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      More than just ticking a box…how patient and public involvement improved the research design and funding application for a project to evaluate a cycling intervention for hip osteoarthritis

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          Abstract

          Plain English summary

          Involving patients and the public in research helps to ensure that research remains relevant, and has an impact on the people it aims to benefit. Funding bodies now require patients and the public to be involved at all stages of research. Patients and members of the public were involved from the outset in research into a cycling and education programme for hip osteoarthritis. A group discussion took place with six participants from a trial of the programme. The group provided feedback on several areas including the relevance of the research, how the researchers proposed to recruit patients, the research design, the programme itself (including what they liked/didn’t like about it), and how the researchers could publicise the research findings. The feedback received was invaluable, and helped shape the entire research project and funding application. The cycling and education programme has been extended in line with comments received from the group. They also helped identify the best way of gathering information from research participants and had suggestions for sharing the results, both of which were incorporated into the funding application. Often involving patients and the public in research can be seen as a ‘tick box’ exercise. However, this example shows how crucial involving patients and the public in research design is. It also shows how the funding application was made stronger as a result of patient input. Researchers should be encouraged to work closely with patients and the public to ensure their research is of the highest quality.

          Abstract

          Background

          Involving patients and the public in research is an essential activity to ensure relevant, accessible, and appropriate research. There is increasing obligation from funding bodies on researchers to have well thought through plans for involving the public, and indeed it is often a condition for funding. Patient and public involvement activity in this project was conducted to inform a funding application to investigate the effectiveness of a cycling and education intervention in the treatment of hip osteoarthritis.

          Methods

          Six participants from a feasibility programme of the intervention attended a two-hour patient and public involvement consultation group to provide feedback on various aspects of the proposed research and intervention. During the consultation group, two independent facilitators followed a detailed plan formulated with the research team. Feedback was validated by the attendees via email following the consultation, and a report was issued to the research team. Further feedback on subsequent changes was sought via email and telephone with members of a Patient Advisory Group.

          Results

          The patient and public involvement consultation group provided invaluable feedback and suggestions which impacted on the design and quality of the research project and the intervention. Key changes to the intervention included extending the duration of the cycling programme from six to eight weeks, and inclusion of an exercise diary to promote adherence to the intervention. Key feedback regarding the design of the research and funding application included suggestions for methods of dissemination, and confirmation of the primary outcome measure.

          Conclusions

          Patient and public involvement was crucial to the design of the proposed research and intervention. It informed many aspects of the research design and made the funding application stronger as a result. Involving patients and the public in research is much more than an obligation, or ‘tick box’ exercise. It can change and improve research quality, which is crucial when answering questions that are meaningful and important to patients, and which leads to increased impact. Collaboration with patients and the public should be planned and reported from the conception of a research idea where the impact of such input can be considerable.

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          Most cited references6

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          The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties.

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            The GRIPP checklist: strengthening the quality of patient and public involvement reporting in research.

            The aim of this study was to develop the GRIPP (Guidance for Reporting Involvement of Patients and Public) checklist to enhance the quality of PPI reporting. Thematic analysis was used to synthesize key issues relating to patient and public involvement (PPI) identified in the PIRICOM and PAPIRIS systematic reviews. These issues informed the development of the GRIPP checklist. The key issues identified included limited conceptualization of PPI, poor quality of methods reporting, unclear content validity of studies, poor reporting of context and process, enormous variability in the way impact is reported, little formal evaluation of the quality of involvement, limited focus on negative impacts, and little robust measurement of impact. The GRIPP checklist addresses these key issues. The reporting of patient and public involvement in health research needs significant enhancement. The GRIPP checklist represents the first international attempt to enhance the quality of PPI reporting. Better reporting will strengthen the PPI evidence-base and so enable more effective evaluation of what PPI works, for whom, in what circumstances and why.
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              Involving Patients in Research: Considering Good Practice

