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A framework for stakeholder identification in concept mapping and health research: a novel process and… Schiller, Claire; Winters, Meghan; Hanson, Heather M; Ashe, Maureen C May 2, 2013

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RESEARCH ARTICLE Open AccessA framework for stakeholder identification inconcept mapping and health research: a novelprocess and its application to older adult mobilityand the built environmentClaire Schiller1,2,3*, Meghan Winters1,3, Heather M Hanson1,2 and Maureen C Ashe1,2AbstractBackground: Stakeholders, as originally defined in theory, are groups or individual who can affect or are affectedby an issue. Stakeholders are an important source of information in health research, providing critical perspectivesand new insights on the complex determinants of health. The intersection of built and social environments witholder adult mobility is an area of research that is fundamentally interdisciplinary and would benefit from a betterunderstanding of stakeholder perspectives. Although a rich body of literature surrounds stakeholder theory, asystematic process for identifying health stakeholders in practice does not exist. This paper presents a framework ofstakeholders related to older adult mobility and the built environment, and further outlines a process forsystematically identifying stakeholders that can be applied in other health contexts, with a particular emphasis onconcept mapping research.Methods: Informed by gaps in the relevant literature we developed a framework for identifying and categorizinghealth stakeholders. The framework was created through a novel iterative process of stakeholder identification andcategorization. The development entailed a literature search to identify stakeholder categories, representation ofidentified stakeholders in a visual chart, and correspondence with expert informants to obtain practice-based insight.Results: The three-step, iterative creation process progressed from identifying stakeholder categories, to identifyingspecific stakeholder groups and soliciting feedback from expert informants. The result was a stakeholder frameworkcomprised of seven categories with detailed sub-groups. The main categories of stakeholders were, (1) the Public,(2) Policy makers and governments, (3) Research community, (4) Practitioners and professionals, (5) Health and socialservice providers, (6) Civil society organizations, and (7) Private business.Conclusions: Stakeholders related to older adult mobility and the built environment span many disciplines and realmsof practice. Researchers studying this issue may use the detailed stakeholder framework process we present to identifyparticipants for future projects. Health researchers pursuing stakeholder-based projects in other contexts areencouraged to incorporate this process of stakeholder identification and categorization to ensure systematicconsideration of relevant perspectives in their work.Keywords: Stakeholders, Concept mapping, Older adults’ mobility, Built environment, Health* Correspondence: claire.schiller@hiphealth.ca1Centre for Hip Health and Mobility, 6F-2635 Laurel Street, Vancouver, BCV5Z 1M9, Canada2Department of Family Practice, University of British Columbia (UBC),Vancouver, BC V6T 1Z4, CanadaFull list of author information is available at the end of the article© 2013 Schiller et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Schiller et al. BMC Public Health 2013, 13:428http://www.biomedcentral.com/1471-2458/13/428BackgroundPublic health problems are inherently complex, spanningacross realms of practice and impacting a variety ofstakeholders. The importance of involving stakeholders inhealth research is increasingly recognized [1-3]. Groupsand individuals affected by an issue (such as public healthpractitioners and community members) possess criticalinsight that may inform all aspects of the research process,providing valuable input in all stages from setting researchpriorities, to disseminating and implementing results [4].The diversity of perspectives that stakeholders possessmay be particularly relevant to understanding the complexdeterminants of health which figure centrally in publichealth research and practice.Concept mapping is a mixed-methods technique thatfacilitates the analysis of stakeholder perspectives. Assuch, it is a useful tool for understanding complex phe-nomena in public health [5]. A detailed explanation ofthe methodology is outlined in Trochim’s seminal work[6] and subsequent publication by Kane and Trochim[7]. In brief, concept mapping integrates group brain-storming and sorting of ideas with quantitative analysisto generate visual representations of concepts. Conceptmaps reflect the relative importance and relationshipsbetween intersecting ideas [7]. A recent review of con-cept mapping attests to the quality and rigor of themethodology [8]. The review