Conceptualizing the use of public involvement in health policy decision-making

Representation in participatory health care decision-making: Reflections on an Application-Oriented Model

Context

The involvement of lay people in health care decision‐making processes is now the norm in many countries. However, one important aspect of participation has not received sufficient attention in the past and remains underexplored: representation.

Objective

This paper explores the question of how public participation efforts in collective health care decision‐making processes can attempt to aim for legitimate representation so that those individuals or groups not present can be taken into account in the decisions affecting them. This paper argues that to make decisions that effectively address those affected, representation needs to be seen as a relevant part of any participatory setting. To support this argument, the paper outlines the concepts of participation and representation and transfers them to health care contexts.

Results

A conceptual reflection on responsiveness and the characteristics of representative actors in representative‐participatory settings is introduced, which could provide actors planning to conduct participatory health care projects with tools to reflect on the merits and possible flaws of participatory constellations.

Patient or Public Contribution

The paper contributes to improving public participation in health care decision‐making.

Journey to Promoting Structural Change for Chronic Disease Prevention: Examining the Processes for Developing Policy, Systems, and Environmental Supports in Native American Nations

Background

Obesity and chronic disease rates continue to be disproportionally high among Native Americans (NAs) compared with the US general population. Policy, systems, and environmental (PSE) changes can address the root causes of these health inequalities by supporting access to healthy food and physical activity resources.

Objective

We aim to describe the actors and processes involved in developing PSE changes supporting obesity prevention in NA Nations.

Methods

As part of the Obesity Prevention Research and Evaluation of InterVention Effectiveness in NaTive North Americans 2 (OPREVENT2) trial (ClinicalTrials.gov registration: NCT02803853), we collected 46 in-depth interviews, 1 modified Talking Circle, 2 workshops, and 14 observations in 3 NA communities in the Midwest and Southwest regions of the United States. Participants included Tribal government representatives/staff, health staff/board members, store managers/staff, and school administrators/staff. We used a Grounded Theory analysis protocol to develop themes and conceptual framework based on our data.

Results

Health staff members were influential in identifying and developing PSE changes when there was a strong relationship between the Tribal Council and health department leaders. We found that Tribal Council members looked to health staff for their expertise and were involved in the approval and endorsement of PSE changes. Tribal grant writers worked across departments to leverage existing initiatives, funding, and approvals to achieve PSE changes. Participants emphasized that community engagement was a necessary input for developing PSE changes, suggesting an important role for grassroots collaboration with community members and staff. Relevant contextual factors impacting the PSE change development included historical trauma, perspectives of policy, and "tribal politics".

Conclusions

This article is the first to produce a conceptual framework using 3 different NA communities, which is an important gap to be addressed if structural changes are to be explored and enacted to promote NA health. The journey to change for these NA Nations provides insights for promoting future PSE change among NA Nations and communities.

The mutual benefits of patient and public involvement in research: an example from a feasibility study (MoTaStim-Foot)

BACKGROUND

Patient and public involvement (PPI) in research has increased steadily over the last two decades and is now both expected and appropriately resourced by many funding bodies, including the National Institute for Health Research (NIHR). However, PPI in research occurs in many different capacities and numerous frameworks exist for reporting or appraising patient involvement activities. The aim of this article is to describe processes involving PPI contributions to an NIHR-funded mixed-methods feasibility study (MoTaStim-Foot). Details of PPI advisors' input, from initial identification and prioritisation of research ideas, to research delivery and dissemination, are discussed.

METHODS

Extensive PPI for MoTaStim-Foot is reported, with consideration of Research Design Service (RDS) advice for PPI for research, involving identifying and prioritising: design; grant proposal development; undertaking/managing research; analysing and interpreting; dissemination; implementation; monitoring and evaluation. Two PPI workshops were undertaken; success in meeting UK standards for public involvement was audited against specific success criteria by two researchers, with discussion and consideration regarding how well our PPI achieved inclusive opportunities, working together, support and learning, governance, communications and impact. How PPI can be improved for future trials was also considered. Although the advantages of PPI for researchers were considered, the benefits for PPI advisors were also analysed.

RESULTS

UK standards for public involvement were achieved, along with seven relevant research processes suggested by the RDS. PPI advisor contributions: informed study design; contributed to successful funding; enhanced trial delivery by informing participant information sheets and daily diaries; added value through undertaking note-taker roles in focus groups and helping to analyse focus group transcripts; and assisted in dissemination. However, benefits were mutual with PPI advisors reporting feeling valued and respected, a sense of pride with renewed confidence and purpose in life.

CONCLUSIONS

Importance and value of PPI, to researchers and patient advisors, have been highlighted, reinforcing the benefits of working in partnership with PPI advisors. Trial registration ISRCTN 13676183; Central Portfolio Management System ID 30449. Registered 02/01/2015, https://www.isrctn.com/ISRCTN13676183 .

Themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making in healthcare systems: a scoping review

OBJECTIVE

To identify the key themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making across the organisation and system domains of healthcare systems.

METHODS

We conducted a scoping review. Seven databases of journal articles were searched from their inception to June 2019. Eligible articles were literature reviews published in English and provided useful information for determining aspects of engaging patients and family caregivers in decision-making to evaluate. We extracted text under three predetermined categories: structure, process and outcomes that were adapted from the Donabedian conceptual framework. These excerpts were then independently open-coded among four researchers. The subsequent themes and their corresponding excerpts were summarised to provide a rich description of each theme.

RESULTS

Of 7747 unique articles identified, 366 were potentially relevant, from which we selected the 42 literature reviews. 18 unique themes were identified across the three predetermined categories. There were six structure themes: engagement plan, level of engagement, time and timing of engagement, format and composition, commitment to support and environment. There were four process themes: objectives, engagement approach, communication and engagement activities. There were eight outcome themes: decision-making process, stakeholder relationship, capacity development, stakeholder experience, shape policy/service/programme, health status, healthcare quality, and cost-effectiveness.

CONCLUSIONS

The 18 themes and their descriptions provide a foundation for identifying constructs and selecting measures to evaluate the quality of initiatives for engaging patients and family caregivers in healthcare system decision-making within the organisation and system domains. The themes can be used to investigate the mechanisms through which relevant initiatives are effective and investigate their effectiveness.

Innovative methods for involving people with dementia and carers in the policymaking process

Background

There are few examples of public patient involvement in policymaking for groups whose ability to participate may be affected by a disability, particularly for people with dementia and their family carers. Principles of engagement and inclusion in democratic processes are as important for these groups as other citizens. We used two innovative methods to increase involvement of people with dementia and family carers in the policymaking process in Ireland, specifically in relation to impending legislation on home care.

Method

A Policy Café was co‐produced with people with dementia using a World Café methodology. A Carer's Assembly was co‐produced with caregivers of people with dementia using a citizen's assembly model.

Results

Ten people with dementia discussed policy developments they wanted to see implemented in relation to diagnosis and home care. Twenty‐eight dementia caregivers prioritized four topics: home care; respite services; psychosocial supports; and financial supports. Film and illustrations were used to create accessible messages for policy‐makers to inform their decision making.

Discussion

Involving people with dementia and carers in policy development requires time and creativity to facilitate and maximize their involvement. Co‐production is essential to ensure the priorities of participants are identified, expressed and communicated effectively. A cumulative sequence of events and messages can generate significant engagement with policy‐makers. Policy‐makers need to hear the direct and authentic voice of people with dementia and carers when faced with important policy decisions.

Patient or public contribution

People with dementia and carers were involved in study design, data analysis and presentation.

(Re)defining legitimacy in Canadian drug assessment policy? Comparing ideas over time

How do experts judge the legitimacy of technical policy processes, and do their ideas change as these processes are opened to other stakeholders and the public? This research examines the adoption of public and patient involvement in pharmaceutical assessment in Canada. It finds tensions between scientific legitimacy that prioritizes rigor and objectivity, and democratic legitimacy that values inclusion and a broader range of evidence. In response to policy change, experts incorporate new ideas about democratic inputs and processes, while maintaining scientific policy goals. The research responds to calls for more precise measurement of ideas and ideational change and more evaluation of public and patient involvement in health policy. It helps us understand the significance of, and limits to, ideational change among experts in health policy domains that are highly technical and publicly salient. Understanding the way democratic and scientific legitimacy are negotiated in policy decisions has a wide applicability in health, but is particularly relevant during a global pandemic when evidence is being generated rapidly, decisions must be made quickly, and these decisions have a significant, immediate effect on the lives of all citizens.

Managing NHS money in Portugal: who decides?

Purpose

The need to reduce health expenditures raises the discussion on rationing possibilities and there is a growing interest in considering society's perspectives. The aim of this paper was to evaluate Portuguese citizens' opinion regarding the imposition of limits on National Health Service (NHS) spending. We also asked who decides how NHS money is spent, in order to obtain the respondents' views on public involvement.

Design/methodology/approach

An online questionnaire was used to collect data. Descriptive and inferential statistics, factorial analysis and a logit model were applied.

Findings

Our results showed that most of the respondents believe citizens have low participation on NHS' financial decisions, confirming the lack of public involvement. Health professionals are more likely to agree with limits on NHS spending, which could indicate potential inefficiencies.

Practical implications

From a health policy perspective, we have concluded that different stakeholders should be involved before deciding how public spending limits should be implemented. Health professionals' perspectives should be considered, taking advantage of their experience.

Originality/value

The main novelty of this paper is the evaluation of whether there should be limits on NHS spending, comparing health professionals and non-health professionals.

