: A Case Study of the Canada–Cuba University Partnership

• Original Article
• Published: 03 July 2018
• Volume 33 , pages 89–109, ( 2020 )

Cite this article

• Marianne A. Larsen   ORCID: orcid.org/0000-0002-4945-6434 1 &
• Clara I. Tascón 1  

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This article reports on the findings of a case study about the Canada–Cuba University Partnership (CCUP), a teaching, research, and service partnership between individuals associated with a Canadian and Cuban University. The research question guiding the study was: “How do the relationships among individuals in the CCUP shape the partnership?” Our review of the existing literature on higher education partnerships reveals the lack of literature focusing on the relationships among individual partnership members. Our study is framed by social capital as our theoretical approach and social network analysis as our methodological approach. These approaches enable us to map out the connections between and among individuals and show the importance of their relationships. We analyze the partnership focusing on social capital, highlighting the mutually beneficial activities and the role of central actors in the network who contributed to the formation of the partnership and the long-lasting relationships among academics in both countries. Relationships in the CCUP are characterized by mutuality, solidarity, and strong and thick ties. The argument we advance is that understanding the collaborative relationships among members of higher education partnerships and the productive capacities of those relationships through the enactment of social capital provides insights into how sustainable and successful partnerships work.

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Larsen, M.A., Tascón, C.I. Social Capital in Higher Education Partnerships: A Case Study of the Canada–Cuba University Partnership. High Educ Policy 33 , 89–109 (2020). https://doi.org/10.1057/s41307-018-0100-1

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Case Studies: Lessons from Public-Private Partnerships

07 Apr Case Studies: Lessons from Public-Private Partnerships

America must address its infrastructure needs—transportation, water, power and energy, and civic structures—to meet the demands of the next generation.

The task is daunting, especially in an era of fiscal constraint, and to accomplish it public officials must think creatively about how to deliver infrastructure more efficiently and cost-effectively. One promising approach is to partner with the private sector in financing and delivering infrastructure projects.

In order to increase understanding and consideration of private-public partnerships (P3s) among public sector leaders, the Bipartisan Policy Center analyzed a number of P3 projects. We have laid out important lessons learned from these projects for public officials considering a P3 approach as well as a few core principles for success, drawing from the experiences of public and private partners across the country.

Explore the case studies below or download the full set of projects . To view the map legend, simply select the icon in the top-left corner.

Bridging the Gap Together: A New Model to Modernize U.S. Infrastructure

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With $3 trillion needed for this infrastructure over the next decade, states, cities, counties and other public and private providers of these critical services must continue their important role, and the federal commitment to infrastructure must be restored. Further, with respect to broadband, federal decision-makers should continue to work in partnership with the private sector and states to foster infrastructure deployment in remaining unserved areas.

• Open access
• Published: 23 April 2024

Factors influencing the commissioning and implementation of health and social care interventions for people with dementia: commissioner and stakeholder perspectives

• Rachael Tucker   ORCID: orcid.org/0000-0001-8133-1909 1 ,
• Robert Vickers   ORCID: orcid.org/0000-0002-3031-2940 2 , 5 ,
• Emma J. Adams   ORCID: orcid.org/0000-0002-5444-6951 1 ,
• Clare Burgon   ORCID: orcid.org/0000-0002-4910-9969 2 ,
• Juliette Lock   ORCID: orcid.org/0000-0003-2028-6889 2 ,
• Sarah E. Goldberg   ORCID: orcid.org/0000-0001-5109-798X 1 ,
• John Gladman   ORCID: orcid.org/0000-0002-8506-7786 2 , 3 , 4 , 5 ,
• Tahir Masud   ORCID: orcid.org/0000-0003-1061-2898 3 ,
• Elizabeth Orton   ORCID: orcid.org/0000-0002-2531-8846 2 ,
• Stephen Timmons   ORCID: orcid.org/0000-0002-3731-1350 6 &
• Rowan H. Harwood   ORCID: orcid.org/0000-0002-4920-6718 1 , 3  

Archives of Public Health volume  82 , Article number:  54 ( 2024 ) Cite this article

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Despite several interventions demonstrating benefit to people living with dementia and their caregivers, few have been translated and implemented in routine clinical practice. There is limited evidence of the barriers and facilitators for commissioning and implementing health and social care interventions for people living with dementia. The aim of the current study was to explore the barriers and facilitators to commissioning and implementing health and social care interventions for people with dementia, using a dementia friendly exercise and physical activity-based intervention (PrAISED [Promoting Activity, Stability and Independence in Early Dementia and Mild Cognitive Impairment]) as a case study.

Qualitative semi-structured interviews were conducted with stakeholders from a range of backgrounds including individuals from health and social care, local government, the voluntary and community sector, universities, and research centres in England. The Consolidated Framework for Intervention Research (CFIR) was used to guide the design and analysis.

Fourteen participants took part, including commissioning managers, service managers, partnership managers, charity representatives, commercial research specialists, academics/researchers, and healthcare professionals. Data were represented in 33 constructs across the five CFIR domains. Participants identified a need for greater support for people diagnosed with dementia and their caregivers immediately post dementia diagnosis. Key barriers included cost/financing, the culture of commissioning, and available resources. Key facilitators included the adaptability of the intervention, cosmopolitanism/partnerships and connections, external policy and incentives, and the use of already existing (and untapped) workforces.

Several barriers and facilitators for commissioning and implementing health and social care interventions for people with dementia were identified which need to be addressed. Recommended actions to facilitate the commissioning and implementation of dementia friendly services are: 1) map out local needs, 2) evidence the intervention including effectiveness and cost-effectiveness, 3) create/utilise networks with stakeholders, and 4) plan required resources.

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Introduction

Dementia is a progressive, neurodegenerative, life limiting condition associated with a range of symptoms including memory loss, declining executive function, and associated changes in behaviour and mood [ 5 ]. Over 55 million people live with dementia worldwide [ 43 ] and this is projected to increase to approximately 153 million by 2050 [ 37 ]. The global cost of dementia in 2019 amounted to US$ 1.3 trillion, with costs expected to exceed US$ 2.8 trillion by 2030 [ 43 ]. As the condition progresses, the amount of support required, and thus, care costs also increase [ 3 ]. Therefore, implementing interventions for dementia that focus on maintaining independence and slowing the rate of functional decline to prevent health and social care use and reduce this economic burden is important.

Translating research into practice

The research into practice gap is well documented. It takes an average of 17 years for innovations to be implemented into routine clinical practice [ 7 , 24 ]. Despite many non-pharmacological interventions for dementia demonstrating benefit, a small number are implemented in practice [ 24 ]. Thus, it is crucial to understand strategies that facilitate their implementation.

There is little evidence for translating dementia friendly exercise/physical activity interventions into practice. A systematic review by Groot Kormelinck et al. [ 27 ] identified barriers and facilitators for implementing complex interventions for residents with dementia living in long term care. In this review, only two interventions had an exercise or physical activity component [ 27 ], and due to its setting, may not have identified factors relevant to implementation across a range of health systems.

Commissioning in England’s National Health Service

The National Health Service (NHS) in England is a publicly funded health system providing universal access to healthcare based on clinical need, not ability to pay [ 20 ]. NHS commissioning is complex whereby different services may be specified and paid for by different commissioners, including nationally (NHS England) and locally (e.g. Primary Care Networks and local government). Services may be provided by the voluntary and community sector (VCS), primary and secondary care health services, and support organisations working interdependently [ 36 , 40 ]. However, social care in England is not universally funded, is commissioned by local government, provided by a range of providers, and is means tested [ 39 ]. Commissioning dementia services is therefore also complex [ 29 ]. Such complexities mean many people with dementia and their families are burdened with care costs and inadequate support [ 4 ].

The PrAISED programme

The Promoting Activity, Independence and Stability in Early Dementia and Mild Cognitive Impairment (PrAISED) programme is a complex intervention which aims to keep people living with dementia independent and healthier for longer [ 11 , 25 ]. PrAISED was developed by physiotherapists, occupational therapists, health psychologists, nurses, geriatricians, and carer representatives [ 11 ] and was tested in a feasibility study [ 25 ]. It is a 12-month exercise and activity-based programme consisting of progressive strength, balance and dual task exercises, functional activities and activities of daily living training, risk analysis, advice, and environmental assessment, all delivered using a motivational approach to support long-term participation in physical activity [ 11 ]. The effectiveness of the PrAISED intervention was studied in the PrAISED-2 multi-site, pragmatic, Randomised Controlled Trial (RCT), which took place between September 2018 and January 2023 [ 6 , 28 ]. Before the results of PrAISED-2 were available and in anticipation of an implementation phase, the current study aimed to explore the views of commissioners and stakeholders on this matter and to inform the commissioning and implementation of wider health and social care dementia interventions.

Given the complexities of commissioning, the current study aimed to identify barriers and facilitators for commissioning and implementing health and social care interventions for people with dementia, using a dementia-friendly exercise and physical activity-based intervention (PrAISED) as a case study and to provide recommendations for future implementation.

Ethical approval

The study received research governance approvals and ethical approval from the Bradford Leeds Research Ethics Committee (18/YH/0059; 236099).

Study design

The Consolidated Framework for Implementation Research (CFIR) [ 17 ] was used as a theoretical framework for the study, to guide the methods, such as the development of the topic guide, and for data analysis (see data analysis section). This framework was chosen as it is comprehensive and is commonly used in implementation research enabling comparisons with other studies. Qualitative, semi-structured interviews were used for data collection. Participants were asked to consider PrAISED in their answers, even if they had not been involved in the PrAISED RCT (see Table A1 in Appendix : interview topic guide).

Participant recruitment

Participants were stakeholders involved in the commissioning and delivery of dementia services. An introductory email was sent out to potential participants and/or contacts from pre-existing networks known to the research team. This included individuals working in the NHS/healthcare, social care, local authorities, the VCS, and other key stakeholder organisations concerned with commissioning, implementing, delivering, or promoting activity-based interventions for people with dementia and/or mild cognitive impairment. Participants were provided with an information sheet and a consent form which was completed prior to their interview. Two researchers (RT and RV) conducted the interviews, all of which were carried out, recorded, and transcribed using Microsoft Teams. Any identifiable information was removed from the transcripts and participants were assigned a participant number. A ‘snowball’ (chain-referral) sampling technique was employed to identify additional participants, who were contacted via email.

Data analysis

Data analysis was carried out using codebook thematic analysis [ 13 ]. This type of thematic analysis uses a structured approach with predetermined themes and codes, or a research framework, to guide the analysis [ 13 ]. This study used the CFIR [ 17 ] as a codebook, thus the transcripts were coded according to the CFIR constructs to identify the barriers and facilitators to commissioning and implementing health and social care interventions for people with dementia from the perspectives of the participants.

The CFIR was developed to consolidate published implementation theories into a consistent typology for use in evaluating implementation [ 17 ]. Since its publication in 2009, the CFIR has grown in recognition and is now used widely across mixed method, quantitative and qualitative studies [ 31 ]. The CFIR consists of five domains: intervention characteristics, outer setting, inner setting, characteristics of individuals involved, and process of implementation. Across these domains are 39 constructs, full details are available at Damschroder et al. [ 17 ] or https://cfirguide.org/ .

Approximately halfway through the data analysis, revised CFIR guidelines were published updating constructs and their definitions [ 18 ]. The methodological implications of this publication were considered collectively by the research team, and the team came to a consensus that the new/expanded constructs from the updated CFIR would be incorporated where relevant to the analysis. As per the updated CFIR framework, the research team worked collaboratively to define each domain in this study. The domains and their constructs used in this study are presented in Table  1 . Constructs that were added, revised or renamed after the publication of the updated CFIR are denoted by *.

Data analysis process

NVivo software version 13 [ 38 ] and a CFIR-approved pre-populated template [available at https://cfirguide.org/tools/tools-and-templates/ ] were used to analyse the data; additional constructs were added where appropriate.