also highlights the increas-ingly widespread use of concept mapping in healthresearch; of the 69 articles reviewed, over 59% had apublic health orientation [8].In order to implement concept mapping projects, in-vestigators must first identify which stakeholders arerelevant to their topic of inquiry. However, this provesto be a challenging task as the literature lacks systematic,practical techniques for identifying stakeholder groupsand individuals [9]. In practice, the process is more oftenguided by intuition and feasibility than structured sys-tematic frameworks [10]. Broad, heterogeneous partici-pation from “relevant people” is generally encouraged inconcept mapping projects [7, p.36]. Techniques such asfocus groups, semi-structured interviews and snowballsampling (described in more detail below) broadly cap-ture methods of identifying stakeholders, but fail to pro-vide a detailed process required to ensure systematicidentification. A challenge, and apparent gap in the lit-erature thus exists with regards to knowing who “rele-vant people” are in practice.We encountered the challenge of identifying stake-holders in a concept mapping project on the intersectionbetween older adult mobility with built and social envi-ronments [11]. This is an important and emerging areaof research; as mobility contributes significantly to thehealth of older adults, and early evidence suggests thatbuilt and social environments interact to impact theability for older adults to engage in community partici-pation [12]. In this context, we defined: mobility as “theability of a person to move about and complete physicalactivities in their community setting” [12]; the built en-vironment as the composite of “urban design, land useand the transportation system”[13]; and the social envir-onment as “social relationships and cultural milieuswithin which defined groups of people function andinteract” [14]. Diverse stakeholder engagement is likelycritical to advancing our understanding of this issue, forit has already contributed to other aspects of built envir-onment and physical activity research [15-17]. Yet theliterature provides little guidance on how to identifystakeholders in practice and there are no detailed frame-works of stakeholders related to older adult mobility andthe built environment. Therefore, in this paper, wepresent a framework to address this gap and outline astakeholder identification process that can be appliedacross public health research, policy and community en-gagement projects. By discussing the applicability of ourframework in the growing practice of concept mapping,we hope to further demonstrate the utility of our work.A brief review of stakeholder theory figures at the fore-front of our analysis as it lends clarity to the term “stake-holder” and provides theoretical underpinnings of ourframework.Stakeholder theoryFreeman is credited with the classic definition of a stake-holder, articulated in his seminal work as “any group orindividual who can affect or is affected by the achieve-ments of the organization’s objective” [18, p.46]. Thisdefinition reflects the business management context inwhich the term originated. As a concept, stakeholder ex-tends the responsibilities of business beyond financial in-vestors to other entities that may be affected by a firm’sactions. Most pertinent to other disciplines is the “affector is affected by” clause which may serve as a criterionto designate individuals or groups as stakeholders.Nuanced variations on the stakeholder definition exist,however Freeman’s is still considered the most broadand balanced [18]. Friedman and Miles identify fifty-fivedefinitions of stakeholder spanning forty years andseventy-five texts; for a more comprehensive comparisonof the term, their work should be referenced [18].In addition to defining the term “stakeholder”,Freeman’s seminal work contributes two other tools forstakeholder identification that may be applied to healthresearch projects. The first is the now common ‘hub-and-spoke’ picture, where stakeholder groups aredepicted at the end of spokes emanating from a centralfirm [19] (See Additional file 1: Figure S1). This figure isan acknowledged oversimplification, as each stakeholdercategory can be further broken down into more specificSchiller et al. BMC Public Health 2013, 13:428 Page 2 of 9http://www.biomedcentral.com/1471-2458/13/428groups, however, this visual map is a useful tool foridentifying stakeholders [18]. The other contribution is abroader stakeholder analysis process, of which stake-holder identification is only the first step [18]. Subse-quent components of stakeholder analysis focus onunderstanding the interests and stance of various stake-holder groups, and on devising a business managementstrategy in response. Stakeholder analysis theories offerinteresting techniques for prioritizing stakeholders andunderstanding relationships, but they do not providepractical guidance on