[Patient and public involvement in health-related research: How is the selection of participants reported?]

BACKGROUND AND OBJECTIVES

In recent years, the reporting on patient and public involvement (PPI) in health-related research has gained significantly in importance. However, little attention is being paid to the selection of target groups or participating citizens and patients. Individual contributions already point out that the selection is often described in a complex but ambiguous way; for example, individual groups are often not sufficiently differentiated from each other. The aim of our study is to provide an overview of the main topics, questions and challenges that are specific to the selection of participants in PPI by means of an explorative sample of different PPI documents (studies with PPI, studies on PPI, PPI guidelines, PPI websites, PPI journals). Based on this overview, we will make recommendations to help authors of studies and other relevant stakeholders in the planning, implementation and reporting of participant selection.

METHODS

First, the explorative sample of the above-mentioned PPI documents was identified by conducting a systematic database and online search. A total of 46 documents were taken into account, including 11 studies with PPI, 12 studies on PPI, 12 guidelines, 6 websites and 5 journals. Relevant text passages were extracted from each of them and evaluated using deductively and inductively developed topic-specific categories.

RESULTS

Overall, the selected PPI documents significantly vary a) in the use of terms, b) in the detailing of the individual aspects of participant selection, and c) in the description of the planning and implementation of participant selection. For the latter, there is usually a lack of systematic, comprehensive explanations, e. g., on how to weigh up a relevant number of participants, on objectives and methods in the selection process and on how to prepare participants.

DISCUSSION

The various documents about and contributions to the topic of PPI should, in future, report more transparently and systematically on the selection of participants, especially to create practical added value for authors of studies. This includes, in particular, the description of the selection (studies with PPI), a complete overview of all relevant steps of the selection process (PPI guidelines), recommendations on how to deal with representativeness (studies on PPI), notes on reporting PPI (journals) as well as overviews of individual steps of the implementation process (PPI websites).

[The difficult steering of health system reform: the case of New Brunswick (Canada)]

INTRODUCTION

In many developed countries, reforms of public healthcare systems are ongoing but do not always achieve desired results. In this article, we present the history of the healthcare system reform in the Canadian province of New Brunswick with the objective of analyzing its difficult steering by the state, in light of the dynamics between the actors involved.

METHOD

Qualitative methods were chosen. Data collection includes semi-structured interviews (N = 39) with representatives of the State, such as health ministers, and other relevant stakeholders, such as managers, citizens or health professionals.

RESULTS

The stakeholders were compelled by various aspects of the reform, for example francophone health care services, that had consequences on the trajectory of change. To stay on target, the State must adapt to the dynamic interactions of the actors involved.

CONCLUSION

Reforms take place over a long period of time and their programming by the State can be very difficult, as it requires the mobilization of different types of instruments at its disposal. In order to influence the behaviour of the actors concerned, the State must define a goal whose general orientations are agreed upon, succeed in forging bonds of trust and managing resistance, and finally, use standardized data in order to provide a normative framework and evaluate the progress of the reform project.

Developing a typology of the roles public contributors undertake to establish legitimacy: a longitudinal case study of patient and public involvement in a health network

OBJECTIVE

To identify how public contributors established their legitimacy in the functioning of a patient and public involvement programme at a health network.

DESIGN

A longitudinal case study with three embedded units (projects) involving public contributors. Interviews (n=24), observations (n=27) and documentary data collection occurred over 16 months.

SETTING

The West of England Academic Health Science Network (WEAHSN), 1 of 15 regional AHSNs in England.

PARTICIPANTS

Interviews were conducted with public contributors (n=5) and professionals (n=19) who were staff from the WEAHSN, its member organisations and its partners.

RESULTS

Public contributors established their legitimacy by using nine distinct roles: (1) lived experience, as a patient or carer; (2) occupational knowledge, offering job-related expertise; (3) occupational skills, offering aptitude developed through employment; (4) patient advocate, promoting the interests of patients; (5) keeper of the public purse, encouraging wise spending; (6) intuitive public, piloting materials suitable for the general public; (7) fresh-eyed reviewer, critiquing materials; (8) critical friend, critiquing progress and proposing new initiatives and (9) boundary spanner, urging professionals to work across organisations. Individual public contributors occupied many, but not all, of the roles.

CONCLUSIONS

Lived experience is only one of nine distinct public contributor roles. The WEAHSN provided a benign context for the study because in a health network public contributors are one of many parties seeking to establish legitimacy through finding valuable roles. The nine roles can be organised into a typology according to whether the basis for legitimacy lies in: the public contributor's knowledge, skills and experience; citizenship through the aspiration to achieve a broad public good; or being an outsider. The typology shows how public contributors can be involved in work where lived experience appears to lack relevance: strategic decision making; research unconnected to particular conditions; or acute service delivery.

