Virtual reality (VR) is increasingly used in healthcare settings as recent technological advancements create possibilities for diagnosis and treatment. VR is a technology that uses a headset to simulate a reality in which the user is immersed in a virtual environment, creating the impression that the user is physically present in this virtual space. Despite the potential added value of virtual reality technology in healthcare, its uptake in clinical practice is still in its infancy and challenges arise in the implementation of VR. Effective implementation could improve the adoption, uptake, and impact of VR. However, these implementation procedures still seem to be understudied in practice. This scoping review aimed to examine the current state of affairs in the implementation of VR technology in healthcare settings and to provide an overview of factors related to the implementation of VR.To give an overview of relevant literature, a scoping review was undertaken of articles published up until February 2022, guided by the methodological framework of Arksey and O’Malley (2005). The databases Scopus, PsycINFO, and Web of Science were systematically searched to identify records that highlighted the current state of affairs regarding the implementation of VR in healthcare settings. Information about each study was extracted using a structured data extraction form.Of the 5523 records identified, 29 were included in this study. Most studies focused on barriers and facilitators to implementation, highlighting similar factors related to the behavior of adopters of VR and the practical resources the organization should arrange for. However, few studies focus on systematic implementation and on using a theoretical framework to guide implementation. Despite the recommendation of using a structured, multi-level implementation intervention to support the needs of all involved stakeholders, there was no link between the identified barriers and facilitators, and specific implementation objectives or suitable strategies to overcome these barriers in the included articles.To take the implementation of VR in healthcare to the next level, it is important to ensure that implementation is not studied in separate studies focusing on one element, e.g., healthcare provider-related barriers, as is common in current literature. Based on the results of this study, we recommend that the implementation of VR entails the entire process, from identifying barriers to developing and employing a coherent, multi-level implementation intervention with suitable strategies. This implementation process could be supported by implementation frameworks and ideally focus on behavior change of stakeholders such as healthcare providers, patients, and managers. This in turn might result in increased uptake and use of VR technologies that are of added value for healthcare practice. Contributions to the literatureVirtual reality is an innovative technology that is increasingly applied within different healthcare settings. Despite its potential to improve treatment, the adoption and uptake of VR are generally lacking.In this scoping review, we identified factors related to the implementation of VR that are important for successful adoption and effective use in practice. However, most often these factors are not sufficiently translated from research outcomes to healthcare practice.The findings of this scoping review contribute to the recognized gaps in the literature, stating recommendations for practice and future research on the systematic implementation of VR in healthcare.Virtual reality (VR) is increasingly used in healthcare settings as recent technological advancements create possibilities for diagnosis and treatment. VR is a technology that uses a headset to simulate a reality in which the user is immersed in a virtual environment, creating the impression that the user is physically present in this virtual space , 2. VR oRegarding uptake in clinical practice, VR is still in its infancy , 12. VarNot only VR uptake is challenging, but also other eHealth technologies experience similar difficulties in implementation . eHealthOne of the reasons for the lacking uptake of  technology is the complexity of the implementation process , 19. Thenon-adoption, abandonment, and challenges to scale up, spread, and sustainability of technology-supported change efforts in health and social healthcare [While implementation interventions could help the systematic implementation of VR, they are rarely used in practice. A way to stimulate systematic implementation and help develop an implementation intervention is by using an implementation model to guide this process. While a broad range of implementation models have been developed, there is still limited use of these models to structure the implementation of VR in healthcare . One fraalthcare . The NASalthcare . The fraalthcare . HoweverIn summary, virtual reality interventions have the potential to improve the quality of care, but only if implemented thoroughly. As VR use becomes more prevalent, studies should expand the focus to identify factors specifically related to the implementation of this new technology . It is ahttps://doi.org/10.17605/OSF.IO/5Z3MN. OSF is an online platform that enables researchers to plan, collect, analyze, and share their work to promote the integrity of research. This scoping review adheres to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [To address the study aims, a scoping review was undertaken on the current state of affairs regarding the implementation of virtual reality in healthcare settings. Due to the broad scope of the research questions, a scoping review is most suitable to examine the breadth, depth, or comprehensiveness of evidence in a given field . As a reSMA-ScR) .A comprehensive, systematic electronic literature search was undertaken using three databases: Scopus, PsycINFO, and Web of Science. In each database, the same search strategy was used. Search terms were identified and included in the search strategy for three main categories relevant to the research questions: implementation, virtual reality, and healthcare. The search terms within a category were combined using the Boolean term “OR” and the term “AND”was used between the different categories. The search strategy was piloted to check if keywords and databases were adequate and adjustments were made whenever necessary. The full electronic search strategy can be found in Appendix All identified records published up until February 2022, that were peer-reviewed, and written in English, Dutch, or German, were included in the initial results. All references and citation details from different electronic databases were imported into the online review management system Covidence and duplicate records were removed automatically. A three-step screening approach, consisting of a title, abstract, and full-text screening, was used to select eligible studies.Records were included if the titles indicated that the article focused on VR within a healthcare setting and that VR was used as a tool for prevention or treatment of patients. Because of the possibility of implementation not being mentioned in the title, broad criteria were used to prevent the unjust exclusion of relevant studies. In addition, records were included if they outline (parts of) the implementation process of VR technology . Furthermore, the primary target group of the VR technology had to be patients with mental or physical disorders. If the studies focused solely on augmented reality (AR) or mixed reality (MR) and/or described a VR technology that was utilized to train healthcare professionals, they were excluded. Additionally, studies were excluded if full texts could not be obtained or if the study design resulted in no primary data collection, such as meta-analyses, viewpoint papers, or book chapters.In the first step, two authors (MK & HK) screened all titles for assessment against the inclusion and exclusion criteria for the scoping review. Titles were included based on consensus between both authors. In the event of doubt or disagreement, the title was discussed by both authors. After screening the titles, both authors screened and assessed the abstracts using the inclusion and exclusion criteria. Abstracts were included or excluded based on consensus. In the final step, one author screened the full-text articles (MK). Reasons for excluding and any reservations about including were discussed with the other authors. The results of the search are reported in full and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram  Fig. 1)1).Fig. 1The data extraction of this scoping review is mostly based on the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions . A systeTo answer the first and second research questions, the fragments from the data extraction forms were coded inductively. To answer the third and fourth research questions, fragments were first coded deductively, based on the main categories of the NASSS framework: technology, adopters, organization(s), wider system or embedding, and