Braun and Clarke’s [ 12 ] and Braun et al.’s [ 13 ] thematic analysis steps were amended and/or combined to reflect the methods used in this study (codebook thematic analysis), which had predetermined codes and themes determined by the CFIR framework. Data analysis followed these steps:

Familiarisation (repeatedly reading transcripts and making notes about content)

Preliminary coding (preliminary coding into relevant constructs as per the CFIR codebook [available at https://cfirguide.org/tools/tools-and-templates/ ] and documenting rationale for coding decisions

Revising and revisiting coding/theme development (data revisited to check interpretations and amend if needed as researchers became more familiar with the data)

Finalising codes/themes (codes finalised within the research team)

Producing the report

Although these steps are presented as a sequence, data analysis followed an iterative process, with each step being revisited and revised. The lead author (RT) acted as lead coder for this study. A second coder (RV) reviewed a third of the transcripts to act as a peer-checker and reviewer of coding decisions. To improve understanding and collaborative use of the CFIR framework, the lead coder, second coder and wider implementation study team met weekly to discuss coding decisions.

A total of 14 participants took part in interviews. Participants included commissioning managers ( n  = 4), service managers ( n  = 3), charity representatives ( n  = 1), partnership managers (responsible for developing and managing strategic partnerships between organisations) ( n  = 1), commercial research specialists ( n  = 1), academics/researchers ( n  = 2), and healthcare professionals ( n  = 2), working across a range of settings including universities, research centres, the VCS, health and social care, and local government. Interviews lasted between 25 and 68 min. Of the 40 constructs (39 original CFIR constructs, plus one from the updated CFIR [ 18 ]) (Table  1 ), six had no entries during the analysis. These were: two constructs from the innovation characteristics domain (relative advantage and trialability), one from the inner setting domain (learning climate), two from the individual characteristics domain (self-efficacy and individual identification with organisation), and one from the process domain (executing). The remaining constructs were used as codes and were representative of extracts from the interview transcripts. The most frequently coded constructs were 1) needs and resources of those served by the organisation (outer setting), 2) available resources (inner setting), and 3) cosmopolitanism/partnership and connections (outer setting). Table 2 shows the frequency of coding for each construct (though frequency does not necessarily reflect importance), along with their classification as a barrier, facilitator, or both.

As barriers and facilitators to the implementation of dementia friendly activity-based interventions were identified across all domains, this paper presents each domain and discusses barriers and facilitators within them, before presenting key meta-themes and considerations for the wider commissioning and implementation climate as part of the discussion.

Innovation characteristics

The innovation source, evidence strength and quality, adaptability, complexity, design quality and packaging, and cost, all represented barriers and facilitators. The PrAISED intervention was coproduced with patient and public representatives and healthcare professionals [ 11 ]. Interviewees suggested coproduction was integral to successful implementation as the individual tailoring was seen to enhance participation, and the involvement of healthcare professionals provided reassurance of its effect:

‘…the fact that it’s also being developed with health professionals is something that’s really quite to its favour, because I think we find that people really look for reassurance from medical professionals, so if they know it’s got that medical endorsement, I think for us would be really positive,’ Participant 2 (Activity Manager).

Another facilitator was the innovation’s ability to be adapted to suit local systems. Several participants suggested that implementation would be facilitated and/or would be more likely to be commissioned if the innovation could be embedded within existing services:

‘I think if it’s something that you can almost add on to an existing provision… so you do have some of that skilled workforce, you have that management structure around it… some of the concerns of commissioners is when you end up with lots of small and then potentially vulnerable services… it just helps because you know you've got that capability there that could be mobilised rather than if you're starting from scratch,’ Participant 1 (Commissioner).

Some suggested utilising day services and/or care homes to deliver an intervention like PrAISED would keep costs down, utilise already existing services and upskill existing staff.

Another facilitator was the potential to use other professionals to deliver PrAISED in practice. In the main trial, PrAISED was delivered by occupational therapists, physiotherapists, and rehabilitation support workers. Participants in the current study suggested other professionals, such as exercise instructors, could take on responsibility for delivering a dementia friendly, exercise-based intervention and would be qualified to do so (discussed in greater depth in the individual characteristics domain). Interestingly, this view differed from those of healthcare professionals interviewed as part of a pilot PrAISED service, who felt it was essential healthcare professionals delivered exercise interventions for people living with dementia [ 1 ]. It was suggested this potential adaptation had collateral benefits for cost, and could reduce the demand on the existing workforce, utilise an untapped workforce and improve collaborative working with the local community, for example, leisure centres.

Evidence was a significant factor and facilitator in the commissioning of an intervention like PrAISED:

‘It’s an area that you’ve got to have as much efficacy evidence as possible… that is what is going to determine the success,’ Participant 7 (Commercial Director).

‘If the evidence isn’t there to support it, then it's not going to be there ultimately,’ Participant 12 (Partnership Manager).

One strand of evidence that was particularly pertinent to successful commissioning was the intervention’s ability to deliver cost savings and where these would be visible, for example, in health as opposed to social care budgets. However, this was deemed difficult to evidence. Participants 13 and 14, both commissioning managers, described the importance of interventions delivering cost savings in influencing decisions and allocating funds:

‘If we can start to evidence that this is delaying or improving outcomes… that would help massively… It’s like that invest to save sort of thing, isn’t it? If we can really show some evidence around that… then I think that you've got more of a chance,’ Participant 13 (Commissioning Manager).

‘Delaying need for social care is a really big thing for us. So, if an organisation came and said look, we can prevent people hitting your services for a long time, that's a really big driver for us, and like promoting independence, so, even if people are using our services, they’re using them less and living at home longer,’ Participant 14 (Commissioning Manager).

Also, participants working outside of commissioning recognised how crucial evidence was to the decision-making process:

‘It’s also important to show that there’s evidence… certainly some people in commissioning are a bit swayed by evidence or are very sceptical about things unless there’s evidence,’ Participant 8 (Professor of Dementia Research).

Interestingly, participant 7 described how different ‘levels’ of evidence would be required, depending on the system of delivery. For example, lower-level evidence would be required if the intervention were to be self-funded, as it would be an ‘emotional purchase’ by family members and/or carers, whereas:

‘…if it’s a statutory service provision model [local authority or NHS], then the bar is higher in terms of the amount of certainty that they would need in order to commission it and that might be certainty around patient outcomes, deferred benefit, cost versus benefit, cost benefit analysis… with limited budgets and competing demands for resources, they want to put their bets on the horses that are going to get them the biggest returns. Otherwise, it might fall into that nice to have, but not essential, which is really hard,’ Participant 7 (Commercial Director).

Whilst evidence of RCT outcomes was mostly advocated, other forms of evidence, such as qualitative research, were also important:

‘… it’s about showing real life stories and the positive impact it can have on someone’s life… I think that's really powerful,’ Participant 6 (Sports Development Officer).

Outer setting

Most participants reported that there is a need for dementia friendly activity-based interventions. Participants recognised the benefits of physical activity, and many proactively promoted this. Some reported that there were vast amounts of initiatives which aimed to engage people with long term conditions in physical activity and exercise. However, importantly, these were mostly deemed unsuitable for people living with dementia:

‘You need to have sort of a specific understanding of their needs and what’s going to be most likely to support them into activity and help them to maintain that… often people with dementia, when we're talking to them about some of the services and support that we're providing, they find it a little bit harder to relate to some of the messaging and a bit harder to undertake some of the activities… they need to be communicated in a particular way and they need to take into consideration their ability level and just them as a whole person,’ Participant 2 (Activity Manager).

There were few dementia specific or dementia friendly services currently being provided, though participant 10 reported that there was ‘ an appetite definitely to improve the provision or enhance the provision or create the provision to start with .’ Participants described the post-diagnostic support as lacking, and at worst, absent:

‘We have a gap… the post-diagnostic offer to people with dementia is pretty woeful,’ Participant 8 (Professor of Dementia Research).

Participants described efforts in their organisation and/or local area to provide or promote dementia friendly interventions, such as dementia friendly swimming and golf. However, what was evident across the data was a need to map what was already available, and to evaluate the needs of the local population living with dementia, including marginalised and underserved communities. Participants attempted to address unmet need and deficits in specialist dementia knowledge through training and education for care home and day centre staff, and dementia specialist accreditation. Some described using roles such as social prescribing (referrals from healthcare professionals to local non-clinical services [e.g., volunteering, sports groups etc.] with the aim of holistically improving health and wellbeing [ 14 ]) to engage this population in exercise, and others created dementia hubs and strategies to support local priorities. Participants identified several barriers to engaging their local community of people living with dementia in physical activity. This included fear and anxiety, avoidance of activity perceived as risky, lacking support, poor awareness of available services, and lacking infrastructure and transport links, which were troublesome in rural areas.

Participants considered an intervention like PrAISED to be an important component in addressing the post-diagnostic support gap which could play an important role in preventing health and social care use. This was a particular concern in the face of exponential growth in the number of people living with dementia. For some, this underpinned the demand for services like PrAISED:

‘It is critical because we are very limited in the resources we have, so everything you can do to keep people at the lower levels of care for as long as possible are critical and keep people in their own homes wherever possible… anything that supports that kind of left shift to our demand management is really critical,’ Participant 1 (Commissioner).

Early support was deemed necessary to not only prevent health and social care consumption, but also to enhance quality of life and promote meaningful activity and engagement in all aspects of life.

A significant facilitator to providing dementia friendly services was collaborative working and the formation of partnerships and connections with other organisations and stakeholders. Participants were hopeful that health service organisational changes (to Integrated Care Systems (ICS) [ 16 ] would improve collaborative working and align commissioning priorities across health and social care in England. Despite optimism regarding these new partnerships, there was confusion surrounding the responsibilities of these groups and concerns that this would complicate the commissioning process. Additionally, competing priorities between organisations attempting to work cohesively posed a challenge.

Nonetheless, these partnerships were imperative to effective commissioning. Most participants emphasised the importance of the voluntary sector in the provision of dementia friendly services (if commissioned to do so). Many stakeholders had experience working with charities in the design, delivery and maintenance of dementia services and they advocated for their presence as specialists in dementia. Some suggested these organisations were best placed to deliver services (if appropriately commissioned) as they had the time, resources, and specialist knowledge to do so. Alongside charities and the voluntary sector, stakeholders described collaborations with national sporting agencies such as Sport England and other partnerships, including universities, place-based partnerships, social enterprises, the Fire and Rescue Service, community groups, commercial advisors, professional sports teams, and health and social care organisations. These partnerships were seen to facilitate service sustainability and long-term presence in the community.

Organisational partnerships also facilitated the financing of dementia friendly services. These organisations had grants which could fund services, though these were often short lived. Financing was a significant barrier to the commissioning and implementation of dementia friendly interventions. There were tensions between the responsibility for funding:

‘Personally, I think [the] NHS should give us money towards it if they want us to implement it… it will have a knock-on effect on the admissions because if we reduce falls for a longer period of time, it means they’ve got less operations to do and less throughput of hospitals,’ Participant 4 (Occupational Therapist).

The private versus public funding debate was influenced by several factors. Some reported private financing of services was a feasible method for delivering interventions like PrAISED. In contrast, public funding was regarded as difficult to obtain and was frequently linked to other constructs, such as external policy and incentives, and available resources in the inner setting. The VCS thus frequently bridged the gap, and there was a reliance on this sector, which was not without consequences:

‘It is a difficult one because it it’s one of the areas where there is a lot of reliance on almost free services as in non-funded services so that they're either a charitable or community… which means it’s quite piecemeal and quite localized. So, it’s quite hard,’ Participant 7 (Commercial Director).

In terms of what drove the commissioning and implementation of dementia friendly services in the outer setting, there was little reference to peer pressure, though participant 9 highlighted the importance of being aware of what competing organisations were doing and what services were already available. A more commonly cited construct was external policy and incentives. There were conflicting views on the value of external policy and incentives in influencing the commissioning and implementation of dementia friendly services, where it was seen as sometimes a facilitator and at other times, non-influential:

‘We always say “oh policy drives action,” but it doesn’t always… At the end of the day, policy is slightly important… this is my own view, [NHS] Trusts tend not to buy things because of policy. Trusts buy things because it solves a problem for them,’ Participant 7 (Commercial Director).

However, other participants felt policy acted as a facilitator:

‘The easiest way to get it funded is where actual national policy says you must have X service in place. That’s the easiest thing. And you have ring fenced money… it’s really hard if you don’t have that… if we’ve got a national policy, we do have to respond to it,’ Participant 1 (Commissioner).

They went onto suggest external monitoring, performance management and Key Performance Indicators (KPIs) also facilitated commissioning.