Réforme du système public de santé du Nouveau-Brunswick : les mœurs au lieu des structures

La plus récente réforme du système public de santé du Nouveau-Brunswick (NB) a été lancée en 2008. Les deux principaux objectifs explicites de cette réforme étaient de rendre le système de soins de santé plus efficace et efficient. Plus de dix ans après l’implantation de ce changement d’envergure, peu d’amélioration est notée au niveau de la performance du système public de santé. Les résultats produits dans le cadre d’une recherche qualitative nous permettent de mettre en lumière des raisons pour lesquelles le système de santé ne s’est pas véritablement transformé. De notre analyse découlent certaines recommandations que nous désirons partager aux décideurs publics qui participeront à l’élaboration d’une prochaine réforme. Elles ont surtout trait à la gouvernance, aux cibles à atteindre et à l’engagement des citoyens.

Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review

CONTEXT

There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care.

OBJECTIVE

The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice.

METHODS

We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored.

RESULTS

We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs.

CONCLUSION

Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.

Patient and public involvement facilitators: Could they be the key to the NHS quality improvement agenda?

OBJECTIVE

Research into patient and public involvement (PPI) has not examined in detail patient and public involvement facilitators' (PPIFs) roles and activities. This study analysed PPIFs' roles using qualitative data gathered from three different UK health-care organizations.

DESIGN

Thematic analysis was used to examine cross-sectional data collected using a mixed-methods approach from three organizations: a mental health trust, a community health social enterprise and an acute hospital trust. The data set comprised of 27 interviews and 48 observations.

FINDINGS

Patient and public involvement facilitators roles included the leadership and management of PPI interventions, developing health-care practices and influencing quality improvements (QI). They usually occupied middle-management grades but their PPIF role involved working in isolation or in small teams. They reported facilitating the development and maintenance of relationships between patients and the public, and health-care professionals and service managers. These roles sometimes required them to use conflict resolution skills and involved considerable emotional labour. Integrating information from PPI into service improvement processes was reported to be a challenge for these individuals.

CONCLUSIONS

Patient and public involvement facilitators capture and hold information that can be used in service improvement. However, they work with limited resources and support. Health-care organizations need to offer more practical support to PPIFs in their efforts to improve care quality, particularly by making their role integral to developing QI strategies.

Who represents me? A patient-derived model of patient engagement via patient and family advisory councils (PFACs)

BACKGROUND

Despite increasing attention to patient and family advisory councils (PFACs), what patients who are not PFAC members expect of PFACs remains understudied. Understanding their expectations is critical if PFACs are to help health systems achieve certain outcomes (eg increased patient satisfaction with health systems).

OBJECTIVE

To obtain rich insights about what patients who are not PFAC members expect of PFACs.

DESIGN

From July to September 2018, we conducted a qualitative study using focus groups.

SETTING AND PARTICIPANTS

We recruited patients and caregivers who receive their care from the Johns Hopkins Medicine Alliance for Patients (JMAP), LLC, a Medicare accountable care organization that in 2014 established a PFAC, the Beneficiary Advisory Council.

APPROACH

Using grounded theory, we analysed field notes, analytic memos and transcripts to develop a theoretical model of patient engagement via PFACs.

RESULTS

Forty-two patients and caregivers participated in five focus groups that included individuals of different ages, races, health statuses and socio-economic statuses. Participants were largely unaware of PFACs. Participants wanted to know who represented them (interpreted as a form of political representation) and emphasized the need for representatives' diversity. Who mattered because who could affect what PFACs do. Participants expected that all patients should be able to communicate with PFACs and that meaningful engagement could enhance perceptions of health systems.

CONCLUSIONS

Eliciting views about patient representation from patients who have not been engaged as advisors or representatives has the potential to inform PFACs' activities. Attention should be given to improving and measuring patients' awareness of, and interactions with, their patient representatives.

"Getting to the Table": Changing Ideas about Public and Patient Involvement in Canadian Drug Assessment

CONTEXT

Involving patients and the public in health policy may contribute to legitimacy and accountability. However, tensions may arise between paradigms of scientific-evidence-based decision making and new ideas valuing inclusivity and patient experience when evaluating and allocating health resources. This article asks whether 10 years of experience with public and patient involvement in Canadian drug assessment has affected participants' ideas about how it works.

METHODS

The author surveyed the ideas of participants in the drug assessment process (members of expert committees, officials, and patient groups) as described in reports and hearings in 2005, 2007, and 2012 and conducted interviews in 2014 and 2016.

FINDINGS

The author found some consensus across groups of participants regarding the broad goals of health technology assessment (HTA) and the validity of some form of public and patient involvement. There were also important areas of disagreement and uncertainty about how public and patient involvement should be used in drug assessment and how much impact it has on deliberations and recommendations. Overall, uncertainly about the specific role for public and patient involvement in HTA limits the potential for ideational change among participants.