adaptation over time . Second,The search strategy, the number of included records, and the reasons for full-text exclusion are provided in Fig. n = 13), quantitative cross-sectional (n = 10), and studies that used qualitative as well as quantitative methods (n = 6).An overview of the characteristics of the 29 included records and the used VR technology is provided in Appendix n = 11) or decrease anxiety in patients with a stress-related disorder (n = 2). In addition, it was applied to offer distraction or relaxation during medical procedures (n = 4). In addition to the variety in settings and applications of VR, the type of technology that was applied differed as well: from interactive VR (n = 26), in which patients can be immersed in a virtual environment, such as a shopping street or a restaurant, via a VR headset and interact with this environment, to (360°) videos (n = 4) in which patients are immersed in a virtual environment shown on a (computer) screen, with limited to no possibility for interaction.Of the 29 included records, 11 focused on VR use in rehabilitation clinics. Additional settings in which VR was applied are general health clinics, mental health clinics, or clinics for specific disorders, e.g., eating disorder clinics or burn clinics. The goal of VR technology was often to be of added value as a treatment tool. It was used to improve movement in rehabilitation patients   or the DThis scoping review was conducted to provide insight into the current state of affairs regarding the implementation process of virtual reality in healthcare and to identify recommendations to improve implementation research and practice in this area. This review has resulted in an overview of current implementation practices. A broad range of study designs was identified: from qualitative studies that described expected factors of implementation, to quantitative methods that summarized observed factors. From the included studies, it can be concluded that the main focus of the implementation of VR is on practical barriers and facilitators, and less attention is paid to creating a systematic implementation plan, including concrete implementation objectives, developing suitable implementation strategies to overcome these barriers, and linking these barriers or facilitators to clear implementation outcomes. Only two studies described objectives for implementation and the practical strategies that were used to reach these objectives. Most implementation strategies that were described were related to practical resources and organizational support to create time and room for healthcare providers to learn about VR and use it in treatment. Despite differences in the type of VR technology, healthcare settings, and study designs, many studies identified the same type of barriers and facilitators. Most identified barriers and facilitators focused on the adopter system and organization categories of the NASSS framework , e.g., tDespite the importance of concrete strategies to successfully implement VR  and the The importance of focusing on the behavior change of all involved stakeholders, such as healthcare providers, patients, support staff, and managers, is reflected in the results of this review. Most barriers, facilitators, strategies, and recommendations are related to stakeholders within the healthcare organization that need to change their behavior in order to support implementation. For example, healthcare providers are expected to learn new skills to use VR and organizational management needs to make time and room available to support healthcare providers in their new learning needs and actual VR use during treatment. This highlights the importance of focusing on strategies that target concrete behavior of stakeholders for successful implementation. Identifying concrete behavior that is targeted in an implementation intervention can help describe who needs to do what differently, identify modifiable barriers and facilitators, develop specific strategies, and ultimately provide an indicator of what to measure to evaluate an intervention’s effect on behavior change . The focTo design implementation interventions that focus on the behavior change of stakeholders, existing intervention development frameworks can be used. An example is Intervention Mapping (IM). Intervention Mapping is a protocol that guides the design of multi-level health promotion interventions and implementation strategies , 66. It The results from this review provide various points of departure for future implementation research and implications for practice. An important implication for both is the need for a systematic approach to the implementation process. Most studies identified in this review focused only on barriers or facilitators to implementation, not paying attention to the systematic process of developing an implementation intervention that specifies implementation objectives, describes suitable strategies that fit with these barriers and facilitators, and conceptualizes implementation outcomes to evaluate the effectiveness of these strategies. The development of an implementation intervention should preferably be supported by theoretical implementation frameworks such as the Consolidated Framework of Implementation Research , or the In addition, it could be valuable to focus on existing intervention development frameworks, such as Intervention Mapping, to guide the design of a complete implementation intervention. Future research could apply these existing frameworks in an implementation context, reflect on the similarity in working mechanisms and evaluate their influence on the implementation process and the behavior change of the involved stakeholders. This way, a first step in identifying the added value of systematic implementation intervention development can be made.Furthermore, as being aware and convinced of the added value of VR within the treatment of patients is seen as an important facilitator of implementation for healthcare providers and organizations, it would be valuable for future research to focus on the evaluation of the efficacy of VR within healthcare practice. However, this raises an interesting paradox. Healthcare organizations and healthcare providers would like to have evidence of the added value of VR before investing in the technology for its implementation, but the efficacy of VR in practice can only be determined in an ecologically valid way when it is already thoroughly implemented in healthcare practice.This review set out to give an overview of factors that are related to the implementation practice of VR in healthcare. A strength of this study is that it used the NASSS framework to structure the analysis and review process. The use of an implementation framework contributed to systematic data collection and analysis, which can increase the credibility of the findings . HoweverFurthermore, when titles of screened records did not focus on the implementation process of VR, e.g., studies that only focused on usability or effectiveness, they were excluded. Since usability studies could still partly focus on implementation, this may have caused us to miss publications that could provide interesting insights on implementation but whose main focus was other than that. We tried to overcome this limitation by selecting detailed inclusion and exclusion criteria for the literature search and abstract screening. The study was excluded only when there was no indication of a link between usability and implementation.In addition, the full-text screening and data-extraction process were executed by one researcher. This could have caused us to miss information related to the topic. However, since the researcher used inclusion criteria that were thoroughly discussed during the title and abstract screening, and used a detailed data-extraction form, the chances of missing information are considered to be low. Furthermore, the first and second authors both extracted data from a few full-text articles, and in case of doubt, full-text were discussed with both authors.Furthermore, because this scoping review aimed to provide an overview of the current state of affairs related to the implementation of VR in healthcare, all available studies were included, regardless of their quality and type of results. This is in line with the general aim of scoping reviews, which is to present a broad overview of the evidence on a topic. Since a quality assessment was not conducted, not all results of included studies might be valid or reliable. In addition, most of the barriers, facilitators, and recommendations stated in this review are observed in studies that took place after actual implementation. However, some of these factors were mentioned as potential factors related to implementation in studies that collected data before actual implementation. These factors were described as expected factors by involved stakeholders, but not observed. Therefore, these findings should be interpreted with care.This scoping review has resulted in an initial overview of the current state of affairs regarding the implementation of VR in healthcare. It can be concluded that in the included publications, a clear focus on practical barriers and facilitators to the implementation of VR has been identified. In only a few studies implementation frameworks, specified strategies, objectives, or outcomes were addressed. To take the implementation of VR in healthcare to the next level, it is important to ensure that implementation is not studied in separate studies focusing on one element, e.g., therapist-related barriers, but that it entails the entire process, from identifying barriers to developing and employing a coherent, multi-level implementation intervention with suitable strategies, clear implementation objectives and predefined outcomes. This implementation process should be supported by implementation frameworks and ideally focus on behavior change of stakeholders such as healthcare providers, patients, and managers. This in turn might result in increased uptake and use of VR technologies that are of added value for healthcare practice.