Local strategy and policy were also seen to both facilitate and hinder implementation, as budgets would be allocated accordingly:

‘I think probably the one of the main factors is it being a strategic priority locally, because then you’ve got the buy in from the whole system and at the top. So, if it ain’t a strategic priority, then even if it is really good, it might not continue to be funded because of the things which are meeting those strategic priorities will likely get more resources allocated because budgets will be allocated on what are those strategic priorities,’ Participant 5 (Commissioning Manager).

Financial incentives and penalties which are used across OECD (Organisation for Economic Co-operation and Development) member countries to motivate performance in health systems [ 34 ] were also perceived facilitators:

‘I suppose targets and financial incentives or financial pen- well incentives are better than penalties, but usually in the NHS is about punishment. So, you know some sort of stimulus that’s hard for them to ignore. So simply giving them advice that they should is “well, we can ignore that then.” So, it needs to be a bit of force behind it to make people actually implement things,’ Participant 8 (Professor of Dementia Research).

Inner setting

Participants described a need to shift the culture of commissioning from short to long term. Several participants expressed concern that commissioners focussed on ‘crisis management’ due to the NHS climate, rather than on preventative interventions that would provide cost efficiency savings longer term. It was perceived as more difficult to achieve buy-in to such interventions, as often cost savings were not immediately visible. Physical activity and public health interventions were perceived as key to preventative care, and whilst there was a shift towards these types of interventions, there was still work to be done:

‘…in terms of how much we value we place on physical activity in terms of prevention and treatment for long term conditions… I don’t think we’re quite where we should be with that… the health service has been increasingly crisis weighted and I think that limits how much we think about building in preventative or wellbeing factors into primary services,’ Participant 12 (Partnership Manager).

There was a shift in culture towards collaborative working, both within the inner setting (networks and communications), and outer setting (cosmopolitanism/partnerships and connections). However, inner setting decision making processes remained complex and, at times, posed a barrier to commissioning and implementation. Indeed, for participant 11, they had observed how networks facilitated implementation, but also introduced biases, causing them to question the system:

‘I seem to find if they like something and they have a good relationship with an organisation, funnily enough, that sometimes leads to funding and renewal of funding… it would be nice to think it is a fair process… but I think with a lot of things particularly that are NHS system based is that they're very rigid in what they want them to achieve and although they may say that they’re person-centred, really, they’re system-centred and then the person is expected to fit in with that,’ Participant 11 (Researcher).

As described earlier, there was an identified need for dementia friendly activity-based interventions. For three participants, their views met the criteria for coding under the construct tension for change, as they viewed the current situation as intolerable or requiring urgent change. Nonetheless, this was subject to challenges. It was important for any innovation attempting commissioning and/or implementation to be compatible with the existing local systems. For example, whether the innovation could be embedded or absorbed into existing services (compatibility), which is linked to the adaptability construct (innovation characteristics). This was a significant facilitator for implementation success.

Furthermore, the relative priority of the innovation was both a barrier and facilitator. Priorities within the commissioning cycle could prevent similar services from being commissioned. For example, participant 5 suggested that if a falls prevention programme had recently been commissioned, other dementia friendly activity-based interventions would be a lower priority for commissioning. Moreover, the wider social, political, and economic climate also shifted commissioning priorities; the most recent example being the COVID-19 pandemic, where public health and pandemic management were inevitably given greater priority. Furthermore, organisational rewards, measurement and KPIs acted as incentives to implement innovations, but only if local priorities and strategies deemed dementia care and falls prevention a priority. More so, should the innovation align with the goals and mission statement of the organisation, this too would escalate the priority of commissioning and implementation.

One of the most significant and highly cited barriers to commissioning and implementing dementia friendly services was a lack of available resources. This included workforce, time, capacity, available providers, and most significantly, funding. Appropriate (and long-term) funding to commission, implement and deliver an innovation was difficult to secure. Often, budgets were already allocated and thus, unavailable:

‘The real challenge we have got of course is there isn’t new money, there isn’t spare money,’ Participant 1 (Commissioner).

Considering the vast array of contextual factors represented across the CFIR constructs, it is significant that participants often came back to the topic of resources. This issue was shared across the stakeholders, including those with commissioning responsibilities, who expressed frustration that they were unable to commission innovations:

‘There isn’t a lot of money… this is a really frustrating thing that you get all these people coming to you with some really good things [innovations], but we don’t really have money for spending on these things anymore,’ Participant 14.

In the context of limited resources, the NHS was suggested to be the most suitable provider of a service like PrAISED:

‘The problem for dementia is that much of it falls between health and social care. Social care is so poorly funded that it is difficult to see it doing a great deal… probably for it to become more widespread the way things currently are, it would require NHS commissioning, I think are the only people with any money,’ Participant 8 (Professor of Dementia Research).

In addition to funding, inadequate staffing levels and capacity of existing staff hampered implementation. Staff would be required to take on additional workload or redirect time from other services to implement innovations, which was undesirable. This was also the case for allocating time for training. Some suggested additional staff could be hired to facilitate implementation; however, this was associated with greater costs, temporary contracts, and thus, job insecurity. The demands of a lengthy programme like PrAISED (delivered over 12 months) was deemed unfeasible, as participant 4 described when looking to implement Otago, a home-based balance and strengthening programme effective at reducing falls in over 65 s [ 15 ]:

‘The main thing is time and follow ups. We just can’t… Otago’s 12 months. We can’t do it. We can’t do it,’ Participant 4 (Occupational Therapist).

Although leadership engagement (such as service managers) could facilitate this, resources frequently dictated the success of commissioning and implementing innovations.

Individual characteristics

The characteristics of individuals responsible for commissioning, implementing and delivering interventions like PrAISED, acted as potential facilitators to success. Participants identified areas where knowledge could be instilled to upskill caregivers (formal and informal) to engage people living with dementia in physical activity interventions. Furthermore, the knowledge of and belief in such interventions acted as a driver. Individuals’ stage of change [ 18 ] thus could initiate service development; for example, when asked what a persuading factor in the commissioning and implementation of a dementia friendly intervention could be, participant 6 stated:

‘I wouldn’t need persuading because I’m completely on board with it,’ Participant 6 (Sports Development Officer).

As mentioned earlier (innovation characteristics), many participants suggested the intervention could be delivered by other professional groups, such as exercise instructors, personal trainers, domiciliary care workers and support workers/therapy assistants. This was captured under the other personal attributes construct of the individual characteristics domain. Professional groups outside of physiotherapy and occupational therapy were suggested as potential deliverers of interventions like PrAISED due to their cheaper cost, connections to local communities (e.g., gyms, leisure centres, community groups), and their perceived undervalue as an untapped workforce with relevant skills. Furthermore, difficulty in recruiting clinicians and the pressure existing clinicians were under were acknowledged and thus, alternative groups taking responsibility for an intervention like PrAISED would ease pressure.

Most participants expressed a growing appreciation of exercise professionals in delivering physical activity interventions:

‘…there are thousands of physical activity exercise professionals who are highly qualified… Let’s use that workforce. Why not? You know, they are an untapped workforce and there’s a lot of them out there who are already got those connections in the community… they’ve got those behaviours, skills and those motivational interviewing techniques to work with those individuals and then perhaps to support the carers directly as well as those are being cared for. So huge opportunities there,’ Participant 10 (Project Manager).

Many suggested these members of the workforce were qualified and competent to deliver an intervention like PrAISED, with many having undergone specialist training in long term conditions. Thus, it was not always deemed necessary to have registered clinical qualified healthcare professionals’ oversight, though some suggested clinicians could work collaboratively to oversee the programme with exercise professionals delivering the intervention. The use of an existing, untapped workforce could impact the success of commissioning, though this had implications for the intervention:

‘…with all the pressures in the system, with workforce, the interventions that can be delivered successfully, carefully, safely, but with the lowest level of staff training required are very appealing… what is the lowest level of staff that you could utilize on this without making it unsafe or ineffective?’ Participant 7 (Commercial Director).

Some suggested having non-registered clinical staff delivering the intervention would be the most realistic option for commissioning and implementing a service such as PrAISED.

References to planning the implementation process were mostly dominated by the planning of commissioning. As this work package was not reflecting retrospectively on an implemented service, participants spoke hypothetically about this process. The greatest concern was how to plan the business case or model to facilitate successful commissioning/securement of funding. These concerns were mostly related to other constructs such as financing (outer setting) and available resources (inner setting). Other concerns were regarding the organisational model within local systems, such as commercialisation and licencing and how these would be managed in the future, as this had implications for an intervention’s sustainability. Additionally, participants suggested it was imperative to be cognisant of the commissioning cycle and plan attempted business cases accordingly, as this could affect success. Participant 5 described it as being ‘in the right place, at the right time.’

In the case of the English NHS, having a range of engaged individuals was integral to implementation success. Participants provided several examples, including opinion leaders (e.g., leaders in dementia research, dementia advocates), formally appointed implementation leaders (e.g., project leads, healthy aging leads), external change agents (e.g., opinion leaders, politicians, councillors, commissioners, advisors, television personalities Footnote 1 ), champions (self and/or formally appointed), key stakeholders (healthcare professionals, staff, organisations), and innovation participants (service users and caregivers). These champions were considered key to driving the implementation process, particularly when faced with challenges or decreasing momentum:

‘We do need to have if you want to call [them] falls, champions or dementia champions, if that’s the right word, but more ambassadors or business change agents…. Within those day services who can take a bit of ownership and accountability to ramp up that effort, ’ Participant 9 (Programme Manager [Commissioning]).

‘…it’s enthusiasm and passion for me that’s such an important driver,’ Participant 11 (Health and Activity Researcher).

Reflection and evaluation were critical parts of the implementation process for some participants and was something that needed to be built in as part of the planning process. This was important to not only evaluate implementation success and ‘continuous improvement,’ but to provide lessons for future implementation.

The aim of the current study was to explore the barriers and facilitators to commissioning and implementing health and social care interventions for people with dementia in England, using a dementia-friendly exercise and physical activity-based intervention (PrAISED) as a case study. We found facilitators and barriers mapped onto the CIFR [ 17 ] which showed:

The credibility and cost-saving nature of the intervention was important, along with the ability to adapt it to local provision and skill mix.

Interventions such as PrAISED may fill the post-diagnostic gap, but there needs to be an organisational system that will get them commissioned; this involves collaboration between commissioners, providers and other stakeholders, including dementia advocates and caregivers.

There also needs to be a policy culture that values prevention, prioritises dementia and is willing to commit resource to it to make it work.

The post-diagnostic gap

The post-diagnostic gap is defined as ‘ an umbrella term encompassing the variety of official and informal services and information aimed at promoting the health, social, and psychological wellbeing of people with dementia and their carers after a diagnosis. Integrated treatment, care, and support are the pillars of effective post-diagnosis models,’  [ 23 ], p.21). This was a common theme in this study and is a global problem [ 22 , 26 ], despite efforts designed to address this [ 10 , 35 ].

Consequently, there is a need for innovations that address the service gap. Many participants advocated for physical activity interventions, though they also identified a broader need for psychosocial, emotional, logistical, practical, and peer support. This echoes the findings of Bamford et al. [ 8 ], who identified 20 components of post-diagnostic support, extending across five themes (timely identification and management of needs,understanding and managing dementia,emotional and psychological wellbeing; practical support; and integrating support). Bamford et al. [ 8 ] suggested there is a need for local planning and coordination of such services, and there was evidence of this in this study, though wider barriers to commissioning and implementation had the potential to hamper efforts.

This study’s findings reflect other literature exploring barriers and facilitators to commissioning and implementing post-diagnostic services. Wheatley et al. [ 41 ] identified unsupportive infrastructure, limited proactive, holistic tailored support, and limited capacity and capability as barriers to implementation. They identified strategies to address this, such as creating opportunities for service improvement, facilitating collaborative working, supporting non-specialists (e.g., non-medically qualified healthcare professionals) to deliver dementia care, and the development of ongoing holistic support [ 41 ]. The current study provides evidence that these strategies are being undertaken, though there is more to be done to enhance collaboration and the utilisation of existing workforces.

Some research suggests that physical activity interventions for older people can be delivered safely and effectively by non-clinically registered professionals (e.g., exercise instructors, postural stability instructors) [ 30 ] and can be delivered in novel environments outside of traditional healthcare settings [ 32 ]. Furthermore, a physical activity intervention for older people with cognitive impairment, delivered by exercise instructors, showed promising improvements in physical and cognitive function, quality of life and caregiver burden, though the sample size was small [ 9 ]. Therefore, the delivery of physical activity interventions by these professionals may offer a solution to the commonly cited barrier of available resources, which was recommended by Wheatley et al. [ 41 ].