how to identify stakeholders.Some additional insight on the practice of stakeholderidentification is gleaned from the discussion of stake-holder management issues within Stakeholders: Theoryand Practice [18]. Notably, the challenge of constructingstakeholder maps is acknowledged, particularly in lightof the heterogeneity of interests within stakeholdergroups, and the possibility of a single stakeholder be-longing to multiple categories [18].The use of stakeholder analysis has broadened consid-erably beyond its original application in business man-agement [10]. Environmental resource management, inparticular, has embraced this study design, as demon-strated by Reed et al. [20]. The authors build on thetheoretical contributions of business management litera-ture, and notably categorize methods employed to iden-tify stakeholders, differentiate between stakeholders, andinvestigate relationships between stakeholders in prac-tice [20]. Three specific methods of identifying stake-holders are listed, mainly; focus groups, semi-structuredinterviews, and snowball sampling. These techniques arelikely familiar to health researchers, however their appli-cation in the explicit context of stakeholder identifica-tion is perhaps more novel. In focus groups, a smallnumber of participants brainstorm lists of stakeholders.This method is notably less structured than others, andmay be supplemented with interviews of a cross-sectionof stakeholders [20]. Semi-structured interviews withselected stakeholders are akin to consulting key infor-mants, which is recommended for the analysis of stake-holders by Varvasovsky and Brugha [21]. The snowballsampling technique consists of individuals from initialstakeholder categories identifying new stakeholders andcontacts. Possible bias towards the social networks ofthe first stakeholders should be noted [20], howeversnowball sampling is nonetheless commonly employedin health management stakeholder analysis [10]. Al-though these techniques broadly capture methods ofidentifying some stakeholder group, they do not providea systematic method for identification in practice.As discussed in the context of concept mapping above,a challenge and gap in the literature exists in regards toknowing who “relevant people” are. A systematic processfor determining which perspectives or stakeholders arerelevant is not described in health research method-ology. In part this is due to the diversity of contexts andthe need to tailor approaches to specific projects. How-ever it also reflects an observation made by Reed et al.,[20] that stakeholders are often presumed to be “self-evi-dent” in the literature. In practice it seems intuition andfamiliarity with a given topic tend to guide identificationof stakeholder categories; whether for specific health re-search projects or broader stakeholder analysis.A more documented, systematic methodology forstakeholder identification stands to benefit public healthresearch and concept mapping projects by increasingtransparency in participant selection and minimizing re-searcher bias towards familiar groups. Frameworks ofstakeholder categories may serve as a starting point forsystematic identification of stakeholders, however suchframeworks are not commonly cited in the literature.Therefore our aim was to develop a framework of healthstakeholder categories and outline its application toolder adults’ mobility and built and social environmentsto identify specific stakeholder groups.MethodsTo inform the development of our framework weconducted a strategic, focused literature search with par-ticular attention to categories of health stakeholdersemployed in concept mapping research, so as to informa separate project conducted by the authors of this paper[11]. The texts Stakeholders: Theory and Practice [18]and Concept Mapping for Planning and Evaluation [7]served as comprehensive, resources on stakeholder the-ory and concept mapping methodology. After reviewingrelevant citations from these texts, we identified “stake-holder analysis” and “concept mapping” as appropriatesearch terms. In order to focus our search on health, welimited our search to the health database of OvidMedline (years 1950 – present). A search in April 2012,identified 68 and 245 citations using our keywords“stakeholder analysis” and “concept mapping” respect-ively. An additional search of the Cochrane Database for“stakeholders” returned no completed reviews. We thenreviewed retrieved articles for relevance to older adultmobility and the built environment in search of applic-able stakeholder frameworks.Identified categories of health stakeholders informedthe organization of our framework, however they didnot provide sufficient guidance on how to adapt theclassification to specific public health contexts, such asthe intersection of older adults’ mobility with the builtand social environments. To address this gap in theliterature and facilitate stakeholder