The untimely and serial death of the physician residents in recent months in Iran shocked the public and the profession, and refocused consideration on young physicians.Physician residents refers to early career physicians in training immediately after graduation from medical school . AlthougThis story of extreme work pressure and lack of support, which has been experienced as unbearable, is pure tragedy . This paThere is no official report on physician trainee's death in Iran; however, local reports have shown that the 13th physician trainee in the past year has lost his life . GeneralThe World Health Organization (WHO) estimates that the world may face a global shortage of almost 4.3 million healthcare workers. The crisis in the healthcare human resource has been labeled as one of the most pressing global health challenges  and 300 Fatigue, frustration, heavy responsibility in medical wards, undeserving treatment from higher levels, assignment of increasing numbers of shifts as punishment, and witnessing the untimely death of their colleagues have given this group a sense of abandonment . They haThe reports show that new physicians are not being recruited; instead, residents are assigned to work in COVID-19 wards. There have also been instances where specialists in unrelated fields, such as ophthalmology, have been used to triage cases in COVID-19 sectors.Researchers believe that fostering healthcare working conditions that supports intrinsic motivation and improves working hours, as well as rewarding physicians fairly and equitably may preclude burnout and job dissatisfaction .In Iran, medical trainees, who are mostly of marriage or reproductive age, either show no intention to start a family due to high work pressure and stress; or, if they marry, do not have children because of their poor economic conditions and considering that childbirth-related leave is not included in their service period.Although medical education in Iran is free, those who are transferred from foreign universities to state universities are forced to take a supplementary course and pay a heavy annual tuition fee to the universities. These individuals sometimes do not even receive a small salary. The main challenges of physician trainees are listed as below.Heavy debt burdens place financial pressure on residents and this trend might have been accelerated during COVID-19 . RegardlThe recent Medscape survey on 1,509 US medical residents showed that more than half of US residents spend 1–5 nights per month on call, while nearly 92% overall spend <10 nights working .Medical residents undergo academic and practical assessment by their education department regularly once a month, and the universities issue permits for their continuation to higher years only after those assessments. However, in 2021, the insistence of the authorities in deputy of education of the Ministry of Health that centralized examinations for medical residents involve in-person examination of the resident collective, even during the fifth peak of the COVID-19 emerging pandemic, requires answers or investigation. In selected countries, nationwide examinations were postponed due to the COVID-19 pandemic  and goveUnder conditions where healthcare personnel are frustrated and suffer from intensive fatigue, the medical equipment is worn out, and the country faced crippling sanctions which may have significantly contributed to the damage to the healthcare system . SanctioCOVID-19 pandemic professed an unprecedented major challenge to the international scientific community  that traConflict of interest still remains a serious challenge in Iran's health system. The following are considered as the underlying causes of conflict of interest in the healthcare system: the structure of the existing financial system fee for service, lack of transparency in the healthcare system, existence of the problem of having two simultaneous jobs dual practice in governmental and private sector, and lack of an integrated information system and electronic healthcare structure . RecentlBased on the Accreditation Council for Graduate Medical Education (ACGME) regulations, institutes should supply sleep facilities that are quiet, safe, private, and must be accessible and available for fellows/residents to support safe patient care and education. Moreover, the institution must ensure satisfactory sleep facilities and safe transportation opportunities for fellows/residents who may be too tired to return home safely . These rThe residency program in the Iranian medical education system is considered to be a student course and therefore the student is given a low salary, bonus, and almost zero profit-sharing. However, it should be noted that physician trainees are medical doctors and Medical Council members who should work 3–5 years in the frontline of hospitals and while at the same time receiving education. By redefining the residency program as a “job” these issues could be resolved . In consThe national educational curriculum of the residency program has not been revised for many years . AdditioThese policies should be driven from higher authority levels, such as parliament, Medical Council, Ministry of Health, and universities. It is difficult to convey the deprived nature of stakeholders to higher authorities. Whistleblowers and nongovernmental organizations must be able to report directly to law enforcement and regulatory agencies and to competent authorities without risking loss of protection and risk of reprisal.The short term strategies to reduce further challenges are listed below: increasing salaries and wages, amending some post-graduation commitment laws, standardizing the number of night shifts and working hours, coercing the administration to hire medical staff instead of using trainees as low-cost employees, improving and equipping doctor's on-call rooms, providing welfare and livelihood packages with an emphasis on insurance facilities, and eliminating conflicting interests from those who interfere with education policy-making. The list of challenges has been presented in The ACGME-accredited program has recommended that institutes encourage fellows/residents to alert their higher authorities when they are concerned that another trainee or lecturer may be displaying signs of burnout, substance abuse, depression, suicidal ideation, or potential for violence . The samIn the context of COVID-19, the best way to combat burnout seems to be precise organization within the hospital and practical training sessions. Effective measures must be taken at the institutional and individual levels . HoweverDespite the significant successes in the field of knowledge and skills transfer in various clinical areas, insufficient attention is paid to personal development and communication skills. Although attention to medical ethics and professional commitment has been emphasized in the latest version of health education reform in Iran , it is qDespite several reforms within the last few decades, the Iran Ministry of Health, as the steward of the healthcare system in Iran, has not been performing efficiently enough to respond clearly to emerging challenges . With 67Protecting healthcare providers is a significant component of public health measures during the COVID-19 pandemic . SpecialThe challenge of ensuring educational equity is remarkable. Different types of quotas and exemptions apply to physician trainees administrative process in Iran. By law, the children of faculty members are allowed to change the majors of their studies (for example from veterinary sciences to pharmacy), or change the city in which they study, easily, while these possibilities are not available to other candidates . RecogniWith a mixture of success and failure, Iran's healthcare system has undergone several major reforms. Unless this essential transformation takes place within the healthcare system, sustainable development in healthcare may remain a moving goal . The perHealthcare workers are mourning the death of their colleagues and are frustrated and tired, but are still standing tall in the defense of the nation against pandemic. It is imperative that officials make haste in presenting a plan to support healthcare workers, and medical residents in particular. Physician trainees are the foot soldiers and front line of the healthcare system in the battleground for protecting people, and their hardship deserves to be noticed, if the authorities would just take note.