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Achieving inclusive research priority-setting: what do people with lived experience and the public think is essential?

Abstract

Background

Engagement of people with lived experience and members of the public is an ethically and scientifically essential component of health research. Authentic engagement means they are involved as full partners in research projects. Yet engagement as partnership is uncommon in practice, especially during priority-setting for research projects. What is needed for agenda-setting to be shared by researchers and people with lived experience and/or members of the public (or organisations representing them)? At present, little ethical guidance exists on this matter, particularly that which has been informed by the perspectives of people with lived experience and members of the public. This article provides initial evidence about what they think are essential foundations and barriers to shared decision-making in health research priority-setting and health research more broadly.

Methods

An exploratory, qualitative study was conducted in 2019. 22 semi-structured interviews were performed with key informants from the UK and Australia.

Results

Three main types of foundations were thought to be essential to have in place before shared decision-making can occur in health research priority-setting: relational, environmental, and personal. Collectively, the three types of foundations addressed many (but not all) of the barriers to power sharing identified by interviewees.

Conclusions

Based on study findings, suggestions are made for what researchers, engagement practitioners, research institutions, and funders should do in their policy and practice to support meaningful engagement. Finally, key international research ethics guidelines on community engagement are considered in light of study findings.

Peer Review reports

Introduction

Patient and public engagement is gaining prominence in health research, with research institutions, international research ethics guidelines, and funding bodies now promoting, or even mandating, engagement as an ethically and scientifically essential component of all health research [8, 28, 36, 39]. Authentic engagement means involving patients, members of the public, or organisations representing them as full partners or collaborators [46]. This implies shared decision-making throughout projects and the greatest community empowerment [37]. It entails involving individuals with lived experience, members of the public, and/or organisations representing them as decision-makers not only when conducting data collection and analysis and disseminating findings but also when setting research projects’ topics and questions and shaping projects’ design [13, 36, 43]. In this paper, the terms ‘people with lived experience’ and ‘members of the public’ are primarily used rather than patient, community, or community member. These terms are used because they capture two key perspectives that people who are engaged bring to research studies: (1) the lay/public/citizen perspective and (2) the patient/community/service user perspective.Footnote 1

Engaging people with lived experience and/or members of the public, especially those from groups who are considered disadvantaged or marginalised by social institutions and norms, as collaborators is essential as a matter of justice [27, 33, 34]. It provides a path for making their voices and concerns more visible in agenda-setting and in the production of scientific knowledge [36]. It can help address epistemic injustices and generate research project topics and questions that are more explicitly focused on improving access and affordability of health care and services for them [2, 27, 33, 34]. Thus, their involvement in priority-setting is especially important.Footnote 2

Yet it is uncommon for such individuals, especially those considered disadvantaged or marginalised, or organisations to be included as decision-makers during agenda-setting for research projects. They rarely initiate new research projects or are invited by researchers to have a say in setting agendas or designing research projects. A recent quantitative study found that over 60% of community organisation respondents had rarely or never jointly submitted a grant application when working in collaborative research partnerships [40]. Current funding mechanisms make it difficult to undertake engagement pre-grant award. Indeed, even when invited to enter decision-making spaces, unequal power dynamics between researchers and people with lived experience and/or members of the public can give rise to tokenism in priority-setting: presence without voice and voice without influence, particularly for the most marginalised [38].

What is needed for priority-setting to be shared by researchers and people with lived experience and/or members of the public (or organisations representing them)? At present, little ethical guidance exists on this matter, particularly that which has been informed by the perspectives of people with lived experience and members of the public. A significant amount of existing literature explores the concepts of engagement and participation in contexts of power disparities, spanning disciplines like political philosophy (see [4, 47, 48]), development studies (see [3, 7, 9, 12, 14, 15]), health policy (see [1, 22, 23]), and community-based participatory research (see [6, 19, 24, 31, 45]). That body of work largely does not consider engagement in the context of research priority-setting [35]. Within it, there is also limited literature drawing on the voices and perspectives of people with lived experience, members of the public, and engagement practitioners.

This study aimed to access their voices to investigate what is essential for shared decision-making during agenda-setting for health research projects. Robust ethical guidance is informed by both theory and the considered judgements of relevant persons—in this case, those with key insights and experiences of engagement in health research. This encompasses not only researchers but also people with lived experience, engagement practitioners, and members of the public. If the latter voices aren’t captured, they are largely absent from ethics discourse and a key source of information is excluded or missing. Talking with them about power sharing in health research addresses an epistemic injustice and helps democratise knowledge within the ethics field.

22 semi-structured interviews were conducted with key informants from the UK and Australia. Both Australian and UK participants were included to explore this topic because engagement in health research is established in both countries. Since “patient and public involvement” in research has been a feature of UK policy for longer and is widely adopted by UK research funders,Footnote 3 it was thought that UK interviewees might have different ideas and experiences related to power-sharing than Australian interviewees. Data were thematically analysed and insights regarding what foundations are needed and what barriers exist to shared decision-making in health research are reported. Foundations and barriers refer to factors that can facilitate or obstruct power-sharing; they help create conditions where power-sharing can or or are unlikely to occur. Foundations are necessary for power-sharing to happen; barriers hinder its occurrence.