              Increasingly, patients and members of the public are involved in the design, conduct and dissemination of research. INVOLVE, the UK’s national body for patient and public involvement, usefully defines this sort of involvement as: ‘research being carried out “with” or “by” members of the public rather than “to”, “about” or “for” them’ (INVOLVE, 2012). At the Musculoskeletal Research Unit in Bristol, we are often asked about our patient involvement work. In light of the questions that we are asked, this editorial highlights some current practice and guidance. We also reflect on the impact of our patient involvement activity and hope that this serves as a useful introduction and points interested readers to further reading. Why involve patients in research? Rationale for involving patients in study design are multiple, and include moral and ethical arguments about citizens’ rights, increasing relevance of research, and the view that doing so can improve research quality, although this may be hard to define (Fudge et al., 2008; Gibson et al., 2012; Ward et al., 2010). There are many examples of patient involvement in research, and patients have been involved at different stages in the research process, including: Identification of research priorities and agenda setting (Gooberman-Hill et al., 2008; Oliver et al., 2009). Development of patient information and consent procedures (Boote et al., 2011); Design of interventions (Angell et al. 2003) and placebos (Gooberman-Hill et al., 2013); Identification of outcomes (Boote et al., 2010; Boote et al., 2011; Vale et al.,. 2012); Data collection (Elliott et al., 2002) and analysis (Hewlett et al., 2005); Informing policy and practice (Barham, 2011). What guidance is there? Available advice about patient involvement in research often focuses on practical elements (Boote et al., 2006; Buckland et al., 2007; de Wit et al., 2011). Within musculoskeletal research, Hewlett and colleagues emphasize how to ‘Facilitate, Identify, Respect, Support and Train’ (FIRST) (Hewlett et al., 2006), which provides a useful set of criteria through which to think about elements of design. An assessment of the FIRST model concludes that it has utility for the implementation of ‘sustainable relationships between patients and researchers’ (de Wit et al., 2013). Relating to clinical trials, a team in Wales have developed a standard operating procedure for involvement, providing some guidance that focuses attention on resources and possible forms of involvement at each stage in the research lifecycle (Evans et al., 2013). Guidance for the reporting of patient involvement also now exists, and aims to encourage transparency. The ‘Guidance for Reporting Involvement of Patients and Public’ (GRIPP) checklist suggests that reports should include methods, context, process and impact (Staniszewska et al., 2011). Existing guidance generally mentions the variety of mechanisms that can be employed to deliver involvement activities. Possible options include group-based panels, forum meetings or citizens’ juries, and individual membership of advisory groups or co-working with researchers. It is not possible to specify that one type of approach is intrinsically better than another, as choice may be informed by topic area alongside requirements and preferences of patients and researchers (Rowe and Frewer, 2005). The ethics of involvement Alongside practical considerations, guidance encourages researchers to consider the ethical dimensions of involvement. If a key rationale for patient involvement is the desire to ensure that patients’ views are central to the design and delivery of research, then there is a need to maximize partnership and avoid exploitation. This is a complex issue and it seems best to focus on scrutiny of these issues rather than to make blanket suggestions about how patient involvement ‘should’ be done. Consideration of the ethical dimensions of patient involvement may be central to best possible practice. By this, we do not mean that patient involvement activity should be reviewed by an ethics committee through an exercise in ‘bureaucratic ethics’ (Heimer and Petty, 2010). Instead, that application and reflection about the principles of ethical practice should be part of the design and conduct of patient involvement. This may reduce the potential for inequality and exploitation. A useful model for thinking about equality and degree of partnership is Arnstein’s ‘ladder of citizen participation’ (Arnstein, 1969). Arnstein argued that degree of involvement could be understood as high or low: citizen control, delegation and partnership are at the upper end of the ladder; informing, therapy and manipulation are at the lower. By considering where an activity sits on the ladder, it becomes possible to highlight any potential power differentials. Although Arnstein’s model has been refined and less linear approaches have been suggested (Tritter and McCallum, 2006), we would wholeheartedly suggest a virtual trip up and down Arnstein’s ladder in any planning or evaluation of patient involvement activity. Striving to achieve good practice In our work at the Musculoskeletal Research Unit in Bristol, we seek to involve patients in research design and conduct through a patient forum: ‘The Patient Experience Partnership in Research’ (PEP-R). PEP-R comprises patients with experience of musculoskeletal conditions. PEP-R sessions are interactive; training and support is provided; and patients are offered payment and expenses. PEP-R is merely one instance of the many patient involvement activities taking place around the UK. Although PEP-R was developed in collaboration between researchers and patients using guidance from INVOLVE to develop its shape, the PEP-R approach is just one possible way that involvement could be carried out. Although there is need for evaluation of the impact of involvement in research (Brett et al., 2012; Staley et al., 2012), gains provided by patient involvement may be diffuse and hard to quantify (Fudge et al., 2008). Therefore, we focused attention on evaluation of the impact of patient involvement on stakeholders (Barber et al., 2011). Although we had no funding to support external evaluation, we assessed the impact by asking involved patients (n = 8) and researchers (n = 14) to complete a qualitative questionnaire. The questionnaire was administered 17 months after PEP-R started, over which time PEP-R had met ten times and provided input into 21 studies and project ideas. Patients and researchers were asked to reflect on the impact of PEP-R on them and their work, to identify the elements that they found most useful, and to suggest improvements. We were aware that internal (rather than external) evaluation might limit any open criticism, and so we asked about possible improvements. Key findings were: Patients described their interest and learning about the topics and research in general. They particularly valued feedback about how PEP-R’s input had shaped studies. Researchers identified the benefits of patients’ views on the importance, relevance and feasibility of projects. They welcomed the opportunity to speak to an interested and knowledgeable group, stressing the importance of early involvement. The work of PEP-R is purely one activity based in a single place and we would not wish to generalize from our experience. However, there appeared to be a sense of positive impact and the evaluation highlighted areas that were particularly valued by patients and researchers. Identification of impact and therefore of value indicates where patients and researchers were achieving some gains from the activity. This points towards mutual benefit. Patient involvement is here to stay We believe that patient involvement is here to stay, representing an ideological shift within which patients can take a more central, driving role in research that affects their health and healthcare. Many more researchers and patients are becoming actively involved in organizing or facilitating such activity. This takes considerable time and effort for all parties. We would suggest, then, that it is critical to consider best practice in patient involvement. To do so it is useful to reflect on the variety of ways that patient involvement has been conducted to date, to explore current guidance and ethical issues, and to consider evaluating involvement activity. All of these can be done in the context of deliberation about the extent to which an activity enables partnership and mutual gain.
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                Author and article information