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Systems modeling offers a valuable tool to support strategic decision-making for complex problems because it considers the causal inter-relationships that drive population health outcomes. This tool can be used to simulate policies and initiatives to determine which combinations are likely to deliver the greatest impacts and returns on investment. Systems modeling benefits from participatory approaches where a multidisciplinary stakeholder group actively engages in mapping and contextualizing causal mechanisms driving complex system behaviors. Such approaches can have significant advantages, including that they may improve connection and coordination of the network of stakeholders operating across the system; however, these are often observed in practice as colloquial anecdotes and seldom formally assessed. We used a basic social network analysis to explore the impact on the configuration of the network of mental health providers, decision-makers, and other stakeholders in Bogota, Colombia active in a series of three workshops throughout 2021 and 2022. Overall, our analysis suggests that the participatory process of the systems dynamics exercise impacts the social network’s structure, relationships, and dynamics. A system model is a tool that can be used to understand the complex causal inter-relationships that drive population mental health outcomes and can simulate policies and initiatives  to determine which are likely to deliver the best outcomes and returns on investment in youth mental health . SystemsInvolvement of stakeholders in the model-building process is particularly important in mental health, as it offers the opportunity to obtain the diverse perspectives of those working in and/or trying to navigate the system, including young people with lived (or living) experience of mental illness. This brings care providers and care receivers together into a joint process of learning and problem solving to strengthen the youth mental health system. Low-and middle-income countries (LMICs) have wider gaps in the adoption of evidence-based information to inform decision-making . DespiteThis process is reported to have several benefits such as improved model credibility, utility, and a robust basis for policy and planning dialogues which can lead to organized, evidence-informed decision making, and active advocacy . HoweverColombia is an upper middle-income country with 48 million inhabitants. It has also been recognized as the most decentralized country in Latin America . Its heaAs Koon et al.  postulat2.This study explores the impact of participatory systems modeling on a youth mental health professional network in Bogota, Colombia. It was part of a broader program of research implemented in 2021–2022. The broader research program aimed to develop a system dynamics model that can be used as a decision-support tool for strategic planning and investments in youth mental health and suicide prevention in Bogota. The research program is a collaborative international endeavor between CSART , The University of Sydney , the Swiss Tropical and Public Health Institute (Switzerland), and Pontificia Universidad Javeriana (Colombia) in collaboration with a broad range of stakeholders in Bogota. It was anticipated that the modeling would inform policymaking on the selection of strategies and services needed to strengthen the youth mental health system and mitigate the social and economic drivers of youth mental health outcomes, e.g., the prevalence of youth mental health problems, emergency department presentations, and youth suicide, in Bogota, including the exacerbation of these outcomes due to the COVID-19 pandemic.2.1.The project employed a participatory approach in the development of the system dynamics model following a similar participatory modeling approach conducted in Australia by the Brain and Mind Centre, University of SydneyA participatory process in system modeling includes actively involving stakeholders, such as experts, decision-makers, and affected community members, in various stages of the modeling process. It seeks to include diverse perspectives and knowledge to ensure a comprehensive and collaborative approach to understanding and addressing complex systems. A broad overview of the participatory system modeling process is as follows:Stakeholder Engagement: Stakeholders are identified and invited to participate in the modeling process. They may include experts from different domains, policymakers, community representatives, and other relevant parties.Problem Definition: Stakeholders work together to define the problem or issue that the system modeling aims to address. This ensures that the modeling effort is aligned with the concerns and priorities of all involved parties.Data Collection and Validation: Stakeholders contribute their expertise and knowledge to collect and validate data used in the modeling process. Their insights help ensure that the data accurately represents the real-world system being modeled. Both qualitative (interviews and surveys) and quantitative  data are collected. Stakeholders review the data in a validation workshop to ensure accuracy.Model Co-creation: Stakeholders collaborate with modelers to develop the system model. They actively contribute their insights, assumptions, and feedback throughout the modeling process in an iterative process.Scenario Development: Participating stakeholders are involved in generating and exploring different scenarios within the model. These scenarios can represent potential interventions, policy changes, or other strategies to address the identified problem.Model Interpretation and Policy Insights: Stakeholders engage in interpreting model results and drawing policy insights guided by the facilitators of the workshop. Their diverse perspectives can lead to a deeper understanding of the system’s behavior and the potential impacts of different interventions.Decision-making and Implementation: Participatory modeling aims to inform decision-making processes. Policymakers and stakeholders use the model results and insights to make informed choices and implement effective strategies.By involving stakeholders throughout the system modeling process, participatory modeling fosters transparency, ownership, and collective learning. It enhances the credibility and relevance of the model’s outcomes and ensures that the modeling effort serves the interests and needs of the people affected by the system under study. This is achieved by providing a safe environment where participants are able to contribute without been judged, there are no right or wrong answers, they hear the participants’ opinions and as such they can also reflect on the mental health network and the relevance of them in their work. In addition, by hearing each other concerns, expertise, contribution and efforts, participants also got a basis to reflect in the importance of communication and collaborative work.2.2.The participatory process was conducted with a multidisciplinary group of stakeholders through three workshops. The participants were purposefully selected from the local Bogota youth mental health system and included a diversity of policymakers, providers at all levels of care, community representatives, representatives across broader health and social systems , special interest groups, civil society, young people with lived experience of mental illness, and caregivers of young people with lived experience. The SNA was part of a broader multi-scale and comprehensive evaluation approach that was employed in Bogota following a similar evaluation process conducted in Australia , 13. The2.3.We followed the stakeholders’ views and perceptions of their network, before, during, and after the series of modeling workshops to explore how the participatory process affected participants’ perspectives and collaboration/connection within the Bogota youth mental health network. Since we could not identify a validated survey to be applied to our needs, we followed the process suggested by Monaghan et al.  of usingi) map the stakeholders involved, the way they are linked, assess the influence of the actors, and determine the structure of the network; and (ii) how these former characteristics change after the participatory activities. All research activities were approved by the Institutional Ethics Committee of the Pontificia Universidad Javeriana (protocol number 2020/039) and participants provided their informed consent to take part in the study.To determine the impact of the PSM on the local social network of mental health, we used a basic SNA, which is a