The paper then critically reflects on the key lessons this study offers for sharing power with people with lived experience and members of the public in health research priority-setting. Based on study findings, suggestions are made for what researchers, engagement practitioners, research institutions, and funders should do in their policy and practice to support inclusive research priority-setting. Their specific ethical responsibilities are proposed because their remits make them especially well-placed to build certain foundations. Finally, key international research ethics guidelines on community engagement are considered in light of study findings.

Methods

Study methods and sample

In-depth interviews were chosen as the primary method to explore the topic because they allow for the rich details of key informants’ experiences and perspectives to be gathered. 22 semi-structured interviews were conducted with key informants in three main categories:

  • People with lived experience who are or have been involved in health research (16)

  • Members of public who are or have been involved in health research (2)

  • Engagement practitioners who work in health research (4)

Engagement practitioners are individuals who work for research institutions and their role is to support and train researchers to engage patients and the public in research projects; build relationships between researchers, research institutions, and the public; and build patient and public capacity to engage in research.

Sampling was initially purposive; potential participants with lived experience who had been involved in health research and engagement practitioners were identified in the UK and Australia through BP’s existing networks. In Australia, snowball sampling and posting information about the study on the Research4MeFootnote 4 Facebook group were then used to identify additional interviewees. In the UK, information about the study was sent out on a university’s patient and public involvement email listserv and this generated the remainder of interviewees.

In total, five men and seventeen women were interviewed. Twelve interviewees live in the UK and ten in Australia. Interviewees had lived experience of mental health conditions (2), chronic illness (6), and forms of disability (physical, psychosocial, cognitive) (6). Two interviewees with lived experience did not disclose the condition(s) with which they were living. Nine interviewees (eight with lived experience and one member of the public) had experience with research priority-setting; two were from Australia and seven were from the UK. Interviewees’ engagement experiences ranged from being a single, short-term engagement (e.g., one focus group) to being engaged in one or more research projects over one to five years to having decades of engagement experience over many projects. Interviews continued until data saturation was achieved.

Data collection and analysis

During interview, people with lived experience and members of the public were first asked what roles they had been engaged to perform in health research. Subsequent interview questions asked about their perspectives and experiences sharing power in the context of that or those specific role(s). This was because not all participants had experience in co-design of research projects, which entails being engaged during agenda-setting, or in research priority-setting.Footnote 5 Where interviewees had a priority-setting role, interview questions were asked in the context of that role only. Collectively, interviewees had the following roles in health research: member of funding panel, member of priority-setting process for the James Lind Alliance, co-applicant, community researcher, member of steering or advisory group, and/or member of focus group. Engagement practitioners were asked about their experiences and perspectives on co-design. Thus, the study data speak to power-sharing not only in health research priority-setting but also more broadly.

Interviews were transcribed verbatim and thematic analysis was undertaken by two coders in the following five phases: initial coding framework creation, coding, inter-coder reliability and agreement assessment, coding framework modification, and final coding of entire dataset [5, 16]. The initial coding framework was developed by BP and NE co-coding five transcripts from Australian interviewees independently and jointly coming up with a list of codes. The remaining Australian interviews were then coded by BP and the initial list of codes was revised. Using the initial coding framework, BP and JS next undertook an iterative process of coding a UK interviewee transcript, assessing intercoder reliability and agreement, and modifying the coding framework [16]. A second co-coder (JS) was brought in to see if the coding framework could be reliably applied by someone with no prior involvement in the study and to test that the coding framework was applicable to the UK interviewee data. Six transcripts were co-coded and 100% intercoder agreement was achieved, with agreement going the way of both parties fairly evenly in most cases. Fifteen new subcategories (of 61 subcategories total) were added to the coding framework based on the UK data. Once the coding framework was finalized, BP applied it to recode all 22 transcripts. According to Campbell et al. [5], once high intercoder agreement is reached, a single person can perform the remaining coding, provided it is the person whose coding generally carried the day during the negotiation process.

Study limitations

It is critical to acknowledge the main limitations of this study. First, interviewees were recruited from Australia and the UK only. While engagement in health research is increasingly common in both countries, there are other countries where engagement is frequently occurring in health research, including in low and middle-income countries. Future research should capture their views as well. The author has started to do so as part of two case studies of health research priority-setting being conducted in India and the Philippines.

The interviewee sample had fewer men than women, members of the public than people with lived experience, and individuals living in urban than rural areas. The diversity of interviewees is also somewhat unclear, as the study did not collect demographic data about interviewees. UK interviewees self-selected themselves to participate after information about the study was sent out on a university’s patient and public involvement listserv. That listserv in itself was not thought to be exceptionally diverse by the engagement practitioner who runs it. Lack of diversity was identified as a problem for engagement in health research as a whole by interviewees. Nonetheless, interviewees had lived experience of a range of disabilities (cognitive, psychosocial, physical) and chronic illnesses. Several mentioned being of non-Caucasian ethnicities such as African, Hungarian, and Indigenous. In terms of age, Australian interviewees spanned younger ages (20s and 30s) to retirement age. UK interviewees were generally older but not all were retired.