                Contributors
                lgaleandrews@bournemouth.ac.uk
                helena@bournemouth.ac.uk
                zsheppard@bournemouth.ac.uk
                guybaylis@lineone.net
                twainwright@bournemouth.ac.uk
                Journal
                Res Involv Engagem
                Res Involv Engagem
                Research Involvement and Engagement
                BioMed Central (London )
                2056-7529
                27 November 2015
                27 November 2015
                2015
                : 1
                : 13
                Affiliations
                [1 ]GRID grid.17236.31, ISNI 0000000107284630, Bournemouth University Clinical Research Unit, , Bournemouth University, Faculty of Health and Social Sciences, ; Royal London House, Bournemouth, BH1 3LT UK
                [2 ]GRID grid.17236.31, ISNI 0000000107284630, Research Design Service South West, c/o Bournemouth University Clinical Research Unit, , Bournemouth University, Faculty of Health and Social Sciences, ; Royal London House, Bournemouth, BH1 3LT UK
                [3 ]Bournemouth University, Faculty of Health and Social Sciences, Royal London House, Bournemouth, BH1 3LT UK
                [4 ]GRID grid.17236.31, ISNI 0000000107284630, Service User c/o Orthopaedic Research Institute, , Bournemouth University, Faculty of Health and Social Sciences, ; Executive Business Centre, Bournemouth, BH8 8EB UK
                [5 ]GRID grid.17236.31, ISNI 0000000107284630, Orthopaedic Research Institute, , Bournemouth University, Faculty of Health and Social Sciences, ; Executive Business Centre, Bournemouth, BH8 8EB UK
                Article
                13
                10.1186/s40900-015-0013-8
                5611566
                29062501
                83b1e8fe-99fa-4a8c-ae6c-5209f17411fe
                © Andrews et al. 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 14 May 2015
                : 17 November 2015
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2015

                ppi,patient and public involvement,impact,osteoarthritis,public engagement,cycling,exercise,funding application

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