quantitative method that uses graph theory and sociograms to analyze and visualize social relationships, where nodes represent the actors, and lines represent their relationships . Therefo2.4.Stakeholders were recruited to attend three participatory modeling workshops between the September 2021 and March 2022, which coincided with the COVID-19 pandemic. This imposed several restrictions that required adaption of the usual conduct of workshops. For example, each workshop was undertaken as several smaller workshops over the course of a week rather than as one large workshop on a single day—due to social distancing requirements and constraints on room capacity—which might or might not have restricted the ability of all stakeholders to engage with each other. Purposive sampling was used to identify and recruit participants for the SNA within the range of expertise needed. The participants selected from Bogota were representative of the diversity of stakeholders in the system.2.5.Shortly after recruitment, the participants were interviewed using a semi-structured interview guide to capture initial impressions and perceptions before their engagement in the participatory process. They were also requested to complete a survey before the first workshop and following the third workshop. The survey questionnaire complemented the interviews by asking similar questions to validate the qualitative data; but the survey, however, contained additional question modules to collect social network data from the stakeholders before and after the participatory workshops. The survey was created using the REDCap software and distributed using a digital link sent by email or instant messaging apps to all the participants before the first workshop (baseline), and after the third and final workshop (end line). The respondents could fill out the survey either in advance of their participation or at the start/end of the workshop. The surveys and interviews contained several questions that served the broader evaluation and are reported somewhere else. The survey’s specific module on SNA contained questions to find out to whom each of the represented organizations was connected, what kind of professional relationship or link they may have, i.e., administrative, implementation or research, and the frequency of the interaction between the linked organizations see .The data collected through the surveys before the first workshop and after the third workshop was analyzed to detect changes in the connections or structural patterns measured. Only those participants that attended all three workshops were considered in the analysis to reduce the risk of confounders and increase the attribution likelihood to the workshop .indegree centrality), i.e., the nodes with whom most of the other nodes have an interaction with, the nodes that send the most links , i.e., the nodes that have the most interactions with other nodes, and the distance between nodes measured by their links    . We alsotrality) . The comhttps://kumu.io). Kumu is an online system mapping tool and visualization platform for mapping systems and relationships that facilitates quantitative analysis using the metrics shown in In the survey, we asked the participants to identify the group that they were representing and to indicate the relationship that their organization has with other stakeholders within the network. As shown in 3.n = 24). The considered participants represented 11 stakeholder group categories , namely the Bogota’s Health District Department (HDD) and the Ministry of Health and Social Protection (MoH), which did not change from baseline to end line ,B. Both In the dimension of closeness centrality, the MoH and the HDD remained as the dominating actors, before and after the workshops, both of which can easily spread information to the rest of the network and hence have high visibility. This holds also for betweenness centrality, denoting high control over the flow of information within the network from these two nodes. This aligns with the fact that both organizations also rank highest in outdegree (number of outgoing connections) and indegree (number of incoming connections) connections before and after the workshops. Both MoH and HDD are the leaders of the network  according to their eigenvector centrality values see .The reach efficiency measure shows the nodes less connected that gain exposure through each direct relationship. This measurement showed a change of nodes from the baseline to the end line see . As per 4.Using a SNA to identify characteristics of a given network such as its most important actors, the most influential ones, and the visibility of others within the network, can be informative in understanding and leveraging social networks in the implementation of decisions made on the basis of the systems modeling tool. This study aimed to detect the impact of a participatory modeling approach on the youth mental health stakeholder network in Bogota, Colombia and contribute to the evidence on this topic. The findings suggest that the use of SNA can be an important tool to understand the change over time in a professional network and the role and influence of stakeholders within it after a PSM. For example, similar to a physical network, a social network has an intrinsic level of rigidity, which is the degree of resistance to change or deformation in its structure , 28. RigOur findings demonstrated that in Bogota, the network’s general measures, such as the number of connections, density, reciprocity, and average degree diminished from the baseline to the end line indicating small changes within the network and the role its members play as a result of the participatory process. These findings suggest that indeed, the participatory process had an impact on the network.The most important changes were:Connections: The number of connections in the network decreased from 321 at baseline to 308 at endline. This indicates that some connections were lost or dissolved during the intervention period.Density: The network density decreased from 0.64 at baseline to 0.57 at endline. The decrease in density suggests that the network became less connected or more fragmented over time.Reciprocity: Reciprocity measures the proportion of mutual connections in the network. It decreased from 0.97 at baseline to 0.82 at endline. This indicates that fewer connections were mutual, and there was a decrease in the level of reciprocity in the network.Diameter: The diameter remained constant at 3 for both baseline and endline, indicating that the overall reach of the network did not change significantly.slightly fewer connections at the endline compared to baseline.Average Degree: The average degree slightly decreased from 19.91 at baseline to 19.13 at endline. The average degree represents the average number of connections each node has in the network. The decrease in average degree suggests that, on average, each node had slightly less efficient in terms of communication and information flow between nodes in relation to the network’s original structure.Average Path Length: The average path length increased from 1.45 at baseline to 1.52 at endline. The increase in average path length indicates that the network became Changes in MICMAC Exposure:At baseline, the Ministry of Health and Health Department had the highest exposure values (both at 1), indicating that they were significantly affected by other nodes in the network.At endline, the Universidad de los Andes and the Ministry of Health had the highest exposure values, suggesting a shift in the nodes that were most influenced or affected by others.Changes in MICMAC Influence:At baseline, several nodes had a high influence value of 1, including the National Health Observatory, School of Medicine, and others. This indicates that these nodes were influential in shaping the network’s dynamics.At endline, the Ministry of Health, Social or community organization, Health District Department, and other entities emerged as influential nodes.These findings impacted the network in the following ways:Structural Changes: The decrease in the number of connections, density, and reciprocity, as well as the increase in average path length, suggest that the network became less cohesive and potentially less effective in information exchange and collaboration between nodes.Shift in Influence: The changes in MICMAC influence reveal a shift in influential nodes within the network. At baseline, certain organizations, such as the National Health Observatory and School of Medicine, held significant influence. However, at endline, the Ministry of Health and other entities emerged as more influential, e.g., Insurance representatives see .Impact of the PSM: The participatory process likely led to changes in the network’s composition and dynamics. Some nodes may have gained or lost influence, resulting in alterations in the network’s structure and connections.Role of Health Institutions: The high exposure values of the Ministry of Health and the Health Department at both baseline and endline indicate their