The culture of commissioning in England

This study identified the need for a policy culture that values prevention. In the UK, prevention of ill health is described as a role for individuals, communities, NHS, social care, public health, and local and national government [ 19 ], and is a global priority [ 42 ]. However, these findings demonstrate the complexities of prevention in practice in a universal publicly funded health system.

Interventions like PrAISED are preventative and they were considered harder to secure commissioning commitment. Participants suggested this was twofold: 1) the benefit of such interventions was not immediately visible, and 2) commissioning was focussed on short term ‘crisis management.’ Participants suggested the underappreciation of preventative services meant interventions that may provide longer term cost savings were harder to gain support for and thus implement. This was coupled with difficulty in evidencing cost savings, particularly as commissioners wanted to be able to evidence specifically where cost savings would be delivered, e.g., health or social care. Despite this, participants with commissioning responsibilities were generally acutely aware of the need for preventative services, with some creating dementia strategies and influencing local priorities to address this. Nonetheless, this has the potential to create fragmentation and inequity across sectors and geographies. Furthermore, despite actions to address this, commissioners were also subject to the barriers to commissioning and implementation identified in this study.

In the wider literature, the discourse surrounding joint commissioning emphasises prevention [ 21 ]. Miller et al. [ 33 ] suggest delaying deterioration and maintaining physical and mental health in older people (and thus, their use of health services) is a commonly cited aspiration in commissioning (e.g., [ 2 ]). However, it appears the ability to exercise this rhetoric is limited in the face of competing priorities and restricted resources (affordability). In this study, the VCS was seen as an able facilitator and provider of preventative care, something earlier suggested by Miller et al. [ 33 ]. While there have been successful examples of this, the issues with demonstrating preventative and rehabilitative services, as well as the need to rebalance the system with such care being integrated [ 2 ], continue to pose challenges in commissioning.

The current study has considered the commissioning and implementation of dementia friendly exercise and physical activity-based interventions using PrAISED as a case study. It has identified key considerations for the future of dementia care, particularly in relation to provision of post-diagnostic support and the culture of commissioning in contemporary healthcare. Furthermore, it has identified barriers (cost/financing, the culture of commissioning, and available resources) and facilitators (adaptability of the intervention, cosmopolitanism/partnerships and connections, external policy and incentives, and use of already existing workforces) to commissioning dementia friendly services. Thus, this study provides insight for stakeholders planning the commissioning, implementation and promotion of dementia services.

Recommendations for commissioning and implementing dementia services

A series of recommendations have been collated based upon the barriers and facilitators identified in this study:

Map out local needs and resources

The needs and resources of the population living with dementia and their caregivers should be identified (including the needs of underserved communities)

Involve people living with dementia and their caregivers in identifying these needs

Map existing services (and how/where the intervention would fit)

Evidence the intervention

Evidence the outcomes of the intervention, including effectiveness and cost-effectiveness (e.g., physical and mental health, psychosocial factors, and financial such as cost benefit analysis, patient and deliverer satisfaction [e.g., qualitative data]), to ensure stakeholders value the innovation and its potential impact to ensure it is commissioned/funded and integrated into routine clinical practice.

Create/utilise networks and partnerships with stakeholders with a role in implementing, commissioning, providing, and promoting dementia friendly interventions

Identify local/organisational priorities, resources, and opportunities for collaboration to facilitate commissioning and implementation

Involve these networks and partnerships in the early stages to plan for sustainability

Plan required resources for delivery (cost, staffing, equipment)

Assess capacity in the local system for non-medical professionals delivering exercise and physical activity interventions (e.g., exercise instructors), where able to do so safely and appropriately.

Strengths and limitations

This study presents the perspectives of a small number of stakeholders thus they will not necessarily represent the views of all stakeholders involved in dementia care or commissioning. As this study was carried out in England, the views may not be representative of stakeholders in other countries and care systems. As this study aimed to investigate the views of those with direct responsibility for commissioning and implementing health and social care interventions, we did not include people with dementia or their caregivers in the interviews. These persons could have important insights into the commissioning and implementation of health and social care interventions for people with dementia; hence, this is a limitation of the study and an area which could be explored in future research.

A strength of the study was the range of perspectives and expertise collected, as all participants were involved in dementia services commissioning and provision. Furthermore, the collective discussion of coding decisions within the wider implementation research team meant a range of perspectives were utilised during data analysis.

This study identified several barriers and facilitators to the commissioning and implementation of health and social care interventions for people with dementia, using a dementia-friendly exercise and physical activity-based intervention (PrAISED) as a case study. Key barriers to commissioning and implementing dementia specific services included their cost/financing, competing commissioning priorities and having available resources. Key facilitators included the adaptability of the intervention, having good partnerships and connections in place, external policy and incentives, and the use of already existing (and untapped) workforces.

Based on the results of this study, four actions are recommended to facilitate the commissioning and implementation of interventions like PrAISED: 1) map out local needs and resources, 2) evidence the intervention including effectiveness and cost-effectiveness, 3) create/utilise networks with stakeholders, and 4) plan required resources. Further research is required to explore the outcomes of proposed recommendations.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available to honour the privacy and confidentiality of participants but are available from the corresponding author on reasonable request.

One participant identified television actress Vicky McClure who had worked extensively with a dementia choir, increasing awareness of the condition (see https://www.ourdementiachoir.com/about-the-choir ).

Abbreviations

Clinical Commissioning Group

Consolidated Framework for Intervention Research

Integrated Care System

National Health Service

National Institute for Health and Care Excellence

Organisation for Economic Co-operation and Development

Promoting Activity, Stability and Independence in Early Dementia and Mild Cognitive Impairment

Voluntary and community sector

World Health Organisation

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Acknowledgements

The authors would like to thank all participants who took part in this research.

This project was funded by the NIHR Programme Grants for Applied Research funding scheme [RP-PG-0614-20007]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

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Conceptualisation: EA, RV, SG, JG, TM, RH Methodology: RV, EA, JG, EO, ST, SG, RH Data collection: RT, RV Data analysis: RT, RV, EA, CB, JL Writing- original draft: RT Writing- review and editing: RT, RV, EA, CB, JL, SG, JG, TM, EO, ST, RH Implementation research expertise: EO, ST, JG All authors reviewed the manuscript and agreed to its submission and publication.

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Rachael Tucker is a Scientific Editor at Elsevier Cell Press. The work presented in this paper was carried out whilst RT worked as a Research Assistant at the University of Nottingham. All other authors have no competing interests to declare. The study was funded by the NIHR Programme Grants for Applied Research funding scheme [RP-PG-0614-20007]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

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Tucker, R., Vickers, R., Adams, E.J. et al. Factors influencing the commissioning and implementation of health and social care interventions for people with dementia: commissioner and stakeholder perspectives. Arch Public Health 82 , 54 (2024). https://doi.org/10.1186/s13690-024-01283-8

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In 2024, Penn Global will support 24 new faculty-led research and engagement projects at a total funding level of $1.5 million.

The Penn Global Research and Engagement Grant Program prioritizes projects that bring together leading scholars and practitioners across the University community and beyond to develop new insight on significant global issues in key countries and regions around the world, a core pillar of Penn’s global strategic framework. 

PROJECTS SUPPORTED BY THE HOLMAN AFRICA RESEARCH AND ENGAGEMENT FUND

• Global Medical Physics Training & Development Program  Stephen Avery, Perelman School of Medicine
• Developing a Dakar Greenbelt with Blue-Green Wedges Proposal  Eugenie Birch, Weitzman School of Design
• Emergent Judaism in Sub-Saharan Africa  Peter Decherney, School of Arts and Sciences / Sara Byala, School of Arts and Sciences
• Determinants of Cognitive Aging among Older Individuals in Ghana  Irma Elo, School of Arts and Sciences;  Iliana Kohler, School of Arts and Sciences
• Disrupted Aid, Displaced Lives Guy Grossman, School of Arts and Sciences
• A History of Regenerative Agriculture Practices from the Global South: Case Studies from Ethiopia, Kenya, and Zimbabwe Thabo Lenneiye, Kleinman Energy Center / Weitzman School of Design
• Penn Computerized Neurocognitive Battery Use in Botswana Public Schools Elizabeth Lowenthal, Perelman School of Medicine
• Podcasting South African Jazz Past and Present Carol Muller, School of Arts and Sciences
• Lake Victoria Megaregion Study: Joint Lakefront Initiative Frederick Steiner, Weitzman School of Design
• Leveraging an Open Source Software to Prevent and Contain AMR Jonathan Strysko, Perelman School of Medicine
• Poverty reduction and children's neurocognitive growth in Cote d'Ivoire Sharon Wolf, Graduate School of Education
• The Impacts of School Connectivity Efforts on Education Outcomes in Rwanda  Christopher Yoo, Carey Law School

PROJECTS SUPPORTED BY THE INDIA RESEARCH AND ENGAGEMENT FUND

• Routes Beyond Conflict: A New Approach to Cultural Encounters in South Asia  Daud Ali, School of Arts and Sciences
• Prioritizing Air Pollution in India’s Cities Tariq Thachil, Center for the Advanced Study of India / School of Arts and Sciences
• Intelligent Voicebots to Help Indian Students Learn English Lyle Ungar, School of Engineering and Applied Sciences

PROJECTS SUPPORTED BT THE CHINA RESEARCH AND ENGAGEMENT FUND

• Planning Driverless Cities in China Zhongjie Lin, Weitzman School of Design

PROJECTS SUPPORTED BY THE GLOBAL ENGAGEMENT FUND 

• Education and Economic Development in Nepal Amrit Thapa, Graduate School of Education
• Explaining Climate Change Regulation in Cities: Evidence from Urban Brazil Alice Xu, School of Arts and Sciences
• Nurse Staffing Legislation for Scotland: Lessons for the U.S. and the U.K.  Eileen Lake, School of Nursing
• Pathways to Education Development & Their Consequences: Finland, Korea, US Hyunjoon Park, School of Arts and Sciences
• Engaged Scholarship in Latin America: Bridging Knowledge and Action Tulia Falleti, School of Arts and Sciences
• Organizing Migrant Communities to Realize Rights in Palermo, Sicily  Domenic Vitiello, Weitzman School of Design
• Exploiting Cultural Heritage in 21st Century Conflict   Fiona Cunningham, School of Arts and Sciences
• Center for Integrative Global Oral Health   Alonso Carrasco-Labra, School of Dental Medicine

This first-of-its-kind Global Medical Physics Training and Development Program (GMPTDP) seeks to serve as an opportunity for PSOM and SEAS graduate students to enhance their clinical requirement with a global experience, introduce them to global career opportunities and working effectively in different contexts, and strengthens partnerships for education and research between US and Africa. This would also be an exceptional opportunity for pre-med/pre-health students and students interested in health tech to have a hands-on global experience with some of the leading professionals in the field. The project will include instruction in automated radiation planning through artificial intelligence (AI); this will increase access to quality cancer care by standardizing radiation planning to reduce inter-user variability and error, decreasing workload on the limited radiation workforce, and shortening time to treatment for patients. GMPTDP will offer a summer clinical practicum to Penn students during which time they will also collaborate with UGhana to implement and evaluate AI tools in the clinical workflow.

The proposal will address today’s pressing crises of climate change, land degradation, biodiversity loss, and growing economic disparities with a holistic approach that combines regional and small-scale actions necessary to achieve sustainability. It will also tackle a key issue found across sub-Saharan Africa, many emerging economies, and economically developed countries that struggle to control rapid unplanned urbanization that vastly outpaces the carrying capacity of the surrounding environment.

The regional portion of the project will create a framework for a greenbelt that halts the expansion of the metropolitan footprint. It will also protect the Niayes, an arable strip of land that produces over 80% of the country’s vegetables, from degradation. This partnership will also form a south-south collaboration to provide insights into best practices from a city experiencing similar pressures.

The small-scale portion of the project will bolster and create synergy with ongoing governmental and grassroots initiatives aimed at restoring green spaces currently being infilled or degraded in the capital. This will help to identify overlapping goals between endeavors, leading to collaboration and mobilizing greater funding possibilities instead of competing over the same limited resources. With these partners, we will identify and design Nature-based Solutions for future implementation.