identification, wepresent a detailed description of the steps employed inthis project in addition to the final framework.Schiller et al. BMC Public Health 2013, 13:428 Page 3 of 9http://www.biomedcentral.com/1471-2458/13/428Broadly speaking, our stakeholder framework was cre-ated through an iterative process of revising stakeholdercategories to encompass individual stakeholders deemedimportant by literature and experienced informants. Theframework is presented as a visual representation andclassification of groups and individuals related to theintersection of older adult mobility with the built andsocial environments.Varvasovszky and Brugha recommend a mixed teamof internal and external analysts to conduct stakehodleranalysis [21]. Our initial chart was thus created by oneauthor (CS) who had little a priori knowledge of the re-lation between older adult mobility and the built and so-cial environment, to increase objectivity and benefitfrom an external, theory driven identification of stake-holders. The scope and methods of analysis were derivedin consultation with all authors (experienced in thisarea), and the final stakeholder framework reflects col-lective expertise.To enhance the project with practice-based insight,four expert informants reviewed and provided feedbackon an initial draft of the stakeholder framework. Expertinformants were professionals with knowledge of thefield and represented policy makers, researchers, practi-tioners and service providers, and were chosen based onthe individuals’ expertise and prior collaboration. Allworked across disciplines but had primary training orworked professionally in the fields of health or socialservices. Expert informants were asked to review thestakeholder framework and provide open-ended feed-back on the organization of stakeholder groups andidentification of missing stakeholders. We collectedcomments via email in accordance with a consent proto-col approved by the Simon Fraser University Depart-ment of Research Ethics (File #:2012s0331). The finalstakeholder framework incorporated recommendationsfrom the expert informants.ResultsCreation processAn account of the systematic process employed in thisproject precedes the final framework (Figures 1 and 2),providing justification for the stakeholders identifiedand, of particular value, guidance for others undertakinga similar task. The iterative process was articulated asthe following series of three main steps:1. Identify a relevant framework of stakeholder categoriesBased on an iterative search of the literature, noframeworks of stakeholder categories specific toolder adult mobility, the built environment, orsocial environments were identified. Threeclassifications of health stakeholders were found[22-24]. The most concise and explicit articulationsof health stakeholders for concept mapping waslisted by Trochim and Kane [23]. Although notpresented as a formal framework for stakeholdercategorization, Trochim and Kane identifiedrelevant health stakeholders including the public,health professionals, health administrators, policymakers and politicians, and the researchcommunity. A second concept mapping project onchronic disease prevention in Canada used thebroad categories of researchers, practitioners, andpolicy specialists to classify health stakeholders [22].In a third example of stakeholder analysis in healthresearch, a comprehensive list of stakeholders ispresented by Future Health Systems: Innovationsfor Equity [24]. Within the context of healthsystems research in developing countries, theauthors recommend systematic consideration of thefollowing eleven stakeholder categories;beneficiaries, central government agencies, ministryof health, local governments, financiers, civil societyorganizations, health governing boards, providerOlder adults’ mobility and built and social environments POLICY MAKERS AND GOVERNMENTSRESEARCH COMMUNITY PRACTITIONERS AND PROFESSIONALSHEALTH AND SOCIAL SERVICE PROVIDERSPUBLICCIVIL SOCIETY ORGANIZATIONSPRIVATE BUSINESSFigure 1 Framework of stakeholder categories related to the intersection of older adults’ mobility with built and social environments.Schiller et al. BMC Public Health 2013, 13:428 Page 4 of 9http://www.biomedcentral.com/1471-2458/13/428organizations, professional organizations and healthworkers, unions, and suppliers [24].The categories of health stakeholders identified byTrochim and Kane [23] were adapted in thisproject as they encompassed most other categorieswhile maintaining an element of simplicity. Thesecategories included the public, health professionals,health administrators, policy makers and politicians,and the research community. As our stakeholderframework evolved, new categories of stakeholderswere added and some were renamed. For example,‘Health providers’ (identified by Hyder et al., [24])replaced health administrators as a main categoryof stakeholders and ‘Health professionals’ wasbroadened to ‘Professionals