crucial role as key nodes significantly affected by other entities in the network.It may be that the most important stakeholders were consolidated during the workshops, causing less important stakeholders to “disappear” from the network, explaining the decrease in the connections and reciprocity in the whole network. However, other small yet important changes may have also taken place since the average path length in the network was a bit larger after the workshops, i.e., a “larger” path for all possible pairs of network nodes, suggesting a repositioning of certain stakeholders, moving further away.For Bogota, the SNA measures not surprisingly showed the public health organizations as the most dominant within the mental health network, i.e., Ministry of Health and Health District Department, leading the number of connections and the flow of information. Indeed, as a policy-making institution, the MoH has a key influence in the mental health system. The measures that underwent the fewest changes between baseline and end line were reach and size, whereas the measures with the most changes were betweenness, eigenvector, and MICMAC influence.Since reach and size are measures related to the structure of the network, the few changes may suggest that the network is quite rigid and not prone to change its structure easily. These findings also provide a hint that intersectoral collaboration may not be in place despite being currently encouraged by the local laws. However, the fact that measures related to influencing stakeholders presented so many changes before and after the workshops suggests that indeed, the workshops may have altered the perceived role of certain stakeholders. The participatory nature of the workshop may have facilitated contact and understanding of the multiple actors within the system, and thus changed the perception of some stakeholders within the “universe of actors” in the system. For example, according to the MICMAC influence, the Children and Adolescent Protection Institute was among the most influential stakeholders with a value of 1 at the baseline but was ranked among the least influential after the workshops, having an end value of 0. In contrast, the emergency services or police passed from a not influential value of 0 to one of the most influential ones, with a value of 0.96. Observations and discussions during the workshops about the role of emergency services may have changed the stakeholders’ perceptions of these services by the last workshop. We recognize it may be true that some of these results could be explained by the priming effects induced by the nature of the workshops, i.e., focused on youth mental health and participation . HoweverOverall, the analysis suggests that the PSM had an impact on the social network’s structure, relationships, and dynamics. The shift in influential nodes and changes in connections and reciprocity indicate potential changes in the network’s effectiveness and ability to coordinate health-related activities. However, further investigation and qualitative analysis are required to understand the specific reasons behind these changes and the implications for the intervention’s objectives and outcomes at a larger term since, e.g., the possible loss in efficiency and cohesiveness captured by the SNA maybe a transitory phase toward a more efficient one.In addition to the insights gained from the current study, SNA could offer a robust framework for future intervention development and implementation. The results of an SNA allows for targeted interventions by identifying key nodes or actors within the network who are most influential in specific aspects of a given intervention, thereby optimizing resource allocation. For example, by identifying the network member that can easily spread information an awareness campaign in mental health problems could be more effective if this member is involved in the design and implementation of the campaign. Moreover, SNA can be employed in the initial stages of intervention planning to conduct a comprehensive needs assessment, thereby ensuring that the intervention is tailored to the specific characteristics and needs of the network. The methodology also lends itself to the creation of an implementation map, pinpointing key stakeholders who are crucial at various stages of intervention rollout. Post-implementation, SNA can be a complementary tool for evaluating the impact of the intervention on network structure, offering quantitative metrics that can inform iterative improvements. Thus, SNA not only enhances our understanding of the current network dynamics but also provides actionable insights for the design, implementation, and evaluation of future interventions.4.1.i) Domination of groups of people preventing all the stakeholders from interacting with each other, or ii) increase of interaction due to being able to interact in smaller groups. Related to this, the compulsory wearing of masks may also have acted as a barrier to the development of interpersonal relationships that are important for networking. Finally, some participants attended the workshops on behalf of two or three different organizations, therefore, the answers to some questions from this type of participants could have been a mixture of perceptions of all the organizations that they represented and/or being a dominant perception by one of the organizations they represented.A limitation of our study is that we sought to undertake only a basic SNA analysis leaving out some other aspects that could also have provided greater insights into how and why the participant network changed. This decision was made on the basis of not overburdening participants given their participation in the participatory modeling workshops as well as the broader evaluation with quantitative and qualitative components. However, the method used did answer the primary research question by being able to detect changes in the social network as a result of the participatory process. This demonstrates the value and feasibility of the approach as part of an evaluation framework for future applications of participatory systems modeling . Another5.Insights provided by this SNA suggest that the participatory approach to systems modeling can impact the relationships between stakeholders and organizations that provide mental health services to young people. The insights from an SNA can assist with identifying the ideal actors within the network, e.g., most influential ones, to distribute information, support initiatives, and foster collective action to improve the mental health system, which in turn can assist decision makers and program designers to form more efficient partnerships in the aftermath of a PSM. The information provided by an SNA can be combined with other insights in available from more traditional evaluation tools applied to participatory processes, e.g., qualitative insights, such as stakeholder interviews and observational notes, to provide additional context for network structures and relationships supporting the co-generation of local and scientific knowledge and cooperation between scientists and decision-makers.The original contributions presented in the study are included in the article/SC: Conceptualization, Formal analysis, Methodology, Writing – original draft. AH: Writing – review & editing. LO-P: Writing – review & editing. MS-N: Investigation, Project administration, Writing – review & editing. DS-R: Data curation, Investigation, Validation, Writing – review & editing. GL: Writing – review & editing. J-AO: Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing.


Background: An emerging service delivery model of integrating health and social care for older people has been actively promoted by the Chinese government since 2016, but the client experience and influencing mechanism still remain unclear. Methods: this study adopts a qualitative methodology to delve deeper into the factors and mechanism shaping the client experience of residential integrated health and social care for older people in the Chinese context, so as to understand the experiences of older residents during the whole process of receiving integrated care services, and on this basis, put forward suggestions for the improvement of a high-quality aged care service system. We coded and analyzed the in-depth interview data of twenty older adults and six staff members from June 2019 to February 2020, recruited from six institutions in Changsha, one of the ninety pilot cities for integrated health and social care in China. Results: the findings showed that the client experience of older adults is mainly affected by factors in three dimensions , which are comprised of six sub-categories . Based on the factors and mechanism (consisting of six influencing paths), we constructed a model of the client experience of integrated health and social care for older people in the Chinese population. Conclusions: the factors and mechanism influencing the client experience of integrated health and social care for older people are complex and multifaceted. Attention