CONCLUSIONS

These findings have implications for evaluation of public and patient involvement, the way we understand ideational change, and practical questions of communicating health resource decisions.

Parental perspectives on retention and secondary use of neonatal dried bloodspots: a Dutch mixed methods study

BACKGROUND

Neonatal bloodspot screening (NBS) identifies conditions to offer early intervention and minimize irreversible damage. NBS policies guide a comprehensive system including processes for storage of neonatal dried blood spots (NDBS). NDBS retention and secondary use policies have been subject of public debates internationally, suggesting that the public's perceptions of NDBS policy are not always on par with existing policies. The current study aims to provide insight in relevant factors for new parents in the Netherlands regarding retention and secondary use of NDBS. These factors can be taken into account when developing or updating NDBS policies.

METHODS

A mixed methods design was used combining an online survey (n = 753), focus groups (6 groups, 37 participants), and individual in-depth interviews (n = 7). The discussed topics included: parental information, obtaining informed consent, support for retention, and support for secondary use. The study population consisted of Dutch-speaking new parents: pregnant women (≥20 weeks) and/or their partner, and parents of at least one child (≤5 years).

RESULTS

New parents expressed needs for easily accessible information, adequate communication on the retention and (potential) use of NDBS, clearly described safeguards for privacy, a more active consent process, regulation for the actors conducting NDBS research, and parental involvement in decisions on secondary use. Overall, participants were positive about prolonged retention and different types of secondary use if those needs were met.

CONCLUSIONS

While parental involvement is a challenge, our study is an example of gauging parent's perspectives on NDBS policy and contributes to including these perspectives in the current policy discussion on longer retention. Prolonged retention could be a feasible option in the Netherlands if several prerequisites are met. Therefore, implementation studies involving parents are needed.

The policy-making trend analysis of municipal solid waste in China 1980-2015

Over the past 35 years, the Chinese government has established various policies to tackle problems related to the municipal handling of solid waste. It is necessary to study policy-making trends in the area of municipal solid waste for further sustainable development in China. This article fills this gap by designing a new analytical framework made up of policymaker indicators, policy practitioner indicators, policy beneficiaries' indicators, policy tool indicators, and policy support indicators in order to analyse the policy-making trend based on China's major municipal solid waste policies from 1 January 1980 to 1 March 2015. Results have shown that policy-making related to municipal solid waste has changed significantly in the past 35 years and that more municipal solid waste policies were issued by one or a few ministerial departments than by the State Council and National People's Congress. Moreover, the study has shown that the government and companies have dedicated more attention to taking action about municipal solid waste than individuals. With regard to the policy tools, policy-making has stressed the use of market-type tools, regulation-type tools, and public participation-type tools together to tackle the municipal solid waste problem since 2000. Finance and information support were used more as policy support by municipal solid waste policies than technology. This article provides some novel insights on the policy-making trend of municipal solid waste in China.

Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study

Background

Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes.

Objective

To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented.

Design

Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; ≈210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes.

Results

Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality [–1.1%, 95% confidence interval (CI) –2.1% to –0.1%], resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% (95% CI 65.6% to 67.1%); comparator = 54.4% (95% CI 53.6% to 55.1%)]. Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS (–2.0 days, 95% CI –2.8 to –1.2 days) only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS (–1.5 days, 95% CI –2.5 to –0.4 days) and clinical interventions [e.g. SU within 4 hours: GMB = 79.1% (95% CI 77.9% to 80.4%); comparator = 53.4% (95% CI 53.0% to 53.7%)] but not on mortality (–1.3%, 95% CI –2.7% to 0.01%; p = 0.05, accounting for reductions observed in RoE); however, there was a significant effect when examining GMB HASUs only (–1.8%, 95% CI –3.4% to –0.2%), resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context.

Limitations

The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views.

Conclusions

Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Collaborative accountability for sustainable public health: A Korean perspective on the effective use of ICT-based health risk communication

The sustainability of public health practices requires collaboration between the government and its citizens. On the government's side, social media can provide a conduit for communicating health risk information in an effective and timely fashion, while also engaging citizens in informed decision-making. On the citizen's side, information communication technology (ICT)-based practices cannot function unless citizens recognize and act on their responsibility to actively engage with government social media platforms. Despite an increasing interest in understanding the adoption of ICT practices and e-government services for health risk communication, there remains a crucial need for a comprehensive framework to explain which factors determine citizen use of digital government resources. The purpose of this study is to investigate how to increase government accountability for motivating citizens to engage in ICT-based health risk communication, thereby attaining sustainable public health practices through collaborative governance.

