Setting the rules of engagement: a qualitative study of challenges and enablers of engaged research in a South African emergency care system

Engaged research requires collaboration with community stakeholders across the research process, yet little is known about its practice in low- and middle-income countries. The Western Cape in South Africa, which includes Cape Town as its largest city, combines substantial socio-economic inequality with strong emergency care academic capacity, offering a distinctive environment in which to explore these dynamics. This study aimed to examine stakeholders’ perspectives on the barriers to and enablers of practising engaged research. This qualitative study used semi-structured interviews to explore experiences of engaged research among a broad spectrum of stakeholders. Purposive and snowball sampling ensured wide representation across public, clinical, academic, managerial, and policy groups. Data were analysed using inductive content analysis. Reporting was guided by Consolidated Criteria for Reporting Qualitative Research (COREQ) and Guidance for Reporting Involvement of Patients and Public v2 (GRIPP2) to ensure trustworthiness. Thirty interviews were completed, with participants offering insights informed by a range of experiences, including overlapping roles across the emergency care community. Analysis generated four overarching categories describing the factors shaping engaged research in this setting: (1) Cultivating relationships and spaces for engagement; (2) Overstretched and under-resourced; (3) Systems, structures, and scholarship; and (4) The rules of engagement. These categories highlighted both key barriers and opportunities for strengthening engagement practices. Meaningful engaged research depends on sustained relationships and shared accountability between academic and non-academic partners. Although stakeholders viewed engagement as necessary and achievable, it is constrained by limited available time, fragmented approval systems, uncertainty about how to participate, and low trust. Strengthening engagement requires early relationship building, structured opportunities to develop engagement skills, and better alignment of degree research with ongoing community priorities. Establishing transparent and mutually agreed rules of engagement is central to embedding collaboration and sustaining trust over time. Research is more useful when the people affected by it help shape it. This process is often termed engaged research. Although it is becoming more common, we still know little about how to carry out engaged research in low resource settings. This study took place in the Western Cape province of South Africa. The region has major social inequality but also a developing emergency care system. This mix makes it a good place to explore what helps and what gets in the way of engaged research in emergency care. We spoke to thirty people from different backgrounds, including the public, healthcare workers, managers, policymakers, and researchers. They shared their experiences of trying to work together as partners on research projects. We found several points, summarised under four main messages. First, building relationships is essential. People need time and supportive spaces to talk, understand each other, and build trust. Second, many groups are overstretched. Busy services, limited time, and few resources make it hard to stay involved. Third, systems and structures, including approval processes, can slow or block progress but could improve with better support. Finally, people wanted clearer rules of engagement so everyone knows their roles, responsibilities, and how decisions will be made. Overall, engaged research is valued and possible but needs support. Participants highlighted the importance of time for relationship building, addressing barriers within approval processes, and improving training and guidance for community members, health care workers, and researchers. These improvements can lead to stronger partnerships, better research, and benefits for communities.