and practitioners’.2. Identify specific stakeholder groups:(i) Begin with relevant research disciplinesWe first discerned relevant research disciplinesto initiate the identification of specific groupsof stakeholders within each category. This stepwas greatly informed by an evidence reviewpublished by co-authors [12]. For the purposeof stakeholder identification, a list of relevantresearch disciplines was generated based onOlder adults Families and caregivers  Taxpayers (community members) Research Centres and networks Post-secondary institutionsHealth ProfessionsMedicine NursingPhysiotherapyOccupational TherapyKinesiologyPublic HealthSocial WorkPsychologyGerontology and ageing studies Health services Social inequities in health ArchitecturePlanningUrban design EngineeringTechnology and society studiesTransportation Health geography Environmental  geographySocial and economic policy Inter-professional networks and advisory groups Health ProfessionsMedicine NursingPhysiotherapyOccupational TherapyKinesiologyPublic HealthSocial WorkPsychologyPharmacologyGerontology and ageing studies Health services Social inequities in health ArchitecturePlanningUrban design Building tradesEngineeringTechnology and society studiesTransportation Health geography Environmental geographySocial and economic policy Chambers of commerce Health and social service suppliersMobility aidsAlternative transportation Land Use DevelopersReal estateInfrastructureMaterial manufacturersConstruction companiesHousing and accommodations Assisted livingResidential care Sustainable housingMortgage corporations  Health insurance providers Occupational health and safetyProvincial medical service plansDisability Services Safety and crime preventionTransportationMaintenance of public spaces POLICY MAKERS AND GOVERNMENTSPRIVATE BUSINESSRESEARCH COMMUNITYPUBLICCIVIL SOCIETY ORGANIZATIONSPRACTITIONERS AND PROFESSIONALSHEALTH AND SOCIAL SERVICE PROVIDERSNon-governmental organizationsInterest groupsThink tanksCharitable organizationsDisease specificDisability orientedCommunity oriented Sustainability orientedFaith-based organizationsIndigenous / ethnic groups Policy networks and advisory  groupsMunicipal Governments Unions of municipalitiesMunicipal insurance associations City councilsElected officialsCitizen’s Advisory Committees Departments of: Legal servicesCommunity servicesEngineering and transportation Human resource servicesSustainabilityParks and recreationProvincial GovernmentsElected officials Ministry of:Children and family Community and culture HealthSocial DevelopmentTransportation / infrastructureEnergy and mines Health Authorities  Federal Government Elected officialsMinistry of:Health State (Seniors)Human resources development Industry (Building codes)  Figure 2 Detailed chart of stakeholders, expanding framework of stakeholder categories related to the intersection of older adultmobility with built and social environments.Schiller et al. BMC Public Health 2013, 13:428 Page 5 of 9http://www.biomedcentral.com/1471-2458/13/428the academic affiliations of authors of thepapers in the review and the types of journalsin which they were published. Twenty-onedisciplines were identified in this manner, andwere added to the framework as stakeholdergroups within the categories of ‘Researchcommunity’, and ‘Professionals andpractitioners’.Subsequently, stakeholder groups related to thesedisciplines within other categories were added tothe framework. For example, community plannerswere identified as important members of theresearch community based on the criticalliterature review. Corresponding professionalplanners were added to the ‘Professionals andpractitioners’ category, and municipal governmentbranches responsible for community planningwere added to the category of ‘Policy makers andgovernments’.(ii)Supplement with collaborative networksInternet searches for working groups andcollaborative networks related to older adults’mobility and the built and the social environmentfurther facilitated the identification of specificstakeholder groups. A list of ‘potential partners’identified by the Canadian Coalition LinkingAction and Science for Prevention wasparticularly useful resources to guide our search[25]. In many instances the networks could beconsidered relevant stakeholders in and ofthemselves, and were added to the framework.However the collective interest of such groupsmay differ from the individual memberorganizations, thus these smaller stakeholdergroups were also individually added. At times,stakeholders identified through this process didnot readily fit within the broader categories,leading to revisions of the stakeholdercategories and reorganization of the framework.A notable example was the addition of acategory for ‘Private business’, not originallyincluded in the categories adapted fromTrochim and Kane [23].3. Solicit feedback from expert informantsFeedback from four expert informants