Environmental change and its impacts on human lives and livelihoods are a major global concern [1]. The adverse effects of rising global temperatures and extreme weather events are evident in increasing physical and economic losses as well as a surge in noncommunicable diseases (NCDs) [2,3]. Those living in low- and middle-income countries (LMICs) are often among the most vulnerable and disproportionately affected due to their high exposure and sensitivity to the impacts on ecosystems, human habitat, and infrastructure [4,5]. Health systems in many of these countries also have the lowest climate readiness scores, meaning that they are poorly prepared to adapt their available resources to climate vulnerabilities [6]. Given the complexity and scale of such climate change–induced health issues, there is a critical need to develop and implement context-specific solutions through collaboration across different sectors and disciplines, also known as multisectoral interventions [7]. Suited to local needs, these multisectoral interventions can help with early mitigation of risks and reduce the extent of human activities that lead to adverse environmental and health outcomes.

The National Institute for Health and Care Research (NIHR) Global Health Research Centre (GHRC) for NCDs and Environmental Change is a collaborative effort among researchers from 4 countries that aims to achieve dual benefits for health and the environment by developing such multisectoral interventions [8]. NIHR GHRC focuses on a context-specific environmental issue in each geographic region that is important both locally and globally. The first problem area is tackling air pollution from plastic burning in Indonesia, where increasing plastic pollution is a major threat because of both the production and import of large quantities of plastics [9]. The second problem area is managing extreme weather events such as heat waves and improving dietary diversity within public food procurement systems in rural India. Heat waves have been associated with increased risks of dehydration, heat stroke, cardiovascular complications, and mortality, especially among vulnerable populations such as older adults and those with preexisting NCDs [10]. Climate change can negatively impact agriculture and dietary diversity of rural and indigenous populations in such settings, which can worsen malnutrition in all its forms and diet-related NCDs [1,11]. The third problem area is mitigating drinking water salinity in coastal areas in Bangladesh, where surface water and groundwater bodies are becoming increasingly salinized because of rising sea levels and tropical storm surges. Regular intake of such saline water can result in a range of health issues, including hypertension and cardiovascular disease [12,13].

Multisectoral interventions designed to address these interconnected challenges must be grounded in local needs and priorities to be effective across diverse contexts. Guided by the Medical Research Council (MRC) framework [14] for developing and evaluating complex interventions, NIHR GHRC adopted cocreation as a collaborative participatory approach for developing and implementing complex multisectoral solutions [15]. Cocreation is an overarching term that includes both coproduction and co-design [16]. This involves engaging diverse stakeholders across multiple disciplines throughout the process of understanding the issue at hand as well as designing and evaluating contextually relevant solutions [15,16]. While a range of frameworks have been developed to assist with co-design [17-20], including policy co-design [21,22], coproduction [23], and cocreation of interventions [24], there is a lack of evidence that demonstrates how these could be integrated in the MRC guidance to develop a complex multisectoral intervention. Furthermore, given the dual focus on the environment and health in this study, it is important to incorporate planetary health perspectives in the design and evaluation of interventions in a structured way [25,26], following recently published guidance [27]. In addition, engagement and involvement with a range of stakeholders across multiple sectors and settings requires a culturally sensitive and setting-specific cocreation process. Therefore, this protocol outlines a practical, context-sensitive framework for cocreating solutions with the communities and partners involved in NIHR GHRC to guide the development of dual-benefit multisectoral interventions that address NCDs and environmental change.

Formative phase research activities started after NIHR GHRC was funded in October 2022. Cocreation workshops as part of this formative research phase will take place over a 6-month period, and the multisectoral interventions are expected to be implemented in each country by the end of December 2025. As part of the planning phase described earlier, core study teams have been established in each country to oversee and coordinate the overall intervention development process. Sampling and recruitment of cocreation group members, informed by research partnerships established with relevant organizations during the formative phase, have been completed in all geographic regions. Each cocreation group consists of 20-30 members depending on the project needs and study location. Due to the iterative nature of the process, findings from each stage may necessitate the involvement of new stakeholders. For example, community members and health care professionals are being recruited first for the cocreation workshops, and the selection of policy and planetary health experts will be based on the initial workshop outcomes. Community engagement activities have helped build trust with the community members and foster a deeper understanding of the local context. On the basis of emerging findings from formative phase research, we prepared tools for each stage of the cocreation process and obtained ethics approvals to conduct these activities.

We plan to produce a series of outputs on the cocreation process to ensure knowledge mobilization. First, we will publish scientific papers for academic audiences as well as present our findings at relevant conferences. The publications will describe the outputs of the cocreation process, outcomes of cocreation evaluation, and how planetary health perspectives were incorporated in the intervention design. Other outputs such as blog posts and videos will be developed for public and policy-level stakeholders and disseminated via NIHR GHRC’s website, social media channels, and other relevant platforms. These outputs are intended to have a broader societal impact by reaching nonacademic audiences. Second, as part of our implementation plan, we will develop training materials for implementers of the codeveloped interventions to facilitate future adoption of these cocreation methods in similar settings. Finally, a formative evaluation report outlining key insights into the cocreation process will be produced for NIHR. This will include an assessment of how effectively the cocreation process supported the development of multisectoral interventions that are reflective of locally articulated priorities.