What is the impact of Public and Patient Involvement in Implementation Reserarch?
Bridging the research to practice gap is a recognised problem in implementation science. Innovative methodologies, such as participatory research, are recommended to advance the field, in line with imperatives for Public and Patient involvement in (PPI) health research. While there have been advances in conceptualisation and operationalisation of PPI in research, less is known about its impact. RESTORE is an EU-funded project involving migrants and other key stakeholders in the implementation of guidelines and training initiatives (G/TIs) to improve communication in cross-cultural consultations in primary care. We explore the impact of stakeholders’ collective efforts on the implementation work, focusing on the degree of control stakeholders had to effect change in different contexts: the participatory research space and the clinical context.
We undertook a qualitative, comparative case study in five primary care settings in Austria, England, Greece, Ireland and the Netherlands, informed by Normalisation Process Theory (NPT) and Participatory Learning and Action (PLA) research methodology. Following the principles of purposeful sampling, 78 stakeholders (migrants, GPs, nurses, administrative staff, interpreters, health service planners) participated. We completed 62 PLA style focus groups (2012 - 2014). Data were generated to evaluate stakeholders’ experience of PLA methodology and elucidate the work required to implement G/TIs. Data were coded, following the principles of framework analysis, using NPT’s four constructs (sense making, engagement, enactment and appraisal) to explore interconnections between methodology and theory. Quality and rigour of analysis was enhanced by co-analysis with stakeholders, double coding of 10% of the data set and searching for data falling outwith NPT.
Participants were very positive about the use of PLA as a methodology, reporting that it created a participatory research space that enabled equal participation and democratic decision making. Across countries, there were multiple examples of collaborative learning in this context, impacting on the value stakeholders placed on the G/TIs (sense making), their commitment to driving their implementation forward (engagement) problem solving to overcome challenges to enact G/TIs in clinical settings (collective action) and planning formal evaluations (appraisal). Participants’ decision making impacted on clinical contexts in two countries (England, Netherlands) where knowledge from TIs was enacted in practice. However, macro level factors (primary care funding models, austerity measures, health policy changes and social views on migrants) emerged as barriers to sustaining these new routines and inhibited the enactment of G/TIs in other countries (Austria, Greece and Ireland)
There was a strong positive impact of stakeholders’ collective work in the participatory research space but only a modest impact on clinical settings. This difference was largely due to macro level factors outwith stakeholders’ control. We need to moderate expectations of PPI in implementation research based on the limits of their collective work in the face of structural, macro level factors.