was collectedto ensure that the stakeholder framework reflectedthe realities of practice and included importantstakeholder groups that may have been missed inour search of the literature. Expert informantscollectively represented policy makers, researchers,practitioners and service providers. All invitedinformants participated and suggestedimprovements on a draft of the stakeholderframework.Overall, informants expressed agreement with thestakeholder categories and organizational structure ofthe framework. Each informant identified some specificstakeholder groups and organizations to be added, andre-categorization of a few specific organizations was sug-gested. The feedback was particularly helpful in furtherdeveloping the categories of ‘Civil society organizations’and ‘Private business’, as these were the stakeholder cat-egories most poorly informed by the literature. Classify-ing non-governmental organizations according to theservices provided, helped structure the ‘Civil societyorganization’ category. It also helped identify ‘Private busi-ness’ stakeholders and ‘Health and social service providerorganizations’ that work to support similar causes. For ex-ample numerous civil society organizations provide sup-port for people with disabilities; however governmentagencies (classified as ‘Health and social service providers’)also address these needs, as do private businesses that pro-vide supplies and disability-oriented services. These add-itional stakeholders were incorporated into the finalframework, and informed development of sub-categories.The practice-based insight of expert informants alsohelped identify some specific government departments,collaborative networks, and additional grey literature onrelated older adult programs [26].Final stakeholder frameworkFeedback from the expert informants and co-authorsguided revisions to the stakeholder framework resultedin the final version shown in Figures 1 and 2. The con-densed version of the framework shown in Figure 1highlights the general categories of stakeholders relatedto the intersection of older adult mobility with the builtand social environments. These include: (1) Public, (2)Policy makers and governments, (3) Research commu-nity, (4) Practitioners and professionals, (5) Health andsocial service providers, (6) Civil society organizations,and (7) Private business. This figure is further groundedin stakeholder theory as it reflects Freeman’s original‘hub and spoke’ diagram [19].Figure 2 captures the rich contributions of thisprocess, as it elaborates on these categories, identifyingsubset groups of relevant stakeholders. Although specificorganizations are not named in this publication, the it-erative process of identifying specific organizations anddetermining which broader categories of stakeholdersthey belonged to was critical to the creation process ofthe framework. Development of new categories spurredthe identification of specific groups, just as the identifi-cation of specific groups informed the development ofnew categories. The large number of stakeholders identi-fied in Figure 2 demonstrates the diversity of individualsand organizations related to the intersection of olderadult mobility with built and social environments.Schiller et al. BMC Public Health 2013, 13:428 Page 6 of 9http://www.biomedcentral.com/1471-2458/13/428DiscussionWe present a framework of stakeholder categories andapplied it to the intersection of older adult mobility withthe built and social environments. The result was a com-prehensive, framework of stakeholder categories that canbe used to understand older adult mobility. Further-more, the novel process of stakeholder identification canbe applied across health disciplines in other conceptmapping projects to understand various matters of pub-lic health concern. For example, one area of research towhich our framework may be readily adapted is thegrowing study of environmental and policy approachesfor promoting physical activity [16,17].The details of the process of stakeholder identificationare of particular value to the literature. The aim of sys-tematic identification of stakeholders is to ensure com-prehensive representation of diverse perspectives on anissue. Poorly structured or unsystematic stakeholderidentification risks missing valuable perspectives or lim-iting participation to groups readily known to health re-searchers. Often marginalized groups and the public’sperspective is lacking from academic literature [20].Without a framework or structured method of identifi-cation, omissions may go undetected. Our frameworkdoes not eliminate the risk of omissions, but is a guideto identifying stakeholder groups and helps identifywhich perspectives may be missing. Our review of stake-holder theory and concept mapping literature suggestedthree general techniques for stakeholder identification:brainstorming, key informant interviews, and snowballsampling. These techniques