Finally, not all of interviewees’ insights were directly about priority-setting because they had not had roles during early phases in health research. Nearly half the interviewees had some priority-setting experience. More of these were from the UK, where engagement roles on funders’ grant panels and as co-applicants are more common.

Results

Foundations

Three main types of foundations were identified as essential to have in place before power sharing and meaningful engagement can occur in health research: relational, environmental, and personal. No differences were found between the foundations reported by Australian versus UK interviewees, though the UK research funding environment was described as more supportive of involving people with lived experience and members of the public in health research agenda-setting relative to the Australian research funding environment.

Relational

Two relational foundations were described: forming connections and building trust. Key types of connections to form are: (1) personal connections between researchers and the specific individuals who are engaged in research projects and (2) connections between researchers, their institutions, and the community or public.

Building personal connections entails having empathy, being open and honest, sharing personal information and stories, listening, putting one’s selves in each other’s shoes to understand where the other is coming from, learning each other’s strengths and weaknesses, and performing acts of kindness. Developing such connections is essential to inclusion:

Once you’ve developed that [relational understanding] between a gatekeeper to a society and someone that’s experienced oppression, you give them an olive branch to become included. So that to me is key. (person with lived experience, Australia)

Building connections with the community or public were described as important to sharing power in agenda-setting:

I do see good researchers do that, you know they, they will spend a couple of years mingling with a community before they ask for something. I think it’s really good practice. (person with lived experience, Australia)

Making ourselves as organisations and as researchers accessible and not asking people to step over our thresholds but stepping over our own thresholds to go and really be accessible to others. (engagement practitioner, UK)

Such connections are necessary for building trust and for building awareness of engagement in research, its value, and the relevance of research to people’s everyday lives.

Informal interactions were identified as key to forming both types of connections. Interviewees noted that taking the time to do less research-focused activities at the outset is just as important as moving on to co-design, particularly when engaging those with experience of marginalisation. To build personal connections, creative activities like crafting or harmonica lessons were described by a UK engagement practitioner as “especially levelling” because “if you can learn to do something with someone where you're both equally unknowledgeable and unpractised, it creates a bond to start you off.” To build connections with communities, activities like community festivals, film nights, and introductory/education sessions with panels that combine researchers and people with lived experience were discussed. Such activities largely:

Had nothing to do with sitting around the table doing co-design with our researchers, but they also had everything to do with how we build our relationship with our community that leads to people wanting to come and sit at the table with us… we set up an expectation that what we really value is our difference of opinion… we are respectful of all voices and we wanna hear all voices. (engagement practitioner, Australia)

Building trust was also identified as a core foundation of power sharing. Trust ran two ways. Researchers needed to have trust in those they had engaged; this was discussed as people with lived experience and members of the public having “credibility”:

You are the consumer, you are the outsider, you have to prove that you’re up to this and then if you manage to establish your credibility people will suddenly start listening to you. (person with lived experience, Australia)

People with lived experience and members of the public had to have trust in researchers and the institutions for whom they work in order to share power with them. According to an Australian engagement practitioner:

When you’ve got that basis of trust there, you can sit across the table and then go actually I really disagree with that you’re saying, what I want you to hear from me is this and you can have far more robust, equal power sharing relationships.

Here, s/he refers to relationships throughout the research process, from priority-setting onwards.

Building these connections and trust makes people who are engaged in health research feel comfortable sharing their vulnerabilities and being critical with researchers. Although people’s vulnerabilities are the hardest to draw out, these are the key stories for agenda setting. Researchers can identify those problems that pain people the most and pursue them in research.

Environmental

Three environmental foundations were described: researcher support, funding mechanisms and policies, and norms. Each must be present in the research environment in order for power sharing to occur in priority-setting. Researcher support meant researchers provide resources and create spaces that enable people with lived experience and members of the public to participate, so that “people who are less confident, that are coming from a marginalised position, can step powerfully into that [research decision making] space.” Five key supports were identified:

  • Training for those engaged (and for researchers)

  • Accommodating varying needs

  • Creating a safe space to share vulnerabilities and be critical

  • Pairing or mentoring system

  • Making people feel valued

Researchers should provide training for those engaged in health research based on their needs. Sixteen interviewees (including four engagement practitioners) noted the importance of training for those engaged. This would encompass training about grant writing and funding processes; ethics processes; research processes, methods, and jargon; and patient and public involvement roles in research. For agenda-setting, training about grant writing and funding processes were identified as especially key by a person with lived experience from Australia:

Skills around okay well what does grant writing look like… a lot of that stuff is really kind of like university bureaucratic behind the scenes stuff and that’s really like where the power kind of relations really are… I also was interested in those processes but that’s kind of not available to you as a community researcher sometimes I think.

Training around grant writing and funding processes is often not accessible to people with lived experience or members of the public and excludes them from participating in those phases of research projects.