Conduct research through fieldwork to examine questions surrounding Jewish identity in Africa. Research will be presented in e.g. articles, photographic images, and films, as well as in a capstone book. In repeat site-visits to Uganda, South Africa, Ghana, and Zimbabwe, we will conduct interviews with and take photographs of stakeholders from key communities in order to document their everyday lives and religious practices.

The overall aim of this project is the development of a nationally representative study on aging in Ghana. This goal requires expanding our network of Ghanian collaborators and actively engage them in research on aging. The PIs will build on existing institutional contacts in Ghana that include:

1). Current collaboration with the Navrongo Health Research Center (NCHR) on a pilot data collection on cognitive aging in Ghana (funded by a NIA supplement and which provides the matching funds for this Global Engagement fund grant application);

2) Active collaboration with the Regional Institute for Population Studies (RIPS), University of Ghana. Elo has had a long-term collaboration with Dr. Ayaga Bawah who is the current director of RIPS.

In collaboration with UNHCR, we propose studying the effects of a dramatic drop in the level of support for refugees, using a regression discontinuity design to survey 2,500 refugee households just above and 2,500 households just below the vulnerability score cutoff that determines eligibility for full rations. This study will identify the effects of aid cuts on the welfare of an important marginalized population, and on their livelihood adaptation strategies. As UNHCR faces budgetary cuts in multiple refugee-hosting contexts, our study will inform policymakers on the effects of funding withdrawal as well as contribute to the literature on cash transfers.

The proposed project, titled "A History of Regenerative Agriculture Practices from the Global South: Case Studies from Ethiopia, Kenya, and Zimbabwe," aims to delve into the historical and contemporary practices of regenerative agriculture in sub-Saharan Africa. Anticipated Outputs and Outcomes:

1. Research Paper: The primary output of this project will be a comprehensive research paper. This paper will draw from a rich pool of historical and contemporary data to explore the history of regenerative agriculture practices in Ethiopia, Kenya, and Zimbabwe. It will document the indigenous knowledge and practices that have sustained these regions for generations.

2. Policy Digest: In addition to academic research, the project will produce a policy digest. This digest will distill the research findings into actionable insights for policymakers, both at the national and international levels. It will highlight the benefits of regenerative agriculture and provide recommendations for policy frameworks that encourage its adoption.

3. Long-term Partnerships: The project intends to establish long-term partnerships with local and regional universities, such as Great Lakes University Kisumu, Kenya. These partnerships will facilitate knowledge exchange, collaborative research, and capacity building in regenerative agriculture practices. Such collaborations align with Penn Global's goal of strengthening institutional relationships with African partners.

The Penn Computerized Neurocognitive Battery (PCNB) was developed at the University of Pennsylvania by Dr. Ruben C. Gur and colleagues to be administered as part of a comprehensive neuropsychiatric assessment. Consisting of a series of cognitive tasks that help identify individuals’ cognitive strengths and weaknesses, it has recently been culturally adapted and validated by our team for assessment of school-aged children in Botswana . The project involves partnership with the Botswana Ministry of Education and Skills Development (MoESD) to support the rollout of the PCNB for assessment of public primary and secondary school students in Botswana. The multidisciplinary Penn-based team will work with partners in Botswana to guide the PCNB rollout, evaluate fidelity to the testing standards, and track student progress after assessment and intervention. The proposed project will strengthen a well-established partnership between Drs. Elizabeth Lowenthal and J. Cobb Scott from the PSOM and in-country partners. Dr. Sharon Wolf, from Penn’s Graduate School of Education, is an expert in child development who has done extensive work with the Ministry of Education in Ghana to support improvements in early childhood education programs. She is joining the team to provide the necessary interdisciplinary perspective to help guide interventions and evaluations accompanying this new use of the PCNB to support this key program in Africa.

This project will build on exploratory research completed by December 24, 2023 in which the PI interviewed about 35 South Africans involved in jazz/improvised music mostly in Cape Town: venue owners, curators, creators, improvisers.

• Podcast series with 75-100 South African musicians interviewed with their music interspersed in the program.
• 59 minute radio program with extended excerpts of music inserted into the interview itself.
• Create a center of knowledge about South African jazz—its sound and its stories—building knowledge globally about this significant diasporic jazz community
• Expand understanding of “jazz” into a more diffuse area of improvised music making that includes a wide range of contemporary indigenous music and art making
• Partner w Lincoln Center Jazz (and South African Tourism) to host South Africans at Penn

This study focuses on the potential of a Megaregional approach for fostering sustainable development, economic growth, and social inclusion within the East African Community (EAC), with a specific focus on supporting the development of A Vision for An Inclusive Joint Lakefront across the 5 riparian counties in Kenya.

By leveraging the principles of Megaregion development, this project aims to create a unified socio-economic, planning, urbanism, cultural, and preservation strategy that transcends county boundaries and promotes collaboration further afield, among the EAC member countries surrounding the Lake Victoria Basin.

Anticipated Outputs and Outcomes:

1. Megaregion Conceptual Framework: The project will develop a comprehensive Megaregion Conceptual Framework for the Joint Lakefront region in East Africa. This framework, which different regions around the world have applied as a way of bridging local boundaries toward a unified regional vision will give the Kisumu Lake region a path toward cooperative, multi-jurisdictional planning. The Conceptual Framework will be both broad and specific, including actionable strategies, projects, and initiatives aimed at sustainable development, economic growth, social inclusion, and environmental stewardship.

2. Urbanism Projects: Specific urbanism projects will be proposed for key urban centers within the Kenyan riparian counties. These projects will serve as tangible examples of potential improvements and catalysts for broader development efforts.

3. Research Publication: The findings of the study will be captured in a research publication, contributing to academic discourse and increasing Penn's visibility in the field of African urbanism and sustainable development

Antimicrobial resistance (AMR) has emerged as a global crisis, causing more deaths than HIV/AIDS and malaria worldwide. By engaging in a collaborative effort with the Botswana Ministry of Health’s data scientists and experts in microbiology, human and veterinary medicine, and bioinformatics, we will aim to design new electronic medical record system modules that will:

Aim 1: Support the capturing, reporting, and submission of microbiology data from sentinel surveillance laboratories as well as pharmacies across the country

Aim 2: Develop data analytic dashboards for visualizing and characterizing regional AMR and AMC patterns

Aim 3: Submit AMR and AMC data to regional and global surveillance programs

Aim 4: Establish thresholds for alert notifications when disease activity exceeds expected incidence to serve as an early warning system for outbreak detection.

  Using a novel interdisciplinary approach that bridges development economics, psychology, and neuroscience, the overall goal of this project is to improve children's development using a poverty-reduction intervention in Cote d'Ivoire (CIV). The project will directly measure the impacts of cash transfers (CTs) on neurocognitive development, providing a greater understanding of how economic interventions can support the eradication of poverty and ensure that all children flourish and realize their full potential. The project will examine causal mechanisms by which CTs support children’s healthy neurocognitive development and learning outcomes through the novel use of an advanced neuroimaging tool, functional Near Infrared Spectroscopy (fNIRS), direct child assessments, and parent interviews.

The proposed research, the GIGA initiative for Improving Education in Rwanda (GIER), will produce empirical evidence on the impact of connecting schools on education outcomes to enable Rwanda to better understand how to accelerate the efforts to bring connectivity to schools, how to improve instruction and learning among both teachers and students, and whether schools can become internet hubs capable of providing access e-commerce and e-government services to surrounding communities. In addition to evaluating the impact of connecting schools on educational outcomes, the research would also help determine which aspects of the program are critical to success before it is rolled out nationwide.

Through historical epigraphic research, the project will test the hypothesis that historical processes and outcomes in the 14th century were precipitated by a series of related global and local factors and that, moreover, an interdisciplinary and synergistic analysis of these factors embracing climatology, hydrology, epidemiology linguistics and migration will explain the transformation of the cultural, religious and social landscapes of the time more effectively than the ‘clash of civilizations’ paradigm dominant in the field. Outputs include a public online interface for the epigraphic archive; a major international conference at Penn with colleagues from partner universities (Ghent, Pisa, Edinburgh and Penn) as well as the wider South Asia community; development of a graduate course around the research project, on multi-disciplinary approaches to the problem of Hindu-Muslim interaction in medieval India; and a public facing presentation of our findings and methods to demonstrate the path forward for Indian history. Several Penn students, including a postdoc, will be actively engaged.  

India’s competitive electoral arena has failed to generate democratic accountability pressures to reduce toxic air. This project seeks to broadly understand barriers to such pressures from developing, and how to overcome them. In doing so, the project will provide the first systematic study of attitudes and behaviors of citizens and elected officials regarding air pollution in India. The project will 1) conduct in-depth interviews with elected local officials in Delhi, and a large-scale survey of elected officials in seven Indian states affected by air pollution, and 2) partner with relevant civil society organizations, international bodies like the United Nations Environment Program (UNEP), domain experts at research centers like the Public Health Foundation of India (PHFI), and local civic organizations (Janagraaha) to evaluate a range of potential strategies to address pollution apathy, including public information campaigns with highly affected citizens (PHFI), and local pollution reports for policymakers (Janagraaha).

The biggest benefit from generative AI such as GPT, will be the widespread availability of tutoring systems to support education. The project will use this technology to build a conversational voicebot to support Indian students in learning English. The project will engage end users (Indian tutors and their students) in the project from the beginning. The initial prototype voice-driven conversational system will be field-tested in Indian schools and adapted. The project includes 3 stages of development:

1) Develop our conversational agent. Specify the exact initial use case and Conduct preliminary user testing.

2) Fully localize to India, addressing issues identified in Phase 1 user testing.

3) Do comprehensive user testing with detailed observation of 8-12 students using the agent for multiple months; conduct additional assessments of other stakeholders.

The project partners with Ashoka University and Pratham over all three stages, including writing scholarly papers.

Through empirical policy analysis and data-based scenario planning, this project actively contributes to this global effort by investigating planning and policy responses to autonomous transportation in the US and China. In addition to publishing several research papers on this subject, the PI plans to develop a new course and organize a forum at PWCC in 2025. These initiatives are aligned with an overarching endeavor that the PI leads at the Weitzman School of Design, which aims to establish a Future Cities Lab dedicated to research and collaboration in the pursuit of sustainable cities.

This study aims to fill this gap through a more humanistic approach to measuring the impact of education on national development. Leveraging a mixed methods research design consisting of analysis of quantitative data for trends over time, observations of schools and classrooms, and qualitative inquiry via talking to people and hearing their stories, we hope to build a comprehensive picture of educational trends in Nepal and their association with intra-country development. Through this project we strive to better inform the efforts of state authorities and international organizations working to enhance sustainable development within Nepal, while concurrently creating space and guidance for further impact analyses. Among various methods of dissemination of the study’s findings, one key goal is to feed this information into writing a book on this topic.

Developing cities across the world have taken the lead in adopting local environmental regulation. Yet standard models of environmental governance begin with the assumption that local actors should have no incentives for protecting “the commons.” Given the benefits of climate change regulation are diffuse, individual local actors face a collective action problem. This project explores why some local governments bear the costs of environmental regulation while most choose to free-ride. The anticipated outputs of the project include qualitative data that illuminate case studies and the coding of quantitative spatial data sets for studying urban land-use. These different forms of data collection will allow me to develop and test a theoretical framework for understanding when and why city governments adopt environmental policy.

The proposed project will develop new insights on the issue of legislative solutions to the nurse staffing crisis, which will pertain to many U.S. states and U.K. countries. The PI will supervise the nurse survey data collection and to meet with government and nursing association stakeholders to plan the optimal preparation of reports and dissemination of results. The anticipated outputs of the project are a description of variation throughout Scotland in hospital nursing features, including nurse staffing, nurse work environments, extent of adherence to the Law’s required principles, duties, and method, and nurse intent to leave. The outcomes will be the development of capacity for sophisticated quantitative research by Scottish investigators, where such skills are greatly needed but lacking.  

The proposed project will engage multi-cohort, cross-national comparisons of educational-attainment and labor-market experiences of young adults in three countries that dramatically diverge in how they have developed college education over the last three decades: Finland, South Korea and the US. It will produce comparative knowledge regarding consequences of different pathways to higher education, which has significant policy implications for educational and economic inequality in Finland, Korea, the US, and beyond. The project also will lay the foundation for ongoing collaboration among the three country teams to seek external funding for sustained collaboration on educational analyses.