broadly capture methods ofidentifying stakeholders, but they fail to provide a de-tailed process required to ensure systematic identifica-tion of relevant stakeholders. Another approach is torely on existing frameworks of stakeholder categories toprovide a starting point for systematic identification;however such frameworks – particularly as they relate tohealth – were not commonly cited in literature.In applying the results of this study to futurestakeholder-based projects, we encourage public healthresearchers and practitioners to use a framework ofstakeholder categories to inform their selection of partic-ipants. At a minimum, categories of stakeholders add alevel of structure to subsequent brainstorming and facili-tate the identification of missing groups. The seven cat-egories of stakeholders developed in this study (Public,Policy makers and governments, Research community,Professionals and practitioners, Health and social ser-vices providers, Civil society organizations, and Privatebusiness) may serve as a template for health-related pro-jects and may be adapted to specific areas of research.Even if all the groups identified are not invited to par-ticipate, these missing perspectives may be acknowl-edged as a limitation of the final results, or justificationfor their exclusion clearly stated. The process of system-atic stakeholder identification can thus increases themethodological rigour of concept mapping and otherstakeholder-based projects.In applying this framework to future research on olderadult mobility and the built and social environment,stakeholders identified in Figure 2 can be further speci-fied to reflect the regional context of interest. Forexample, specific provincial, state, or municipal stake-holders could be identified depending on the scope ofstudy. Initially a national scope was proposed for theconcept mapping project that motivated this project.However, as the stakeholder categories of our frameworkdeveloped, a provincial focus was adopted to providebetter context for the stakeholder chart and a more feas-ible scope for the project.One of the biggest challenges in developing a frame-work of stakeholders is representing a complex, intersec-tional issue in a simplistic model. Distinctions betweenresearchers, professionals, and policy makers, for ex-ample, are intuitively convenient but blurred in practice.Many disciplines, and even individual people, fulfill amultiplicity of roles and could be classified under severalstakeholder groups. The task of identifying and organiz-ing stakeholder groups within categories thus proved tobe a challenging conceptual exercise, and more thanmere ‘filling in the blanks’ of a generic framework. It isour intent that this framework and process of stake-holder identification will enable other health researchersto complete the task more effectively.Which stakeholders should and do participate in anystakeholder-based project depend on a number of fac-tors. Thoughtful identification of stakeholders does notin and of itself guarantee comprehensive participation inpublic health and concept mapping projects; recruitmentand engagement strategies will also be required to en-sure participation of desired groups. Prioritization ofstakeholders is also often required, and this may limitthe breadth of participation. We, like others[20], cautionresearchers against prematurely limiting the scope of iden-tified stakeholders, as even remotely affected groups mayprove to be important contributors. Concern of identifyingtoo many or irrelevant stakeholders should not inhibit aninitial thorough assessment of stakeholder groups. Whensubsequent boundaries must be drawn, it should be onwell-founded, clearly articulated criteria [20].This project had an explicit health focus, as older adultmobility was the main outcome of interest. Prioritizinghealth helped define the scope and refine the analyticapproach used to create the framework. Recognizing, asothers have [21], that researchers are often stakeholdersin the issues under study, we took steps to enhance ob-jectivity in developing the framework before startingother projects. For example, in order to facilitate aSchiller et al. BMC Public Health 2013, 13:428 Page 7 of 9http://www.biomedcentral.com/1471-2458/13/428systematic, literature driven process of stakeholder iden-tification, the initial framework was created by a singleauthor (CS) previously external to the project. Thisprocess was complemented by feedback from co-authorsand external expert informants with diverse expertise tominimize the bias of any one perspective. Although thisframework was developed within the regional context ofBritish Columbia, we have provided direction on how itcan be generalizable to other settings. We can also attestto the utility of the framework in practice. We relied on itto identify and invite stakeholders from each of the sevencategories to participate in our concept mapping projecton older