Training for researchers was also discussed and entailed introducing them to what patient and public engagement is and how to undertake it in a way that is genuinely inclusive. To start the training process, a UK engagement practitioner noted that s/he might:

have a panel of which the researchers can, who come, can post their questions and we’ll also have some sort of pre-decided questions so that patients can talk a bit about their experience and then we’ve got some group work. And it’s, as much as anything, I think it’s trying to show researchers that a lot of researchers who don’t see patients day to day are quite frightened of them, they’re really anxious about talking to patients and I think it’s showing them that they aren’t there unnecessarily to criticise, patients really, genuinely, they really want to help and they will do that in a constructive way.

Researchers should accommodate varying needs, which was defined by people with lived experience as making reasonable adjustments so engagement activities can be accessible and performed and as supporting in “an unequal manner to provide equity”. Two ways of accommodating were spoken about (and overlap with each other): providing information in ways those engaged can understand and taking account of disabilities (physical (mobility, vision, hearing), psychosocial, cognitive). The former included (but was not limited to) writing for varying literacy levels and language fluencies, not using technical jargon, and having language interpreters at meetings. The latter included (but was not limited to) making things physically accessible, using easy to read large print, employing sign language interpreters, and being flexible about how tasks could be completed by those engaged.

Researchers should also create safe spaces for engagement, make those engaged feel valued, and employ a pairing or mentoring system where possible. A safe space was described as an atmosphere where people are encouraged to be critical and where the people are comfortable with each other. They feel free to speak up and share their experiences and vulnerabilities with the group without feeling “stupid”. Making people feel valued was discussed by a UK person with lived experience as providing a comfortable venue with refreshments, remembering people’s names and things about them, being friendly and welcoming, and making statements such as “we really value [you] and feel you can make a valuable contribution”. A pairing system could link a person with little to no engagement experience with another person with significant engagement experience. It could also pair someone with lived experience or from the public who had been engaged with a researcher.

Funders should offer funding for pre-grant engagement, which supports people with lived experience and members of public to be part of developing grant applications and setting research project agendas:

In England, there’s local organisation so they, they operate across an area called research design service, RDS, and they can give researchers access to some pots of money that can help them do the patient and public involvement work before the main funding comes, if it comes. As I say in Scotland that doesn’t exist I’ve been told. (person with lived experience, UK)

They should make engagement a funding criterion too, which some funders have done. According to a UK interviewee with lived experience, the UK National Institute of Health Research has such criteria. S/he states:

If you don’t show evidence that you’ve actively involved people with a condition, then you’ve got no chance whatsoever getting funded [by the National Institute of Health Research].

These supports and funding practices are valuable because they enable people with lived experience and members of the public to be engaged early in health research (pre-grant award) and feel comfortable sharing their stories and their criticisms of proposed research.

Beyond research support and funding, an environment is needed where the norms surrounding research and public engagement support power sharing in health research. Where research culture values different forms of experience and evidence, it can facilitate community knowledge being valued and used in agenda-setting and design of health research projects.

Personal

Specific personal qualities and skills of researchers and of people with lived experience and members of the public were identified as essential pre-requisites for power sharing in health research. Lead researchers who value engagement were strongly identified as essential to share power throughout research, including during priority-setting:

I have heard from people who have done a lot of PPI [patient and public involvement], when they get, feel like the chief or the principal investigator is fully onboard with it and treats them as like you know an equal and bothers to keep in touch with them, that is absolutely vital. (engagement practitioner, UK)

Aside from valuing engagement and co-design, other qualities that researchers ideally should have are being humble and being open to sharing personal information to develop relationships and to listening to people who have different opinions to them. Essential skills were good communication, facilitating engagement and co-design, negotiation, and conflict resolution.

The qualities and skills people with lived experience and members of the public who are engaged in health research should include that they:

  • Reflect the diversity of lived experience of using a service or a community

  • Are well-connected and informed across the community: Have deep understanding of their community and the issues impacting it

  • Can be a voice for others and tell their stories; Aren’t fixated on their own problems

  • Want to make a difference for others and the health system

  • Are confident to speak up and be assertive

  • Are articulate

  • Are credibleFootnote 6

  • Have analytical skills

  • Have team-work and interpersonal skills

  • Have negotiation and conflict resolution skills

Selecting people with lived experience and members of the public with the confidence to sit at a table with senior researchers and to challenge their ideas was identified as critical where researchers have limited experience with engagement and co-design and/or have a tokenistic view of what it entails. According to an Australian engagement practitioner,

it felt like this first experience of co-design was a test case that was kind of winning them over to a new way of working. So for this particular co-design, especially I needed really skilled people sitting at the table coming from a lived experience perspective because it’s cracking open the door and opening the way.

Understanding research and having credibility could also be useful qualities to have in that context. However, the interviewee also recognised that selecting confident and articulate individuals could easily exclude voices. A research institution’s engagement program should thus seek to build people’s capacity to engage in research for a diversity of individuals within the given community or public “so that people that are less confident, that are coming from a more marginalised position can step up into that space.”