By integrating trust and health risk information into the e-government adoption model (GAM), this research examines factors that influence citizens' likelihood of using government social media resources. Survey data from 700 Korean citizens were analyzed using structural equation modeling. The results indicated that individuals with higher social media competency are more likely to (a) seek risk information through social media and (b) perceive the government's social media sites as easy to use. Consistent with the GAM, intentions to use the government's social media sites for information and interactions appear to increase as citizens perceive more value in using them regarding information quality, ease of use, functional benefit, and security. Furthermore, perceived trust in the government's social media resources appears to function as a mediator of this process. Initial trust in the government is an important determinant of perceptions of its digital resources. Citizens who trust the government tend to evaluate new initiatives positively and are more likely to accept and make use of them.

The results of this study can inform policy design and implementation by elucidating the mechanisms that determine citizens' adoption and usage of digital government services. Theoretically, this work expands the GAM to include health risk communication and adds empirical evidence to the small yet growing body of knowledge of e-government initiatives. These findings also highlight the importance of public trust in the government, as this encourages citizens to seek health risk information and assistance from the government. Overall, the data and model generated in this investigation represent an important step toward the successful and sustainable modernization of public services.

Involving patients and the public in medical and health care research studies: An exploratory survey on participant recruiting and representativeness from the perspective of study authors

Research on patient and public involvement so far concentrates on defining involvement, describing its methods, and analyzing involvement practices in various individual research disciplines. There is little empirical data on the process of and aims for selecting (lay) PPI participants, and to what extend they can and should be representative of the population at large. To explore practices and perceptions on these issues and on future PPI conduct more generally, we sent an electronic survey to authors who published involvement activities as part of their studies in medical and social science journals. We identified such authors with a systematic search of five databases and applied descriptive statistics for analysis. Of those who returned the survey (n = 127 of 315; 40%), most had previously conducted involvement activities (73%). 45% reported more than one type of involvement, e.g. consultation and deliberation and participation (14%) and to have recruited more than one type of participant for their PPI activity (56%), e.g. ‘lay publics’ and ‘expert publics’ (33% of 71). Representativeness was often seen as a crucial objective when selecting PPI participants, while less than half found it very easy (9%) or rather easy (34%) to select participants. Many respondents considered achieving good representativeness difficult (52%) or very difficult (17%). They identified significant respective challenges and desired more guidance on various aspects of planning and conducting PPI (56%). 55% thought that the concept of “involvement” should be changed or improved. We conclude that recruiting lay people for PPI activities and deciding about and handling representativeness are controversial in current PPI practice, given the manifold challenges mentioned by the survey respondents. Our findings may inform further research particularly regarding–the potentially many cases of–unpublished PPI.

Learning as an outcome of involvement in research: what are the implications for practice, reporting and evaluation?

Public involvement in research has evolved over the last two decades in a culture dominated by the principles of evidence-based medicine. It is therefore unsurprising that some researchers have applied the same thinking to involvement, particularly to involvement in research projects. This may explain why they tend to conceptualise involvement as an intervention, seek to evaluate its impact in the same way that treatments are tested, highlight the need for an evidence-base for involvement, and use the language of research to describe its practice and report its outcomes. In this article we explore why this thinking may be unhelpful. We suggest an alternative approach that conceptualises involvement as 'conversations that support two-way learning'. With this framing, there is no 'method' for involvement, but a wide range of approaches that need to be tailored to the context and the needs of the individuals involved. The quality of the interaction between researchers and the public becomes more important than the process. All parties need to be better prepared to offer and receive constructive criticism and to engage in constructive conflict that leads to the best ideas and decisions. The immediate outcomes of involvement in terms of what researchers learn are subjective (specific to the researcher) and unpredictable (because researchers don't know what they don't know at the start). This makes it challenging to quantify such outcomes, and to carry out comparisons of different approaches. On this basis, we believe obtaining 'robust evidence' of the outcomes of involvement in ways that are consistent with the values of evidence-based medicine, may not be possible or appropriate. We argue that researchers' subjective accounts of what they learnt through involvement represent an equally valid way of knowing whether involvement has made a difference. Different approaches to evaluating and reporting involvement need to be adopted, which describe the details of what was said and learnt by whom (short term outcomes), what changes were made as a result (medium term outcomes), and the long-term, wider impacts on the research culture and agenda. Sharing researchers' personal accounts may support wider learning about how involvement works, for whom and when.

Synthesising conceptual frameworks for patient and public involvement in research - a critical appraisal of a meta-narrative review

Background

A number of conceptual frameworks for patient and public involvement (PPI) in research have been published in recent years. Although some are based on empirical research and/or existing theory, in many cases the basis of the conceptual frameworks is not evident. In 2015 a systematic review was published by a collaborative review group reporting a meta-narrative approach to synthesise a conceptual framework for PPI in research (hereafter ‘the synthesis’). As the first such synthesis it is important to critically scrutinise this meta-narrative review. The ‘RAMESES publication standards for meta-narrative reviews’ provide a framework for critically appraising published meta-narrative reviews such as this synthesis, although we recognise that these were published concurrently. Thus the primary objective of this research was to appraise this synthesis of conceptual frameworks for PPI in research in order to inform future conceptualisation.

