Modelling the relationship between implementation processes and their operational contexts: pre-implementation study of a health and wellbeing coaching intervention for people living with HIV

Understanding the interplay between implementation processes and their operational contexts is a critical challenge in implementation science and healthcare practice. This study examines this relationship through a qualitative analysis of key informants’ perspectives on implementing a health and wellbeing coaching intervention for people with HIV within the SPHERE Trial. We aimed to identify clinicians’ and service providers’ attributions of the relational and systemic mechanisms shaping the implementation of the SPHERE coaching intervention, and to explore their beliefs about the collaborative work required for its operationalization in NHS settings. Semi-structured interviews were conducted with 20 key informants, (NHS staff n = 12 and voluntary sector staff n = 8). Attribution analysis and qualitative content analysis, informed by Normalization Process Theory (NPT), were used to analyse participants’ beliefs about contextual mechanisms and collective action driving implementation. These methods identified relational and systemic factors influencing the intervention and mapped them against NPT-derived implementation strategies. Key informants highlighted relational mechanisms—such as diagnostic shock, stigmatization, and social destabilisation—that shape people with HIV’s engagement with care, necessitating trauma-informed and stigma-responsive coaching. Systemic mechanisms, including service degradation due to austerity and commissioning constraints, explained the need for coaching to support navigation of fragmented services. Key informants identified shared sense-making, mobilization of existing multidisciplinary teams, and adaptive strategies to integrate coaching into routine workflows while addressing workforce and funding challenges. We translated these into a set of generalisable propositions that would support further analysis. Combining attribution analysis with NPT provides a robust framework for understanding how relational and systemic contexts dynamically shape implementation processes. Successful integration of health and wellbeing coaching for people with HIV demands trauma-informed approaches, strategic use of existing service infrastructures, and adaptive leadership to navigate operational constraints, ensuring coaching addresses psychosocial needs and enhances service integration. 47,187,932