Barriers

Seventeen barriers to sharing power in health research were identified by interviewees, spanning the personal, relational, and environmental (Table 1). Certain barriers reflected qualities, behaviours, and feelings of those engaged: lack of knowledge, lack of awareness of engagement in research, cliques, internalised powerlessness, and feeling intimidated. Some barriers reflected qualities and attitudes of researchers: lack of engagement experience, lack of buy-in for engagement practice, playing favourites, and devaluing community knowledge. Other barriers reflected how engagement was organised: funding, lack of diversity, bureaucracy, logistics, technology, time, language, and lack of or insufficient compensation.

Table 1 Barriers to power-sharing in health research.

Collectively, the three types of foundations addressed many (but not all) of the barriers to power sharing in health research identified by interviewees. Building connections address barriers to sharing power like devaluing community knowledge, lack of buy-in and awareness of engagement in research, and lack of diversity of those engaged. Researcher supports help address lack of knowledge and buy-in for engagement, make those engaged feel less intimidated by researchers, reduce the lack of diversity amongst those engaged, and reduce feelings of internalised powerlessness. For instance, an interviewee remarked that a safe and encouraging space is essential to capture the voices of those who have had:

intense personal experiences of all their power stripped away…I think there is a feeling of powerlessness that those experiences leaves that you bring with you when you come and sit at the table. And so if we genuinely wanna hear those voices I think we have to go the extra mile to make it a safe space and encouraging space for them to feel that their voices have value and they can be heard. (engagement practitioner, Australia)

Barriers not addressed by the identified foundations were:

  • Having too much knowledge (scientific or medical) or engagement experience

  • Illness

  • Funding

  • Bureaucracy

  • Logistics

  • Technology

  • Lack of or insufficient compensation

  • Playing favourites amongst those engaged

  • Cliques amongst those engaged

Barriers only identified by UK interviewees were: bureaucracy, lack of diversity, and having too much clinical or scientific knowledge or engagement experience (Table 1). The latter was spoken about by two interviewees who had been turned down for engagement roles due to having a clinical background and PhD respectively. The interviewee with a PhD noted that she was thankful her degree was in plant science and not a health-related field because “I quite often have to persuade them that I am actually some use because some people think I’m actually a scientist and that’s not what they’re looking for.” The other interviewee remarked that it seems that researchers at times only want to work with members of the public with no engagement experience and/or members of the public with no background in the area of research: “just Joe or Josephine public”. Other times researchers like to have people who have some background in the area under study or are happy with a mix of people. Australian interviewees spoke about class and education disparities as barriers but did not link them to feeling intimidated, whereas several UK interviewees did.

Discussion

Robust ethical guidance for authentic engagement cannot be developed unless it is informed by the issues and concerns experienced by both researchers and their patient, public, and community partners. This paper begins to identify the essential foundations for meaningful engagement in health research from the perspective of people with lived experience and members of the public. It builds an understanding of power sharing in health research from a non-academic researcher viewpoint.

Although the findings reported in this paper speak to shared decision-making in health research generally, they offer insights as to what foundations are thought to be important to achieve it during health research priority-setting. It is particularly vital to develop ethical guidance on inclusive research priority-setting given that agenda-setting in health research is typically dominated by academic researchers and funders. Authentic engagement in health research begins with shared decision-making in priority-setting.

The study shows that relational foundations such as forming connections and creating safe spaces will help people with lived experience and members of the public to share vulnerabilities, which provide key insights for identifying research topics and questions to explore. Environmental foundations such as training about funding processes and pre-grant funding mechanisms for engagement will enable people with lived experience and members of the public to participate in grant writing and facilitate their joining projects before research topics and questions are set. Environmental foundations like having a research culture that values the voices of people with lived experience and members of the public in setting research priorities are important too. Personal foundations such as lead researchers who value engagement will help ensure that people with lived experience and members of the public are involved early on.

The value of forming connections, researcher support, and research culture to sharing power in health research priority-setting are key insights generated by this study. Previous research capturing the perspectives of researchers, ethicists, and community organisation staff also identified building trust, personal qualities and skills of researchers and community members, funding, and broader cultural norms as facilitating shared decision-making in health research priority-setting [34]. The wider literature on participatory development and participatory research, however, has identified forming connections, trust, personal qualities of researchers like cultural humility, and supports like training and pairing those engaged with academic researchers as important to achieving inclusion [6, 7, 11, 24, 32, 44]. The qualities and skills of people with lived experience and members of the public necessary to achieve power-sharing are perhaps less reported in those literatures. Norms around valuing different types of knowledge equally have also been identified as essential, especially when participation occurs in science and technology fields [20]. Use of evidence language as the norm and existing hierarchies in science and technology fields means people with lived experience and the public are less likely to have their ideas and views listened to because they are seen as having lower credibility than health professionals [17, 20, 21, 44].

The study provides more evidence that achieving inclusive health research priority-setting depends on work being done by researchers, engagement practitioners, research institutions, and funders in advance of and independent of funding or conducting specific research projects. What their ethical responsibilities to support authentic engagement might look like in light of the study findings is now considered. It is suggested that researchers, engagement practitioners, research institutions, and funders should adopt certain policies and practices. Their specific obligations are proposed below and assigned because their remits make them especially well-placed to build certain foundations. (Please note, however, these obligations do not encompass the entirety of researchers, research institutions, engagement practitioners, and funders’ ethical responsibilities in relation to engagement in health research.)