Methods

Four researchers critically appraised the synthesis using the RAMESES publication standards as a framework for assessment. Data were extracted independently using a data extraction form closely based on the RAMESES publication standards. Each item from the standards was assessed on a four point scale (0 = unmet, 1 = minimally met, 2 = partly met, 3 = fully met). The four critical appraisals were then compared and any differences resolved through discussion.

Results

A good degree of inter-rater reliability was found. A consensus assessment of the synthesis as a meta-narrative review of PPI conceptual frameworks was achieved with an average of ‘1’ (minimally met) across all 20 items. Two key items (‘evidence of adherence to guiding principles of meta-narrative review’ and ‘analysis and synthesis processes’) were both wholly unmet. Therefore the paper did not meet our minimum requirements for a meta-narrative review. We found the RAMESES publication standards were a useful tool for carrying out a critical appraisal although some minor improvements are suggested.

Conclusions

Although the aims of the authors’ synthesis were commendable, and the conceptual framework presented was coherent and attractive, the paper did not demonstrate a transparent and replicable meta-narrative review approach. There is a continuing need for a more rigorous synthesis of conceptual frameworks for PPI.

Sharpening the focus: differentiating between focus groups for patient engagement vs. qualitative research

PLAIN ENGLISH SUMMARY

Patient engagement is an opportunity for people with experience of a health-related issue to contribute to research on that issue. The Canadian Strategy for Patient-Oriented Research (SPOR) highlights patient engagement as an important part of health research. Patient engagement, however, is a new concept for many researchers and research ethics boards, and it can be difficult to understand the differences between patient engagement activities and research activities. Focus groups are one example of how research and patient engagement activities are often confused.We distinguish these two types of activities by using different terms for each. We use focus groups to refer to research activities, and discussion groups to refer to patient engagement activities. In focus groups, researchers collect data by speaking with a group of research subjects about their experiences. Researchers use this information to answer research questions and share their findings in academic journals and gatherings. In patient engagement, discussion groups are a way for patients to help plan research projects. Their contributions are not treated as research data, but instead they help make decisions that shape the research process. We have found that using different language to refer to each type of activity has led to improved clarity in research planning and research ethics submissions.

ABSTRACT

Background In patient-oriented research (POR), focus groups can be used as a method in both qualitative research and in patient engagement. Canadian health systems researchers and research ethics boards (REBs), however, are often unaware of the key differences to consider when using focus groups for these two distinct purposes. Furthermore, no one has clearly established how using focus groups for these two purposes should be differentiated in the context of Canada's Strategy for Patient-Oriented Research (SPOR), which emphasizes appropriate patient engagement as a fundamental component of POR. Body Researchers and staff in the Maritime SPOR SUPPORT Unit refer to focus groups in patient engagement as discussion groups for clarity, and have developed internal guidelines to encourage their appropriate use. In this paper, the guidelines comparing and contrasting the design and conduct of focus groups and of discussion groups is described, including: the theoretical framework for each; the need for research ethics board review approval; identifying participants; collecting and analyzing data; ensuring rigour; and disseminating results. Conclusion The MSSU guidelines address an important and current methodological challenge in patient-oriented research, which will benefit Canadian and international health systems researchers, patients, and institutional REBs.

Attendance to cervical cancer screening among Roma and non-Roma women living in North-Western region of Romania

OBJECTIVES

Romania has Europe's highest incidence and mortality rates of cervical cancer. Participation in the national cervical cancer-screening programme is low, especially among minority Roma women.

METHODS

We conducted a cross-sectional study, using a structured questionnaire aiming to quantify reasons for screening attendance among women in North-Western region of Romania.

RESULTS

980 women were enrolled in this study. Data were analysed using logistic regression, estimating odds ratios (OR) and 95% confidence intervals (CI). This study revealed that Roma women (46%) attended screening less frequently that non-Roma women (63%),; however, ethnicity in itself was not associated with screening attendance. Instead we found that attendance to the cervical cancer screening programme was determined by having ever heard about a screening opportunity (OR 5.90, 95% CI 3.76-9.27) and having three or more sex partners (OR 5.99, 95% CI 1.71-21.04).

CONCLUSIONS

We concluded that information about the screening programme's existence and its rationale does not reach the women targeted for screening sufficiently and argue that a process of user involvement aiming to build contact, interaction and cooperation between the programme and its potential participants is warranted.