adult mobility and the built environment [11].As with any review of the literature, our work is lim-ited by its inability to report on newly published articles.Since April 2012 when we conducted our literaturesearch, 13 new citations for “stakeholder analysis” and56 on “concept mapping” were indexed in Ovid Medline.This increase in concept mapping publications, however,reflects a growing interest in this type of research andprovides all the more justification for why a frameworkof identifying stakeholders is timely and of value.ConclusionThis paper provides guidance for those undertakingstakeholder-based projects on ways to increase themethodological rigour of participant selection. Thestakeholder framework presented is of direct relevanceto the study of older adult mobility and the built and so-cial environments, but is also of broader value to anyoneseeking stakeholder involvement and in particular forconcept mapping projects. This process of stakeholderidentification may be adapted and applied in other pub-lic health contexts to gain a broader understanding ofcomplex issues. For those to whom the intersection ofolder adults’ mobility with built environments is aninterest, the detailed framework and seven categories ofstakeholders may help identify important collaboratorsto engage in future research.As health research agendas are increasingly shaped bystakeholder involvement, critical reflection on whoconstitutes a stakeholder is warranted. Others undertak-ing stakeholder-based initiatives are encouraged tosystematically identify participants based on explicitcategorization frameworks. This added rigour in the ini-tial stages of stakeholder identification stands to enhanceour understanding of complex public health issues, andensure that critical perspectives are not overlooked.Additional fileAdditional file 1: Figure S1. Stakeholder Map of a Very LargeOrganization [19], p.55. Reprinted with permission from CambridgeUniversity Press.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsCS, MA and HH contributed to the conception of the project, and all authorscontributed to the study design. CS completed data collection and analysisfor initial framework in partial fulfillment of a Master’s Degree. CS, MA, HH,and MW contributed to refined versions of the framework. All authorscontributed to manuscript drafts and reviewed the final manuscript.AcknowledgementsWe wish to thank Dr. Ryan Allen for his guidance in developing this project,and the expert informants for sharing their insights. This work was supportedby Canadian Institutes of Health Research (CIHR) grant FRN: 116631; careeraward support for MA from CIHR and the Michael Smith Foundation forHealth Research, and CIHR Master’s Award for CS.Author details1Centre for Hip Health and Mobility, 6F-2635 Laurel Street, Vancouver, BCV5Z 1M9, Canada. 2Department of Family Practice, University of BritishColumbia (UBC), Vancouver, BC V6T 1Z4, Canada. 3Faculty of Health Sciences,Simon Fraser University (SFU), Burnaby, BC V5A 1S6, Canada.Received: 23 October 2012 Accepted: 29 April 2013Published: 2 May 2013References1. Boote J, Telford R, Cooper C: Consumer involvement in health research: areview and research agenda. Health Policy 2002, 61(2):213–236.2. Israel BA, Schulz AJ, Parker EA, Becker AB: Review of community-basedresearch: assessing partnership approaches to improve public health.Ann Rev Publ Health 1998, 19(1):173–202.3. 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Health Pol Plann 2000,15(3):338–345.22. Manafò E, Petermann L, Lobb R, Keen D, Kerner J: Research, practice, andpolicy partnerships in Pan-Canadian coalitions for cancer and chronicdisease prevention. J Publ Health Manag Pract 2011, 17(6):E1–E1.23. Trochim W, Kane M: Concept mapping: an introduction to structuredconceptualization in health care. Int J Qual Health Care 2005, 17(3):187–191.24. Hyder A, Syed S, Puvanachandra P, Bloom G, Sundaram S, Mahmood S,Iqbal M, Hongwen Z, Ravichandran N, Oladepo O, et al: Stakeholderanalysis for health research: case studies from low- and middle-incomecountries. Public Health 2010, 124(3):159–166.25. Canadian Partnership Against Cancer: Coalitions Linking Action and Sciencefor Prevention (CLASP) Phase I Report. Toronto: Canadian Partnership AgainstCancer; 2009.26. Gallagher E, Scott V: Taking S.T.E.P.S. ; Modifying Pedestrian Environments ToReduce The Risk Of Missteps And Falls. Canada: University Of Victoria SchoolOf Nursing; 1995.doi:10.1186/1471-2458-13-428Cite this article as: Schiller et al.: A framework for stakeholderidentification in concept mapping and health research: a novel processand its application to older adult mobility and the built environment.BMC Public Health 2013 13:428.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSchiller et al. BMC Public Health 2013, 13:428 Page 9 of 9http://www.biomedcentral.com/1471-2458/13/428


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