Funders, research institutions, and engagement practitioners should help create a normative environment where engagement in health research, including during priority-setting, is valued. To do so, governments could run national campaigns to build awareness about engagement roles in health research and funders could set up research design services that support engagement during the development of research proposals. Funders could further demonstrate that they value engagement in health research priority-setting by engaging people with lived experience and members of the public when setting their own priorities and on their grant selection panels. Existing examples to drawn on include the James Lind Alliance, Diabetes UK, UK National Institute of Health Research, and the US Patient-Centred Outcomes Research Institute [10, 18, 26, 29]. Research institutions could make meaningful engagement in health research a core promotion and performance review criterion.

Funders and research institutions should also adopt funding policies, grantmaking principles, and funding selection criteria requiring engagement in health research, with engagement as shared decision-making and starting during agenda-setting being weighted more heavily than engagement as consulting and engagement starting late in research projects. Grantmaking principles could give preference to research teams that include people with lived experience and members of the public. Funders should further offer engagement grants to support forming relationships with communities and to build communities’ capacity to be engaged in health research. Patient-Centred Outcomes Research Institute Engagement grants are one example of such practice [30]. Research institutions should establish engagement departments/units to build strong connections with their local communities and to help build researchers’ training in and value of engagement, including during priority-setting. Engagement practitioners should help achieve both aims.

Researchers should, as part of their general practice, lay the groundwork for meaningful engagement by spending time with the communities with whom they conduct research and by cultivating certain skills and qualities within themselves, e.g., openness, good communication. They should form personal connections with people from those communities and support them to participate in particular research projects from the agenda-setting phase onwards by providing training, accommodating needs, creating safe spaces, and making people feel valued. They should be supported to do this by engagement practitioners/managers and departments at their research institutions.

The findings of this study and proposed ethical responsibilities can usefully be compared to key international research ethics guidelines on community engagement such as UNAIDS Good participatory practice guidelines for HIV prevention trials, Recommendations for community involvement in National Institute of Allergy and Infectious Diseases HIV/AIDS clinical trial research, and the Council for International Organizations of Medical Sciences’ International ethical guidelines for health-related research involving humans [8, 25, 41]. The latter largely does not address building foundations for engagement or who is responsible for doing so. The UNAIDS and NIAID guidance documents do discuss building an environmental foundation—researcher support—and some of the personal qualities identified in this paper—researchers’ value of engagement and their communication skills [25, 41]. Researcher support encompasses training, pairing systems, and accommodating varying needs but does not mention creating safe spaces or making people feel valued [25]. The NIAID recommendations even call for giving training on funding mechanisms and priority-setting [25]. However, none of the guidance documents discuss building relational or other environmental foundations before projects. They also do not assign responsibilities to build foundations to research institutions and funders. Only researchers and community representatives (e.g., community advisory board staff) are identified as obligation-bearers.

Additionally, it is important to note that the identified foundations do not address several of the barriers—largely structural barriers—described by interviewees in this study. Potentially many of these barriers (bureaucracy, logistics, compensation) could be addressed through better engagement policies at the government, research institution, and/or funding levels. These policies should be developed with people with lived experience and members of the public. They could (amongst other things) streamline application procedures for engagement roles, call for performing engagement locally, set compensation levels that sufficiently cover people’s time and expenses, and mandate ongoing training in facilitating engagement for all research staff. Future research could usefully explore what foundations are needed to overcome structural barriers to engagement and who should be responsible for establishing them.

Finally, UK interviewees identified several barriers that Australian interviewees did not: bureaucracy, lack of diversity, and having too much clinical or scientific knowledge or engagement experience. This could likely reflect a more bureaucratic system of patient and public involvement in the UK as well as engagement in health research being more established in the UK. Future research could gather information from interviewees in other countries, especially low- and middle-income ones, as their voices need to be captured to inform ethical guidance on engagement in health research as well. Additional barriers and foundations within the three (or additional) categories may be identified by such studies.

Conclusions

This article provides initial evidence about what people with lived experience and members of the public think are essential foundations to build to share decision-making in health research priority-setting and health research more broadly. Capturing their perspectives is necessary because they offer key insights that will otherwise be excluded, which is a form of epistemic injustice.

Importantly, interviewees identified relational and environmental foundations in addition to individual level personal foundations. Researchers, supported by engagement practitioners/managers, research institutions, and research funders are well positioned to create these foundations. Their policy and practice should thus encompass building them to support the meaningful engagement of people with lived experience and members of the public in health research priority-setting.

Availability of data and materials

The de-identified datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Notes

  1. 1.

    They use the service being researched, have the condition being researched, or are from the community being researched.

  2. 2.

    The paper’s focus is not meant to imply it is sufficient to share decision-making in the priority- setting phase of research alone. Engagement is critical in all phases of health research projects.

  3. 3.

    Within UK policy, public participation has been presented as a solution to help renew and improve society’s trust, interest and relationship with science since 2004. Many UK funding bodies ask that researchers include patient and public engagement in their research plans. Over the last 15 years, UK research funders have embarked on several large-scale collaborative initiatives to support patient and public engagement within research [42].