Patient, carer and public involvement in major system change in acute stroke services: The construction of value

BACKGROUND

Patient and public involvement is required where changes to care provided by the UK National Health Service are proposed. Yet involvement is characterized by ambiguity about its rationales, methods and impact.

AIMS

To understand how patients and carers were involved in major system changes (MSCs) to the delivery of acute stroke care in 2 English cities, and what kinds of effects involvement was thought to produce.

METHODS

Analysis of documents from both MSC projects, and retrospective in-depth interviews with 45 purposively selected individuals (providers, commissioners, third-sector employees) involved in the MSC.

RESULTS

Involvement was enacted through consultation exercises; lay membership of governance structures; and elicitation of patient perspectives. Interviewees' views of involvement in these MSCs varied, reflecting different views of involvement per se, and of implicit quality criteria. The value of involvement lay not in its contribution to acute service redesign but in its facilitation of the changes developed by professionals. We propose 3 conceptual categories-agitation management, verification and substantiation-to identify types of process through which involvement was seen to facilitate system change.

DISCUSSION

Involvement was seen to have strategic and intrinsic value. Its strategic value lay in facilitating the implementation of a model of care that aimed to deliver evidence-based care to all; its intrinsic value was in the idea of citizen participation in change processes as an end in its own right. The concept of value, rather than impact, may provide greater traction in analyses of contemporary involvement practices.

Influencing health policy through public deliberation: Lessons learned from two decades of Citizens'/community juries

Citizens'/community juries [CJs] engage members of the public in policy decision-making processes. CJs can be employed to develop policy responses to health problems that require the consideration of both community values and scientific evidence. Based on the principles of deliberative democracy, recent reviews indicate that findings from CJs have successfully been used to influence health policy decision-making. Despite this evidence of success, there appears to be a gap between the goals of health researchers who organize CJs and the needs of policy actors and decision makers. Drawing on our experiences working with CJs and recent research on CJ methods, we describe a synopsis of the current state of the art organized around four key questions, and informed by insights from deliberative theory and critical policy studies. Our intention is to stimulate further discussion as to the types of health policy questions that can be usefully addressed through public deliberation, and provide guidance on the methodological and political dimensions that need to be considered in deciding whether a CJ is an appropriate approach for informing a policy decision-making process.

Understanding the factors that make public participation effective in health policy and planning: a realist synthesis

Although researchers argue for the importance of involving the public in developing health policy, there has been little focus on central research questions – such as what techniques of public participation work, in what circumstances, and why. This paper presents a realist synthesis which identifies and explains the underlying mechanisms and specific contextual factors that lead to effective public participation in health policy and planning. Peer-reviewed, English language literature was searched, which resulted in 77 articles for review and synthesis. This synthesis uncovered the underlying mechanism of ‘political commitment’ that generates public participation effectiveness. The other three possible underlying mechanisms, namely: ‘partnership synergy’, ‘inclusiveness’ and ‘deliberativeness’, were found to potentially provide further explanation on public participation effectiveness for health policy and planning. The findings of this review provide evidence that can be useful to health practitioners and decision-makers to actively involve the public when drafting public health policies and programs and, more importantly, guide them in deciding which strategies to best employ for which contexts.

Developing a conceptual model for the application of patient and public involvement in the healthcare system in Iran

INTRODUCTION

Patient and public involvement is engaging patients, providers, community representatives, and the public in healthcare planning and decision-making. The purpose of this study was to develop a model for the application of patient and public involvement in decision making in the Iranian healthcare system.

METHODS

A mixed qualitative-quantitative approach was used to develop a conceptual model. Thirty three key informants were purposely recruited in the qualitative stage, and 420 people (patients and their companions) were included in a protocol study that was implemented in five steps: 1) Identifying antecedents, consequences, and variables associated with the patient and the publics' involvement in healthcare decision making through a comprehensive literature review; 2) Determining the main variables in the context of Iran's health system using conceptual framework analysis; 3) Prioritizing and weighting variables by Shannon entropy; 4) designing and validating a tool for patient and public involvement in healthcare decision making; and 5) Providing a conceptual model of patient and the public involvement in planning and developing healthcare using structural equation modeling. We used various software programs, including SPSS (17), Max QDA (10), EXCEL, and LISREL. Content analysis, Shannon entropy, and descriptive and analytic statistics were used to analyze the data.

RESULTS

In this study, seven antecedents variable, five dimensions of involvement, and six consequences were identified. These variables were used to design a valid tool. A logical model was derived that explained the logical relationships between antecedent and consequent variables and the dimensions of patient and public involvement as well.

CONCLUSION

Given the specific context of the political, social, and innovative environments in Iran, it was necessary to design a model that would be compatible with these features. It can improve the quality of care and promote the patient and the public satisfaction with healthcare and legitimate the representative of people they served for. This model can provide a practical guide for managers and policy makers to involve people in making the decisions that influence their lives.