Multi-method approaches to develop and refine a tobacco cessation workflow within a federally qualified health center

The incorporation of implementation science approaches into tobacco control program delivery remains limited. Programs developed using these approaches, including co-creation, are often more feasible and sustainable, as they are designed to consider the operational and cultural context of an organization. This study utilized multiple implementation science approaches to co-create a tobacco cessation workflow within a Federally Qualified Health Center (FQHC), where tobacco use is disproportionately higher than the national average.

In this study we conducted six structured meetings across two advisory groups between July-September 2025. Multiple implementation science methods (i.e., functions and forms , brainwriting premortem, and Practical, Robust Implementation and Sustainability Model (PRISM) assessments) were integrated to optimize the tobacco cessation workflow for future piloting, along with co-creation and evaluation methods (i.e., ethnographic observations, engagement survey) to evaluate advisory board engagement. Qualitative and quantitative data were collected and analyzed simultaneously using rapid qualitative analysis and descriptive statistics allowing for a comprehensive understanding and iterative incorporation of the results.

Thirteen individuals participated in this study as co-creation partners who were between the ages 27 to 69 years (M = 38.6). Participants represent various roles within the FQHC including front-line staff, administrators, providers, and patients. Workflow Optimization: Participants identified 5 core functions and 16 forms in the refinement of the tobacco cessation workflow. Brainwriting Premortem resulted in 28 unique failures and 19 solutions within the workflow across PRISM contextual domains, of which 16 were integrated. The final version of the co-created workflow had high acceptability (M = 4.8), appropriateness (M = 4.6), and feasibility (M = 4.5). Participant Engagement: A total of 394 interactions were identified across meetings. The most frequent interaction was giving information (53%), followed by seeking information (18%). The quality and frequency of advisory board engagement was rated favorably (average 4.7 of 5). Rapid qualitative analysis of open-ended responses highlighted the value of co-creation with participants stating: "I am glad I participated in this advisory panel… and I am able to bring [this information] back to my team to help our patients."

This study highlights how co-creation through multiple implementation science methods can be used to conceptualize, adapt, and refine programs responsive to FQHC needs. As formative, pre-implementation work, these findings reflect acceptability, feasibility and appropriateness of co-creation processes; real-world adoption and effectiveness remain untested and represent important next steps for future research.