  4. 4.

    Research4Me is an extended network of people and organisations in Australia that share a common passion for involving people in health and medical research: https://research4.me/

  5. 5.

    This is despite recruitment scripts asking for such participants.

  6. 6.

    According to a person with lived experience from Australia, credibility means being trusted and believed in to provide useful information that is “maybe even essential” to what the researchers are going to do. Developing credibility takes substantial time and entails convincing researchers that the person being engaged is interested in what they do and in seeing it succeed and that they can help shape the research in ways that will make it more beneficial.

Abbreviations

UK:

United Kingdom

CIOMS:

Council for international organizations of medical sciences

NIAID:

National institute of allergy and infectious diseases (US National Institutes of Health)

UNAID:

Joint United Nations programme on HIV/AIDS

References

  1. 1.

    Abelson J, Giacomini M, Lehoux P, Gauvin F-P. Bringing, “the public” into health technology assessment and coverage policy decisions: From principles to practice. Health Policy. 2007;82:37–50.

    Article  Google Scholar 

  2. 2.

    Ahmed SM, Palermo AS. Community engagement in research: frameworks for education and peer review. Am J Public Health. 2010;100(8):1380–7.

    Article  Google Scholar 

  3. 3.

    Arnstein SR. A ladder of citizen participation. J Am Inst Plann. 1969;35:216–24.

    Article  Google Scholar 

  4. 4.

    Benhabib S. Towards a deliberative model of democratic legitimacy. In: Benhabib S, editor. Democracy and Difference: Contesting the Boundaries of the Political. Princeton, NJ: Princeton University Press; 1996. p. 67–94.

    Chapter  Google Scholar 

  5. 5.

    Campbell JL, Quincy C, Osserman J, Pedersen OK. Coding in-depth semistructured interview: problems of unitization and intercoder reliability and agreement. Sociol Methods Res. 2013;42:294–320.

    Article  Google Scholar 

  6. 6.

    Cargo M, Mercer SL. The value and challenges of participatory research: strengthening its practice. Annu Rev Publ Health. 2008;29:325–50.

    Article  Google Scholar 

  7. 7.

    Cornwall A. Whose voices? Whose choices? reflections on gender and participatory development. In: Cornwall A, editor. The participation reader. New York, NY: Zed Books; 2011. p. 203–23.

    Google Scholar 

  8. 8.

    Council for International Organizations of Medical Sciences. International ethical guidelines for healthrelated research involving humans. Geneva, Switzerland: CIOMS;2017.

  9. 9.

    Crocker DA. Ethics of global development: agency, capability, and deliberative democracy. Cambridge: Cambridge University Press; 2008.

    Book  Google Scholar 

  10. 10.

    Diabetes UK. Patient and Public Involvement (PPI) in your Study [Internet] [cited 28 Feb 2020]. https://www.diabetes.org.uk/research/for-researchers/apply-for-a-grant/help-with-involving-participants

  11. 11.

    Gaventa J. Towards participatory governance: assessing transformative possibilities. In: Hickey S, Mohan G, editors. Participation from tyranny to transformation. London: Zed Books; 2004. p. 25–58.

    Google Scholar 

  12. 12.

    Gaventa J, Cornwall A. Challenging the boundaries of the possible: participation, knowledge and power. IDS Bull. 2006;37:122–8.

    Article  Google Scholar 

  13. 13.

    Gichuru E, Kombo B, Mumba N, Sariola S, Sanders EJ, van der Elst EM. Engaging religious leaders to support HIV prevention and care for gays, bisexual men, and other men who have sex with men in coastal Kenya. Crit Public Health. 2018;28(3):294–305.

    Article  Google Scholar 

  14. 14.

    Goulet D. Development ethics at work: explorations-1960-2002. New York, NY: Routledge; 2006.

    Book  Google Scholar 

  15. 15.

    Hickey S, Mohan G. Towards participation as transformation: critical themes and challenges. In: Hickey S, Mohan G, editors. Participation from tyranny to transformation. London: Zed Books; 2004. p. 2–24.

    Google Scholar 

  16. 16.

    Hruschka DL, Schwartz D, St John DC, Picone-Decard E, Jenkins RA, Carey JW. Reliability in coding open ended data: lessons learned from HIV behavioral research. Field Methods. 2004;16:307–31.

    Article  Google Scholar 

  17. 17.

    Hutchison K, Rogers W, Entwistle VA. Addressing deficits and injustices: the potential epistemic contributions of patients to research. Health Care Anal. 2016. https://doi.org/10.1007/s10728-016-0323-5.

    Article  Google Scholar 

  18. 18.

    James Lind Alliance. The James Lind Alliance [Internet]. [cited 28 Feb 2020]. http://www.jla.nihr.ac.uk/

  19. 19.

    Kitchin R. The researched opinions on research: disabled people and disability research. Disabil Soc. 2000;15(1):25–47.

    Article  Google Scholar 

  20. 20.