With matching funds from PLAC and CLALS, we will jointly fund four scholars from diverse LAC countries to participate in workshops to engage our community regarding successful practices of community-academic partnerships.

These four scholars and practitioners from Latin America, who are experts on community-engaged scholarship, will visit the Penn campus during the early fall of 2024. As part of their various engagements on campus, these scholars will participate after the workshops as key guest speakers in the 7th edition of the Penn in Latin America and the Caribbean (PLAC) Conference, held on October 11, 2024, at the Perry World House. The conference will focus on "Public and Community Engaged Scholarship in Latin America, the Caribbean, and their Diasporas."

Palermo, Sicily, has been a leading center of migrant rights advocacy and migrant civic participation in the twenty-first century. This project will engage an existing network of diverse migrant community associations and anti-mafia organizations in Palermo to take stock of migrant rights and support systems in the city. Our partner organizations, research assistants, and cultural mediators from different communities will design and conduct a survey and interviews documenting experiences, issues and opportunities related to various rights – to asylum, housing, work, health care, food, education, and more. Our web-based report will include recommendations for city and regional authorities and other actors in civil society. The last phase of our project will involve community outreach and organizing to advance these objectives. The web site we create will be designed as the network’s information center, with a directory of civil society and services, updating an inventory not current since 2014, which our partner Diaspore per la Pace will continue to update.

This interdisciplinary project has four objectives: 1) to investigate why some governments and non-state actors elevated cultural heritage exploitation (CHX) to the strategic level of warfare alongside nuclear weapons, cyberattacks, political influence operations and other “game changers”; 2) which state or non-state actors (e.g. weak actors) use heritage for leverage in conflict and why; and 3) to identify the mechanisms through which CHX coerces an adversary (e.g. catalyzing international involvement); and 4) to identify the best policy responses for non-state actors and states to address the challenge of CHX posed by their adversaries, based on the findings produced by the first three objectives.

Identify the capacity of dental schools, organizations training oral health professionals and conducting oral health research to contribute to oral health policies in the WHO Eastern Mediterranean region, identify the barriers and facilitators to engage in OHPs, and subsequently define research priority areas for the region in collaboration with the WHO, oral health academia, researchers, and other regional stakeholders.

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• Published: 01 April 2024

Adaptive neighborhood rough set model for hybrid data processing: a case study on Parkinson’s disease behavioral analysis

• Imran Raza 1 ,
• Muhammad Hasan Jamal 1 ,
• Rizwan Qureshi 1 ,
• Abdul Karim Shahid 1 ,
• Angel Olider Rojas Vistorte 2 , 3 , 4 ,
• Md Abdus Samad 5 &
• Imran Ashraf 5  

Scientific Reports volume  14 , Article number:  7635 ( 2024 ) Cite this article

238 Accesses

Metrics details

• Computational biology and bioinformatics
• Machine learning

Extracting knowledge from hybrid data, comprising both categorical and numerical data, poses significant challenges due to the inherent difficulty in preserving information and practical meanings during the conversion process. To address this challenge, hybrid data processing methods, combining complementary rough sets, have emerged as a promising approach for handling uncertainty. However, selecting an appropriate model and effectively utilizing it in data mining requires a thorough qualitative and quantitative comparison of existing hybrid data processing models. This research aims to contribute to the analysis of hybrid data processing models based on neighborhood rough sets by investigating the inherent relationships among these models. We propose a generic neighborhood rough set-based hybrid model specifically designed for processing hybrid data, thereby enhancing the efficacy of the data mining process without resorting to discretization and avoiding information loss or practical meaning degradation in datasets. The proposed scheme dynamically adapts the threshold value for the neighborhood approximation space according to the characteristics of the given datasets, ensuring optimal performance without sacrificing accuracy. To evaluate the effectiveness of the proposed scheme, we develop a testbed tailored for Parkinson’s patients, a domain where hybrid data processing is particularly relevant. The experimental results demonstrate that the proposed scheme consistently outperforms existing schemes in adaptively handling both numerical and categorical data, achieving an impressive accuracy of 95% on the Parkinson’s dataset. Overall, this research contributes to advancing hybrid data processing techniques by providing a robust and adaptive solution that addresses the challenges associated with handling hybrid data, particularly in the context of Parkinson’s disease analysis.

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Introduction.

The advancement of technology has facilitated the accumulation of vast amounts of data from various sources such as databases, web repositories, and files, necessitating robust tools for analysis and decision-making 1 , 2 . Data mining, employing techniques such as support vector machine (SVM), decision trees, neural networks, clustering, fuzzy logic, and genetic algorithms, plays a pivotal role in extracting information and uncovering hidden patterns within the data 3 , 4 . However, the complexity of the data landscape, characterized by high dimensionality, heterogeneity, and non-traditional structures, renders the data mining process inherently challenging 5 , 6 . To tackle these challenges effectively, a combination of complementary and cooperative intelligent techniques, including SVM, fuzzy logic, probabilistic reasoning, genetic algorithms, and neural networks, has been advocated 7 , 8 .

Hybrid intelligent systems, amalgamating various intelligent techniques, have emerged as a promising approach to enhance the efficacy of data mining. Adaptive neuro-fuzzy inference systems (ANFIS) have laid the groundwork for intelligent systems in data mining techniques, providing a foundation for exploring complex data relationships 7 , 8 . Moreover, the theory of rough sets has found practical application in tasks such as attribute selection, data reduction, decision rule generation, and pattern extraction, contributing to the development of intelligent systems for knowledge discovery 7 , 8 . Extracting meaningful knowledge from hybrid data, which encompasses both categorical and numerical data, presents a significant challenge. Two predominant strategies have emerged to address this challenge 9 , 10 . The first strategy involves employing numerical data processing techniques such as Principal Component Analysis (PCA) 11 , 12 , Neural Networks 13 , 14 , 15 , 16 , and SVM 17 . However, this approach necessitates converting categorical data into numerical equivalents, leading to a loss of contextual meaning 18 , 19 . The second strategy leverages rough set theory alongside methods tailored for categorical data. Nonetheless, applying rough set theory to numerical data requires a discretization process, resulting in information loss 20 , 21 . Numerous hybrid data processing methods have been proposed, combining rough sets and fuzzy sets to handle uncertainty 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 . However, selecting an appropriate rough set model for a given dataset necessitates exploring the inherent relationships among existing models, presenting a challenge for users. The selection and utilization of an appropriate model in data mining thus demand qualitative and quantitative comparisons of existing hybrid data processing models.

This research endeavors to present a comprehensive analysis of hybrid data processing models, with a specific focus on those rooted in neighborhood rough sets (NRS). By investigating the inherent interconnections among these models, this study aims to elucidate their complex dynamics. To address the challenges posed by hybrid data, a novel hybrid model founded on NRS is introduced. This model enhances the efficiency of the data mining process without discretization mitigating information loss and ambiguity in data interpretation. Notably, the adaptability of the proposed model, particularly in adjusting the threshold value governing the neighborhood approximation space, ensures optimal performance aligned with dataset characteristics while maintaining high accuracy. A dedicated testbed tailored for Parkinson’s patients is developed to evaluate the real-world effectiveness of the proposed approach. Furthermore, a rigorous evaluation of the proposed model is conducted, encompassing both accuracy and overall effectiveness. Encouragingly, the results demonstrate that the proposed scheme surpasses alternative approaches, adeptly managing both numerical and categorical data through an adaptive framework.

The major contributions, listed below, collectively emphasize the innovative hybrid data processing model, the adaptive nature of its thresholding mechanism, and the empirical validation using a Parkinson’s patient testbed, underscoring the relevance and significance of the study’s findings.

Novel Hybrid Data Processing Model: This research introduces a novel hybrid data processing model based on NRS, preserving the practical meaning of both numerical and categorical data types. Unlike conventional methods, it minimizes information loss while optimizing interpretability. The proposed distance function combines Euclidean and Levenshtein distances with weighted calculations and dynamic selection mechanisms to enhance accuracy and realism in neighborhood approximation spaces.

Adaptive Thresholding Mechanism: Another key contribution is the integration of an adaptive thresholding mechanism within the hybrid model. This feature dynamically adjusts the threshold value based on dataset characteristics, ensuring optimal performance and yielding more accurate and contextually relevant results.

Empirical Validation through Parkinson’s Testbed: This research provides a dedicated testbed for analyzing behavioral data from Parkinson’s patients, allowing rigorous evaluation of the proposed hybrid data processing model. Utilizing real-world datasets enhances the model’s practical applicability and advances knowledge in medical data analysis and diagnosis.

The subsequent structure of the paper unfolds as follows: section “ Related work ” delves into the related work. The proposed model is introduced in section “ Adaptive neighborhood rough set model ”, Section “ Instrumentation ” underscores the instrumentation aspect, section “ Result and discussion ” unfolds the presentation of results and ensuing discussions, while section “ Conclusion and future work ” provides the concluding remarks for the paper. A list of notations used in this study is provided in Table  1 .

Related work

Rough set-based approaches have been utilized in various applications like bankruptcy prediction 42 , attribute/feature subset selection 43 , 44 , cancer prediction 45 , 46 , etc. In addition, recently, several innovative hybrid models have emerged, blending the realms of fuzzy logic and non-randomized systems (NRSs). One such development is presented by Yin et al. 47 , who introduce a parameterized hybrid fuzzy similarity relation. They apply this relation to the task of granulating multilabel data, subsequently extending it to the domain of multilabel learning. To construct a noise-tolerant multilabel fuzzy NRS model (NT-MLFNRS), they leverage the inclusion relationship between fuzzy neighborhood granules and fuzzy decisions. Building upon NT-MLFNRS, Yin et al. also devise a noise-resistant heuristic multilabel feature selection (NRFSFN) algorithm. To further enhance the efficiency of feature selection and address the complexities associated with handling large-scale multilabel datasets, they culminate their efforts by introducing an efficient extended version of NRFSFN known as ENFSFN.

Sang et al. 48 explore incremental feature selection methodologies, introducing a novel conditional entropy metric tailored for dynamic ordered data robustness. Their approach introduces the concept of a fuzzy dominance neighborhood rough set (FDNRS) and defines a conditional entropy metric with robustness, leveraging the FDNRS model. This metric serves as an evaluation criterion for features, and it is integrated into a heuristic feature selection algorithm. The resulting incremental feature selection algorithm is built upon this innovative model

Wang et al. 19 introduced the Fuzzy Rough Iterative Computational (FRIC) model, addressing challenges in hybrid information systems (HIS). Their framework includes a specialized distance function for object sets, enhancing object differentiation precision within HIS. Utilizing this function, they establish fuzzy symmetric relations among objects to formulate fuzzy rough approximations. Additionally, they introduce evaluation functions like fuzzy positive regions, dependency functions, and attribute importance functions to assess classification capabilities of attribute sets. They developed an attribute reduction algorithm tailored for hybrid data based on FRIC principles. This work contributes significantly to HIS analysis, providing a robust framework for data classification and feature selection in complex hybrid information systems.

Xu et al. 49 introduced a novel Fitting Fuzzy Rough Set (FRS) model enriched with relative dependency complement mutual information. This model addresses challenges related to data distribution and precision enhancement of fuzzy information granules. They utilized relative distance to mitigate the influence of data distribution on fuzzy similarity relationships and introduced a fitting fuzzy neighborhood radius optimized for enhancing the precision of fuzzy information granules. Within this model, the authors conducted a comprehensive analysis of information uncertainty, introducing definitions of relative complement information entropy and formulating a multiview uncertainty measure based on relative dependency complement mutual information. This work significantly advances our understanding of managing information uncertainty within FRS models, making a valuable contribution to computational modeling and data analysis.

Jiang et al. 50 presented an innovative approach for multiattribute decision-making (MADM) rooted in PROMETHEE II methodologies. Building upon the NRS model, they introduce two additional variants of covering-based variable precision fuzzy rough sets (CVPFRSs) by applying fuzzy logical operators, specifically type-I CVPFRSs and type-II CVPFRSs. In the context of MADM, their method entails the selection of medicines using an algorithm that leverages the identified features.