should be paid to the direct effects of perception and emotion, institutional functions, intimacy and trust in the client experience, and the indirect effects of social foundation and participation on the client experience. China is currently experiencing a surge in its aging population, which continues to increase rapidly. At the end of 2021, 14.2% of the population were aged 65 years and older, up from 7% in 2000 . Given tYiyang Jiehe’ in Chinese—was scheduled to be actively promoted No. 35), which officially pointed out, for the first time, that a service mode delivering integrated health and social care for older people—referred to as ‘promoted . Since 2Yiyang Jiehe’ was published in 2005 [In addition to changes in policies and practices, Chinese research has been enhanced by the international concept of ‘integrated care’. Since the first piece of Chinese academic literature with the theme of ‘ in 2005 , related in 2005 .However, most studies have focused on expounding the theoretical basis of the integrated service delivery models , analyziThe perspective of service recipients should be valued more highly in integrated care for older people, focusing on the following two aspects. First, the older adults’ individual experiences form a core value of person-centeredness in care . The cliResearch on customer-value orientation and the quality-of-care orientation have different definitions of the client experience, but they all focus on service recipients’ subjective feelings and judgments during and after the journey through the care service system . AlthougThis research was designed to explore the influencing factors and mechanism of the service experience of integrated health and social care for older people, based on the qualitative method of grounded theory. This method searches for the core concepts reflecting social phenomena in the systematic collection of data, and then constructs theories from the bottom up through exploring the connections among these concepts . CompareThe study sample was taken from institutions delivering integrated health and social care to older people in Changsha City, Hunan Province, China. Hunan is one of the most aging provinces in China. In 2000, Hunan formally became an aging society, and since then, the aging rate has accelerated. In 2020, 14.8% of the total population in Hunan Province were older people aged 65 and over, an increase of 5.04% and 7.37%, respectively, compared with 2010 and 2000. As the provincial capital city of Hunan, Changsha was selected as one of the initial national pilot cities of integrated care for older people in 2016, and has made remarkable achievements in the ‘expanding existing institutions’ mode of health and social care integration. In the list submitted to the central government in 2022, for the election of national-level demonstration institutions of integrated health and social care for older people, the Changsha region accounted for five out of nineteen institutions in Hunan.In accordance with the principle of theoretical sampling advocated by the grounded theory method ,25, fromIn this study, face-to-face in-depth interviews were used to collect data. The interviewers were five senior postgraduate students under the supervision of a professor in Social Medicine and Health Care Management. The research team had received training in grounded theory and communication skills. According to the requirements of grounded theory, the interviewers did not begin with a fixed, strict, and unified outline. The five interviewers independently conducted the interviews without any interferences or presets. During the interviews, they did not interrupt the speech of older residents, and avoided inducing behaviors. Therefore, the data collection process consisted of two phases. The first one was a small-scale preliminary interview, mainly inquiring about the most urgent needs of older people, their feelings about the health and social care services delivered by the institutions, and their satisfaction with the national support policies for older people. The feedback from this phase was used to determine whether the scope of the existing interview questions needed to be widened, or if a new group of interviewees in other institutional settings needed to be involved. Thus, in the second phase, a detailed investigation of the older individuals’ family situation, economic conditions, social status, mental health, and interpersonal communication was added to the interview  coding the inconsistent results separately, and then discussing them together; (2) making judgments based on opinions of a third person when there is a conflict of views; (3) referring to the literature. All the information was synthesized into a verbatim manuscript of more than 70,000 words. One researcher interpreted the meaning of the data through constant comparisons, gradually reducing, transforming, and abstracting the original data into higher-level concepts and categories, and proposing a conceptual framework through in-depth analysis of the nature, characteristics, and relations of the categories. In the entire process, the data were compared, summarized, and deduced in a circular manner to form a theory that conforms to the original materials. The research team agreed upon the interpretation of the results.Credibility and dependability have been used to describe various aspects of trustworthiness in qualitative content research . We beliThe encoding reliability test method, advocated by Huberman and Miles, was adopted in this study, and the scientific reliability of the encoding results was confirmed through analysis of the coding consistency percentages of two independent coders . The speFurthermore, the research team invited two professors of Social Medicine and Health Management and two care managers at the integrated aged care institutions to evaluate the degree of consistency between the results and the actual situation. Their positive feedback verified the high validity of the research results.We used NVivo 11.0 to perform auxiliary coding and analysis. Given the interviewees’ linguistic expression conventions, and the format of the data structure, sometimes multiple lines of data were needed to express a complete concept or category . TherefoTo start the data analysis, first, we applied concept naming to all the original material. Then, we merged similar concepts, establishing the ascription between phenomenon and categories. Some ambiguous or overlapping concepts had to be repeatedly compared and analyzed to complete the categorization. Next, we discovered and established logical connections between the categories by categorizing and analyzing the scattered data and integrating them again. Selective coding is the final step, which organizes the data and discovers the core category by describing the ‘storyline’ of the phenomenon .A total of twenty older adults from the six sampled institutions, across three institutional settings, formed the final sample The social foundation includes the all-round support of the economy, politics, and culture. It directly promotes the development of integrated health and social care for older people, but it has a more indirect impact on older adults’ experience, mainly through improving the service delivery of integrated health and social care . Systemi‘…not implemented… it is just not implemented by the low-level governments. There is an example: For people over 80 years old, their pensions are tens of yuan (each month) … The money in the last quarter has to be paid in the next quarter. What is the trick? Look, it’s like a game. The money in December has not arrived yet. It will not arrive until February. What do you think the trick this is? What can I do? The government is just like this… Do you think the leader is aware of this? Does he know? Nobody tells him.’ (YFa10)The social context is a part of the cognition system and cannot exist independently of cognitive activities. Compared with the macro context of the institutional system and financial investment, older people pay more attention to media reports and public evaluation, things they can access on integrated health and social care. Diversified modes of news communication are widely favored by older people, which to a large extent meet their requirements for leisure, entertainment, and daily communication convenience. The interpretation of integrated care policies by the media, and the reports of related events, could shape and affect their cognition, particularly if some biased news reports and comments mislead them. The older people bring their fragmented cognition into the service process, and compare the reality with their subjective understanding. They become constructors of information, and influence the group’s experience or satisfaction through their relationship network. For example, one older adult stated:‘You can see on the mobile phone that the babysitter steals things and abuses the older people all day long. Many children don’t know about it, and they have to install monitors to find it. There is no filial son in front of the bed after a long illness. If your own children are unwilling to serve you, how can they be sincere to you?’ (HRa16)Older adults’ experience of integrated health and social care is related to their inner perception and emotion—the two factors have been proven to be more inseparable than is commonly assumed —before a‘We can accept the bad living conditions, but the staff must be good to us, which is the most important thing. Service belongs to non-physical configuration while living conditions belong to physical configuration (of the institution). If there is only physical configuration and no non-physical configuration (here), the residence will not be interesting.’ (LLa01)‘Some old people want to go home, and their children take them back once a month. Well, I am alone. I cannot move or go home now, and everything is taken care of by them. Their services basically cover all aspects of my life, but sometimes I feel really lonely (choking…).’ (Hra16)The client experience of integrated health and social care for older people takes services or service behaviors as the carriers, and is jointly manifested through the interaction between service providers and recipients. It is worth noting that although interaction between staff and clients has been widely recognized as one of the key factors contributing to the client experience , we founWhen this interaction results in an intimate interpersonal relationship, the services delivered by the staff and institution will be more likely to gain credibility. In addition to forms of interaction, such as co-building WeChat groups with medical personnel Most studies have shown that customer participation in service production is conducive to creating happy experiences and meeting their personalized needs . More of‘Last time, I said that the food was too bland and tasteless. She told me that she did not dare to make it too salty. “Relatively mild-flavored food is good for your health, and you should take care of the taste of most seniors”, she told me that, and I understood. She said that she could cook me some slightly more flavorful meals alone, but I would definitely not accept it. It will undoubtedly increase the workload of others. After all, I am not living in my own home, and there are so many older people living here.’ (YJa13)Aims at understanding the experience of older people during the whole process of receiving residential integrated care services and making policy proposals, this study adopts a qualitative methodology to delve deeper into the factors and mechanism shaping the client experience of residential integrated health and social care for older people in the Chinese context. Overall, we found that the vast majority of older people were satisfied with their experience of integrated health and social care. Even some small-scale institutions with limited health care facilities also received high praise from older people, because such institutions tend to make improvements to the non-physical aspect of care delivery to compensate for shortcomings in the physical aspect.This study identified six factors in three dimensions  affecting the client experience of integrated health and social care for older people, and revealed how they function in the Chinese context. The results are consistent with the research of Jiun-Sheng Chris Lin et al. (2016), and generally cover the seven topics of service experience they summarized: customer/employee emotion, service employee management, service environment, customer participation, self-service technologies, service failure/recovery, and customer loyalty management . In addiThis research shows that the self-reported experience of institutional integrated health and social care for older people is grounded in the scene construction of care delivery. There are numerous critical factors in institutional characteristics, such as size, location, level, service content, etc., which all influence residents’ experience . StudiesWe also discovered that China’s social foundation—including factors of political and economic support, atmosphere of public opinion, and contradictions existing in the structure of the implementation system—indirectly impact the client experience of integrated health and social care for older people through institutional functions, such as the scale of institutions, layout of the living environment, service content, and brand image. In the Chinese context, the functions of integrated care institutions are shaped by medical and long-term care insurance policies, land-use planning, etc. Studies in China have likewise confirmed the causal relationship between policies and service quality of institutional care . PrefereConsistent with the existing studies (mostly focused on the private sector rather than the public sector), we also found that the service encounters between older adults and staff are crucial to the evaluation of service experience across the care continuum . Older aIn addition, older adults will also take the rate and nature of interaction with staff as important indicators in the evaluation of client experience. Under the condition of relatively limited care capacity, most older people are eager to receive as much attention as possible from service providers. This attention may be expected to provide timely solutions to problems reported by service users, as evidence of their participation in the process of improving the quality of care. On the other hand, inadequate participation demand and ability of older adults may hinder the staff–resident interaction in the institutional setting. From the perspective of staff, they prefer to interact more with residents with a higher degree of mental functioning, rather than with residents with a lesser degree of mental functioning .Cognition is constructed on a social foundation. This study discovered that the client experience of older people is influenced by cognition and understanding based on a social foundation. For example, the social evaluation of aged care institutions influences the choice of institutions for older people. Some previous studies have suggested that private nursing homes tend to be more popular with older Chinese people because of their better social reputation, evaluation, and publicity than their public counterparts . HoweverThis study also confirms that the perception and emotion of older people have a direct effect on client experience. Older people’s perception of services is influenced by their physical health, education level, socioeconomic status (SES), and emotions ,55. An iOn this basis, our study verifies that participation of older people can influence the client experience indirectly by affecting their perceptions and emotions. The participatory model that emphasizes collaboration and partnership can lead to changes in the balance of power between staff and clients . This baDespite its strengths in initially addressing the factors and mechanism of institutional integrated care experience among older people in China, this study has limitations in the following two aspects. First, the diversified and personalized service needs of older people with different health conditions are supposed to affect the client experience of integrated health and social care, but this study only involved older people with clear cognition and expression, failing to examine the differences in the client experience between physically or mentally disabled older people and other older people. Second, this study employed a constructivist approach, and the proposed theoretical model requires further empirical evidence. The next step is to test the fitness of the model among older adults in China and beyond, through the development of quantitative tools and structural equation modeling.Differing from the quantitative research prevalent in the extant literature on the client experience , this stFirst, as the related resources and policies of integrated health and social care for older people are still fragmented and scattered among departments of civil affairs, medical insurance, and health care, etc., China’s government needs to put more effort into reducing the cross-departmental cooperation resistance caused by uneven interest distribution, and making the service delivery smoother and more seamless. Second, the government departments should scientifically arrange the location, space, and facilities of integrated aged care institutions, matching the actual needs of older adults, by consulting and collaborating with the institutions. Institutions and practitioners are supposed to be more concerned about the self-reported experience of older residents, and accurately identify their service needs to strengthen the person-centeredness of the delivered services. Finally, as clients and co-producers, it is necessary for older adults to participate in the policy formulation and analysis, instrument development and validation, and other aspects in improving the quality of institutional integrated care. This, however, requires more authoritative institutional arrangements to guarantee.