Qu et al. 51 introduced the concept of Adaptive Neighborhood Rough Sets (ANRSs), aiming for effective integration of feature separation and linkage with classification. They utilize the mRMR-based Feature Selection Algorithm (FSRMI), demonstrating outstanding performance across various selected datasets. However, it’s worth noting that FSRMI may not consistently outperform other algorithms on all datasets.

Xu et al. 52 introduced the Fuzzy Neighborhood Joint Entropy Model (FNSIJE) for feature selection, leveraging fuzzy neighborhood self-information measures and joint entropy to capture combined feature information. FNSIJE comprehensively analyzes the neighborhood decision system, considering noise, uncertainty, and ambiguity. To improve classification performance, the authors devised a new forward search method. Experimental results demonstrated the effectiveness of FNSIJE-KS, efficiently selecting fewer features for both low-dimensional UCI datasets and high-dimensional gene datasets while maintaining optimal classification performance. This approach advances feature selection techniques in machine learning and data analysis.

In 53 , the authors introduced a novel multi-label feature selection method utilizing fuzzy NRS to optimize classification performance in multi-label fuzzy neighborhood decision systems. By combining the NRS and FRS models a Multi-Label Fuzzy NRS model is introduced. They devised a fuzzy neighborhood approximation accuracy metric and crafted a hybrid metric integrating fuzzy neighborhood approximate accuracy with fuzzy neighborhood conditional entropy for attribute importance evaluation. Rigorous evaluation of their methods across ten diverse multi-label datasets showcased significant progress in multi-label feature selection techniques, promising enhanced classification performance in complex multi-label scenarios.

Sanget et al. 54 introduced the Fuzzy Dominance Neighborhood Rough Set (NRS) model for Interval-Valued Ordered Decision Systems (IvODS), along with a robust conditional entropy measure to assess monotonic consistency within IvODS. They also presented two incremental feature selection algorithms. Experimental results on nine publicly available datasets showcased the robustness of their proposed metric and the effectiveness and efficiency of the incremental algorithms, particularly in dynamic IvODS updates. This research significantly advances the application of fuzzy dominance NRS models in IvODS scenarios, providing valuable insights for data analysis and decision-making processes.

Zheng et al. 55 generalized the FRSs using axiomatic and constructive approaches. A pair of dual generalized fuzzy approximation operators is defined using arbitrary fuzzy relation in the constructive approach. Different classes of FRSs are characterized using different sets of axioms. The postulates governing fuzzy approximation operators ensure the presence of specific categories of fuzzy relations yielding identical operators. Using a generalized FRS model, Hu et al. 18 introduced an efficient algorithm for hybrid attribute reduction based on fuzzy relations constructing a forward greedy algorithm for hybrid attribute reduction resulting in optimal classification performance with lesser selected features and higher accuracy. Considering the similarity between two objects, Wang et al. 36 redefine fuzzy upper and lower approximations. The existing concepts of knowledge reduction are extending fuzzy environment resulting in a heuristic algorithm to learn fuzzy rules.

Gogoi et al. 56 use rough set theory for generating decision rules from inconsistent data. The proposed scheme uses indiscernibility relation to find inconsistencies in the data generating minimized and non-redundant rules using lower and upper approximations. The proposed scheme is based on the LEM2 algorithm 57 which performs the local covering option for generating minimum and non-redundant sets of classification rules and does not consider the global covering. The scheme is evaluated on a variety of data sets from the UCI Machine Learning Repository. All these data sets are either categorical or numerical having variable feature spaces. The proposed scheme performs consistently better for categorical data sets, as it is designed to handle inconsistencies in the data having at least one inconsistency. Results show that the proposed scheme generates minimized rule without reducing the feature space unlike other schemes, which compromise the feature space.

In 58 , the authors introduced a novel NRS model to address attribute reduction in noisy systems with heterogeneous attributes. This model extends traditional NRS by incorporating tolerance neighborhood relation and probabilistic theory, resulting in more comprehensive information granules. It evaluates the significance of heterogeneous attributes by considering neighborhood dependency and aims to maximize classification consistency within selected feature spaces. The feature space reduction algorithm employs an incremental approach, adding features while preserving maximal dependency in each round and halting when a new feature no longer increases dependency. This approach selects fewer features than other methods while achieving significantly improved classification performance, demonstrating its effectiveness in attribute reduction for noisy systems.

Zhu et al. 59 propose a fault tolerance scheme combining kernel method, NRS, and statistical features to adaptively select sensitive features. They employ a Gaussian kernel function with NRS to map fault data to a high-dimensional space. Their feature selection algorithm utilizes the hyper-sphere radius in high-dimensional feature space as the neighborhood value, selecting features based on significance measure regardless of the classification algorithm. A wrapper deploys a classification algorithm to evaluate selected features, choosing a subset for optimal classification. Experimental results demonstrate precise determination of the neighborhood value by mapping data into a high-dimensional space using the kernel function and hyper-sphere radius. This methodology proficiently selects sensitive fault features, diagnoses fault types, and identifies fault degrees in rolling bearing datasets.

A neighborhood covering a rough set model for the fuzziness of decision systems is proposed that solves the problem of hybrid decision systems having both fuzzy and numerical attributes 60 . The fuzzy neighborhood relation measures the indiscernibility relation and approximates the universe space using information granules, which deal with fuzzy attributes directly. The experimental results evaluate the influence of neighborhood operator size on the accuracy and attribute reduction of fuzzy neighborhood rough sets. The attribute reduction increases with the increase in the threshold size. A feature will not distinguish any samples and cannot reduce attributes if the neighborhood operator exceeds a certain value.

Hou et al. 61 applied NRS reduction techniques to cancer molecular classification, focusing on gene expression profiles. Their method introduced a novel perspective by using gene occurrence probability in selected gene subsets to indicate tumor classification efficacy. Unlike traditional methods, it integrated both Filters and Wrappers, enhancing classification performance while being computationally efficient. Additionally, they developed an ensemble classifier to improve accuracy and stability without overfitting. Experimental results showed the method achieved high prediction accuracy, identified potential cancer biomarkers, and demonstrated stability in performance.

Table  2 gives a comparison of existing rough set-based schemes for quantitative and qualitative analysis. The comparative parameters include handling hybrid data, generalized NRS, attribute reduction, classification, and accuracy rate. Most of the existing schemes do not handle hybrid data sets without discretization resulting in information loss and a lack of practical meanings. Another parameter to evaluate the effectiveness of the existing scheme is the ability to adapt the threshold value according to the given data sets. Most of the schemes do not adapt threshold values for neighborhood approximation space resulting in variable accuracy rates for different datasets. The end-user has to adjust the value of the threshold for different datasets without understanding its impact in terms of overfitting. Selecting a large threshold value will result in more global rules resulting in poor accuracy. There needs to be a mechanism to adaptively choose the value of the threshold considering both the global and local information without compromising on the accuracy rate. The schemes are also evaluated for their ability to attribute reduction using NRS. This can greatly improve processing time and accuracy by not considering insignificant attributes. The comparative analysis shows that most of the NRS-based existing schemes perform better than many other well-known schemes in terms of accuracy. Most of these schemes have a higher accuracy rate than CART, C4.5, and k NN. This makes the NRS-based schemes a choice for attribute reduction and classification.

Adaptive neighborhood rough set model

The detailed analysis of existing techniques highlights the need for a generalized NRS-based classification technique to handle both categorical and numerical data. The proposed NRS-based techniques not only handle the hybrid information granules but also dynamically select the threshold \(\delta \) producing optimal results with a high accuracy rate. The proposed scheme considers a hybrid tuple \(HIS=\langle U_h,\ Q_h,\ V,\ f \rangle \) , where \(U_h\) is nonempty set of hybrid records \(\{x_{h1},\ x_{h2},\ x_{h3},\ \ldots ,\ x_{hn}\}\) , \(Q_h=\left\{ q_{h1},\ q_{h2},\ \ q_{h3},\ \ldots \,\ q_{hn}\right\} \) is the non-empty set of hybrid features. \( V_{q_h}\) is the domain of attribute \(q_h\) and \(V=\ \cup _{q_h\in Q_h}V_{q_h}\) , and \(f=U_h\ x\ Q_h\rightarrow V\) is a total function such \(f\left( x_h,q_h\right) \in V_{q_h}\) for each \(q_h\in Q_h, x_h\in U_h\) , called information function. \(\langle U_h,\ Q_h,\ V,\ f\rangle \) is also known as a decision table if \(Q_h=C_h\cup D\) , where \(C_h\) is the set of hybrid condition attributes and D is the decision attribute.

A neighborhood relation N is calculated using this set of hybrid samples \(U_h\) creating the neighborhood approximation space \(\langle U_h,\ N\rangle \) which contains information granules \( \left\{ \delta ({x_h}_i)\big |{x_h}_i\in U_h\right\} \) based on some distance function \(\Delta \) . For an arbitrary sample \({x_h}_i\in U_h\) and \(B \subseteq C_h\) , the neighborhood \(\delta _B({x_h}_i)\) of \({x_h}_i\) in the subspace B is defined as \(\delta _B\left( {x_h}_i\right) =\{{x_h}_j\left| {x_h}_j\right. \in U_h,\ \Delta B(x_i,x_j) \le \delta \}\) . The scheme proposes a new hybrid distance function to handle both the categorical and numerical features in an approximation space.

The proposed distance function uses Euclidean distance for numerical features and Levenshtein distance for categorical features. The distance function also takes care of the significant features calculating weighted distance for both the categorical and numerical features. The proposed algorithm dynamically selects the distance function at the run time. The use of Levenshtein distance for categorical features provides precise distance for optimal neighborhood approximation space providing better results. Existing techniques add 1 to distance if two strings do not match in calculating the distance for categorical data and add 0 otherwise. This may not result in a realistic neighborhood approximation space.

The neighborhood size depends on the threshold \(\delta \) . The neighborhood will contain more samples if \(\delta \) is greater and results in more rules not considering the local information data. The accuracy rate of the NRS greatly depends on the selection of threshold values. The proposed scheme dynamically calculates the threshold value for any given dataset considering both local and global information. The threshold calculation formula is given below where \({min}_D\) is the minimum distance between the set of training samples and the test sample containing local information and \(R_D\) is the range of distance between the set of training samples and the test sample containing the global information.

The proposed scheme then calculates the lower and upper approximations given a neighborhood space \(\langle U_h, N\rangle \) for \(X \subseteq U_h\) , the lower and upper approximations of X are defined as:

Given a hybrid neighborhood decision table \(HNDT=\langle U_h,\ C_h\cup \ D, V, f\rangle \) , \(\{ X_{h1},X_{h2},\ \ldots ,\ X_{hN} \}\) are the sample hybrid subjects with decision 1 to N , \(\delta _B\left( x_{hi}\right) \) is the information granules generated by attributes \(B \subseteq C_h\) , then the lower and upper approximation is defined as:

and the boundary region of D is defined as:

The lower and upper approximation spaces are the set of rules, which are used to classify a test sample. A test sample forms its neighborhood using a lower approximation having all the rules with a distance less than a dynamically calculated threshold value. The majority voting is used in the neighborhood of a test sample to decide the class of a test sample. K-fold cross-validation is used to measure the accuracy of the proposed scheme where the value k is 10. The algorithm 1 of the proposed scheme has a time complexity of \(O(nm^{2})\) where n is the number of clients and m is the size of the categorial data.

Instrumentation

The proposed generalized rough set model has been rigorously assessed through the development of a testbed designed for the classification of Parkinson’s patients. It has also been subjected to testing using various standard datasets sourced from the University of California at Irvine machine learning data repository 63 . This research underscores the increasing significance of biomedical engineering in healthcare, particularly in light of the growing prevalence of Parkinson’s disease, which ranks as the second most common neurodegenerative condition, impacting over 1% of the population aged 65 and above 64 . The disease manifests through distinct motor symptoms like resting tremors, bradykinesia (slowness of movement), rigidity, and poor balance, with medication-related side effects such as wearing off and dyskinesias 65 .

In this study, to address the need for a reliable quantitative method for assessing motor complications in Parkinson’s patients, the data collection process involves utilizing a home-monitoring system equipped with wireless wearable sensors. These sensors were specifically deployed to closely monitor Parkinson’s patients with severe tremors in real time. It’s important to note that all patients involved in the study were clinically diagnosed with Parkinson’s disease. Additionally, before data collection, proper consent was obtained from each participant, and the study protocol was approved by the ethical committee of our university. The data collected from these sensors is then analyzed, yielding reliable quantitative information that can significantly aid clinical decision-making within both routine patient care and clinical trials of innovative treatments.

Testbed for Parkinson’s patients.

Figure  1 illustrates a real-time Testbed designed for monitoring Parkinson’s patients. This system utilizes a tri-axial accelerometer to capture three signals, one for each axis \((x,\ y,\ and\ z)\) , resulting in a total of 18 channels of data. The sensors employed in this setup employ ZigBee (IEEE 802.15.4 infrastructure) protocol to transmit data to a computer at a sampling rate of 62.5 Hz. To ensure synchronization of the transmitted signals, a transition protocol is applied. These data packets are received through the Serial Forwarder using the TinyOS platform ( http://www.tinyos.net ). The recorded acceleration data is represented as digital signals and can be visualized on an oscilloscope. The frequency domain data is obtained by applying the Fast Fourier Transform (FFT) to the signal, resulting in an ARFF file format that is then employed for classification purposes. The experimental flowchart is shown in Fig.  2 .

Experimental flowchart.

The real-time testbed includes various components to capture data using the Unified Parkinson’s Disease Rating Scale (UPDRS). TelosB MTM-CM5000-MSP and MTM-CM3000-MSP sensors are used to send and receive radio signals from the sensor to the PC. These sensors are based on an open-source TelosB/Tmote Sky platform, designed and developed by the University of California, Berkeley.

TelosB sensor uses the IEEE 802.15.4 wireless structure and the embedded sensors can measure temperature, relative humidity, and light. In CM3000, the USB connector is replaced with an ERNI connector that is compatible with interface modules. Also, the Hirose 51-pin connector makes this more versatile as it can be attachable to any sensor board family, and the coverage area is increased using SMA design by a 5dBi external antenna 66 . These components can be used for a variety of applications such as low-power Wireless Sensor Networks (WSN) platforms, network monitoring, and environment monitoring systems.

MTS-EX1000 sensor board is used for the amplification of the voltage/current value from the accelerometer. The EX1000 is an attachable board that supports the CMXXXX series of wireless sensors network Motes (Hirose 51-pin connector). The basic functionality of EX1000 is to connect the external sensors with CMXX00 communication modules to enhance the mote’s I/O capability and support different kinds of sensors based on the sensor type and its output signal. ADXL-345 Tri-accelerometer sensor is used to calculate body motion along x, y, and z-axis relative to gravity. It is a small, thin, low-power, 3-axis accelerometer that calculates high resolution (13-bit) measurements at up to ±16g. Its digital output, in 16-bit twos complement format, is accessible through either an SPI (3- or 4-wire) or I2C digital interface. A customized main circuit board is used having a programmed IC, registers, and transistors. Its basic functionality is to convert the digital data, accessed through the ADXL-345 sensor, into analog form and send it to MTS1000.

Result and discussion

The proposed generalized and ANRS is evaluated against different data sets taken from the machine learning data repository, at the University of California at Irvine. In addition to these common data sets, a real-time Testbed for Parkinson’s patients is also used to evaluate the proposed scheme. The hybrid data of 500 people was collected using the Testbed for Parkinson’s patients including 10 Parkinson’s patients, 20 people have abnormal and uncontrolled hand movements, and the rest of the samples were taken approximating the hand movements of Parkinson’s patients. The objective of this evaluation is to compare the accuracy rate of the proposed scheme with CART, k NN, and SVM having both simple and complex datasets containing numerical and hybrid features respectively. The results also demonstrate the selection of radius r for dynamically calculating the threshold value.

Table  3 provides the details of the datasets used for the evaluation of the proposed scheme including the training and test ratio used for evaluation in addition to data type, total number of instances, total feature, a feature considered for evaluation, and number of classes. The hybrid datasets are also selected to evaluate to performance of the proposed scheme against the hybrid feature space without discretization preventing information loss.

The accuracy of the NRS is greatly dependent on the threshold value. Most of the existing techniques do not dynamically adapt the threshold \(\delta \) value for different hybrid datasets. This results in the variant of NRS suitable for specific datasets with different threshold values. A specific threshold value may produce better results for one dataset and poor results for others requiring a more generic threshold value catering to different datasets with optimal results. The proposed scheme introduces an adaptable threshold calculation mechanism to achieve optimal results regardless of the datasets under evaluation. The radius value plays a pivotal role in forming a neighborhood, as the threshold values consider both the local and global information of the NRS to calculate neighborhood approximation space. Table  4 shows the accuracy rate having different values of the radius of the NRS. The proposed threshold mechanism provides better results for all datasets if the value of the radius is 0.002. Results also show that assigning no weight to the radius produces poor results, as it will then only consider the local information for the approximation space. Selecting other weights for radius may produce better results for one dataset but not for all datasets.

Table  5 presents the comparative analysis of the proposed scheme with k NN, Naive Bayes, and C45. The results show that the proposed scheme performs well against other well-known techniques for both the categorical and numerical features space. Naive Bayes and C45 also result in information loss, as these techniques cannot process the hybrid data. So the proposed scheme handles the hybrid data without compromising on the information completeness producing acceptable results. K-fold cross-validation is used to measure the accuracy of the proposed scheme. Each dataset is divided into 10 subsets to use one of the K subsets as the test set and the other K-1 subsets as training sets. Then the average accuracy of all K trials is computed with the advantage of having results regardless of the dataset division.

Conclusion and future work

This work evaluates the existing NRS-based scheme for handling hybrid data sets i.e. numerical and categorical features. The comparative analysis of existing NRS-based schemes shows that there is a need for a generic NRS-based approach to adapt the threshold selection forming neighborhood approximation space. A generalized and ANRS-based scheme is proposed to handle both the categorical and numerical features avoiding information loss and lack of practical meanings. The proposed scheme uses a Euclidean and Levenshtein distance to calculate the upper and lower approximation of NRS for numerical and categorical features respectively. Euclidean and Levenshtein distances have been modified to handle the impact of outliers in calculating the approximation spaces. The proposed scheme defines an adaptive threshold mechanism for calculating neighborhood approximation space regardless of the data set under consideration. A Testbed is developed for real-time behavioral analysis of Parkinson’s patients evaluating the effectiveness of the proposed scheme. The evaluation results show that the proposed scheme provides better accuracy than k NN, C4.5, and Naive Bayes for both the categorical and numerical feature space achieving 95% accuracy on the Parkinson’s dataset. The proposed scheme will be evaluated against the hybrid data set having more than two classes in future work. Additionally, in future work, we aim to explore the following areas; (i) conduct longitudinal studies to track the progression of Parkinson’s disease over time, allowing for a deeper understanding of how behavioral patterns evolve and how interventions may impact disease trajectory, (ii) explore the integration of additional data sources, such as genetic data, imaging studies, and environmental factors, to provide a more comprehensive understanding of Parkinson’s disease etiology and progression, (iii) validate our findings in larger and more diverse patient populations and investigate the feasibility of implementing our proposed approach in clinical settings to support healthcare providers in decision-making processes, (iv) investigate novel biomarkers or physiological signals that may provide additional insights into Parkinson’s disease progression and motor complications, potentially leading to the development of new diagnostic and monitoring tools, and (v) conduct patient-centered outcomes research to better understand the impact of Parkinson’s disease on patients’ quality of life, functional abilities, and overall well-being, with a focus on developing personalized treatment approaches.

Data availability

The datasets used in this study are publicly available at the following links:

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Imran Raza: Conceptualization, Formal analysis, Writing—original draft; Muhammad Hasan Jamal: Conceptualization, Data curation, Writing—original draft; Rizwan Qureshi: Data curation, Formal analysis, Methodology; Abdul Karim Shahid: Project administration, Software, Visualization; Angel Olider Rojas Vistorte: Funding acquisition, Investigation, Project administration; Md Abdus Samad: Investigation, Software, Resources; Imran Ashraf: Supervision, Validation, Writing —review and editing. All authors reviewed the manuscript and approved it.

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Raza, I., Jamal, M.H., Qureshi, R. et al. Adaptive neighborhood rough set model for hybrid data processing: a case study on Parkinson’s disease behavioral analysis. Sci Rep 14 , 7635 (2024). https://doi.org/10.1038/s41598-024-57547-4

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Case Study | How to Create Cultural Moments on Any Budget

• Diana Pearl

Key insights

• Creating marketing that’s centred around culture — from sports to Hollywood to events — offers brands a chance to team up with a person or asset with a built-in audience.
• Brands must carefully consider not only who or what they put at the centre of their marketing effort, but the format it takes, such as a campaign or product collaboration and how they get it in front of consumers.
• If executed effectively, brands create a moment that earns its own place in the zeitgeist.

It was the ad heard round the world.

In the early days of January 2024, Calvin Klein launched its Spring campaign with a video starring actor Jeremy Allen White, clad only in the brand’s signature logo-ed boxers, doing pull-ups and climbing a ladder on a New York City rooftop. The impact was immediate and impossible to ignore.

On social media, feeds were flooded with reaction videos of slack-jawed people watching the ad, or gawking at a two-story billboard featuring White in New York City’s SoHo neighbourhood. The first post featuring White on Calvin Klein’s Instagram feed collected 1.8 million likes — for comparison, the preceding post had just shy of 34,000.

The ad went far beyond Calvin Klein’s Instagram account, running in paid social media ads, out-of-home placements across the globe, as well as on streaming platforms and in traditional media outlets. The brand also planned in advance for White’s first major appearance after the ads dropped: At the Golden Globe Awards two days later, when White took home the award for Best Actor in a TV Series, Musical or Comedy for his starring role in “The Bear,” he was clothed in head-to-toe Calvin Klein.

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The ad did more than just get people talking: Calvin Klein saw a 30 percent year-over-year increase in underwear sales in the week after it launched. Within 48 hours, the campaign overall had reached $12.7 million in media impact value, a measure of the online buzz around a particular brand or campaign from performance measurement firm Launchmetrics . That number far surpassed other buzzy campaigns Launchmetrics tracked, including Bottega Veneta’s Pre-Spring 2024 campaign featuring paparazzi shots of Kendall Jenner and A$AP Rocky , which generated $2.8 million in the same time frame. Within a few weeks, Calvin Klein’s ad had become more than just marketing — it was a cultural phenomenon.

Every brand dreams of achieving what Calvin Klein did with its White campaign: creating a genuine cultural moment. Most marketing captures consumer attention for a few fleeting seconds by hopping on a trend or jumping into an ongoing discussion. But the best campaigns aspire to more than that. Their goal is to not just draft off the cultural conversation but to drive it. When these moments are executed well, they create culture rather than just responding to it.

But creating a cultural moment is, by definition, not easy. There are more channels than ever to reach consumers, from art to film to sports to social media, and more brands competing within them. In a fragmented media landscape, audiences have split into a constellation of niches, leaving fewer opportunities to capture the masses’ attention. Simply casting a beloved celebrity or coming up with a clever concept for an ad isn’t enough. Brands need to find the partnership that strikes the balance between perfectly fitting yet remaining unexpected. That could mean using an unexpected face for a campaign, or deploying a familiar one in a surprising way that breaks through the sea of other celebrity-driven marketing. Or it could mean releasing a product collaboration with an under-the-radar television show that’s about to go big, or engaging with the right event.

“Brands really have to acknowledge that there isn’t a mass media monoculture anymore that’s driving those big moments,” said Ellie Bamford, the North America chief strategy officer at advertising company VML. “You have to go in and find them yourself.” This case study breaks down the strategy that goes into creating a cultural moment that stands out, captures consumer attention and leads to a meaningful lift for a brand, whether in sales or affinity — and whether you have Calvin Klein’s budget or not. Along with insights from Calvin Klein, American Eagle and Reformation , there are lessons from smaller players such as activewear label Castore and fragrance brand Brown Girl Jane.

By the end, you’ll gain a better understanding of how to identify the right cultural figure or asset for your brand to partner with, the right channel to bring your partnership to life, how to promote that partnership to consumers and how to measure its impact.

Diana Pearl is News and Features Editor at The Business of Fashion. She is based in New York and drives BoF’s marketing and media coverage.

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• Marketing : Celebrity & Influencers
• Marketing : Branding
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• Launchmetrics
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• American Eagle
• The Reformation

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