    Leach M, Scoones I. Science and citizenship in a global context. IDS Working Paper 205. Brighton: Institute of Development Studies; 2003.

    Google Scholar 

  21. 21.

    Leach M, Scoones I, Thompson L. Citizenship, science and risk: conceptualising relationships across issues and settings. IDS Bull. 2002;33(2):40–8.

    Article  Google Scholar 

  22. 22.

    Mitton C, Smith N, Peacock S, Evoy B, Abelson J. Integrating public input into healthcare priority-setting decisions. Evidence & Policy. 2011;7(3):327–43.

    Article  Google Scholar 

  23. 23.

    Mitton C, Smith N, Peacock S, Evoy B, Abelson J. Public participation in health care priority setting: a scoping review. Health Policy. 2009;91:219–28.

    Article  Google Scholar 

  24. 24.

    Muhammad M, Wallerstein N, Sussman AL, et al. Reflections on the researcher identity and power: the impact of positionality on community based participatory research (CBPR) processes and outcomes. Crit Sociol. 2015;14:1045–63.

    Article  Google Scholar 

  25. 25.

    National Institute of Allergy and Infectious Disease (NIAID). (2009). Recommendations for community involvement in National Institute of Allergy and Infectious Diseases HIV/AIDS clinical trial research. Retrieved March 13, 2019, from http://www.mtnstopshiv.org/sites/default/files/attachments/CAB_Recommendations_Certified.pdf

  26. 26.

    National Institute of Health Research. Research Design Service [Internet]. [cited 28 Feb 2020]. https://www.nihr.ac.uk/explore-nihr/support/research-design-service.htm

  27. 27.

    Oswald K, Gaventa J, Leach M. Introduction: interrogating engaged excellence in research. IDS Bull. 2016;47(6):1–18.

    Article  Google Scholar 

  28. 28.

    Participants in the Community Engagement & Consent Workshop. Consent and community engagement in diverse research contexts. J Empir Res Hum Res Ethics. 2013;8(4):1–18.

    Article  Google Scholar 

  29. 29.

    Patient-Centred Outcomes Research Institute. Engagement in Healthcare Research [Internet]. [cited 28 Feb 2020a]. https://www.pcori.org/engagement

  30. 30.

    Patient-Centred Outcomes Research Institute. Engagement Award: Capacity Building [Internet]. [cited 28 Feb 2020b]. https://www.pcori.org/funding-opportunities/announcement/engagement-award-capacity-building

  31. 31.

    Peuravaara K. Reflections on collaborative research: to what extent and on whose terms? Scand J Disabil Res. 2015;17(3):272–83.

    Article  Google Scholar 

  32. 32.

    Ponic P, Reid C, Frisby W. Cultivating the power of partnerships in feminist participatory action research on women’s health. Nurs Inq. 2010;17(4):324–35.

    Article  Google Scholar 

  33. 33.

    Pratt B. Engagement as “co-constructing knowledge”: a moral necessity in public health research. Bioeth. 2019;33(7):805–13.

    Article  Google Scholar 

  34. 34.

    Pratt B. Towards inclusive priority-setting for global health research projects: recommendations for sharing power with communities. Health Policy Plan. 2019;34(5):346–57.

    Article  Google Scholar 

  35. 35.

    Pratt B. Constructing citizen engagement in health research priority-setting to attend to dynamics of power and difference. Dev World Bioeth. 2018;19(1):45–60.

    Article  Google Scholar 

  36. 36.

    Reynolds L, Sariola S. The ethics and politics of community engagement in global health research. Crit Public Health. 2018;28(3):257–68.

    Article  Google Scholar 

  37. 37.

    Sharp RR, Foster MW. Involving study populations in the review of genetic research. J Law Med Ethics. 2000;28(1):41–51.

    Article  Google Scholar 

  38. 38.

    Shayo EH, Norheim OF, Mboera L, Byskov J, Maluka S, Kamuzora P, Blystad A. Challenges to fair decision-making processes in the context of health care services: a qualitative assessment from Tanzania. Int J Equity Health. 2012;11:30.

    Article  Google Scholar 

  39. 39.

    Solomon MZ, Gusmano MK, Maschke KJ. The ethical imperative and moral challenges of engaging patients and the public with evidence. Health Aff. 2016;35(4):583–9.

    Article  Google Scholar 

  40. 40.

    Tremblay C. Global trends in community university research partnerships. In: Hall B, Tandon R, Tremblay C, editors. Strengthening community university research partnerships: global perspectives. Victoria: University of Victoria and PRIA; 2015. p. 31–40.

    Google Scholar 

  41. 41.

    UNAIDS. Good participatory practice guidelines for HIV preventiontrials. Geneva: UNAIDS; 2011.

  42. 42.

    van Bekkum JE, Hilton S. UK research funding bodies’ views towards public participation in health-related research decisions: an exploratory study. BMC Health Serv Res. 2014;14:318.

    Article  Google Scholar 

  43. 43.

    Versfeld A, Scheibe A, Shelly S, Wildschut J. Empathic response and no need for perfection: reflections on harm reduction engagement in South Africa. Crit Public Health. 2018;28(3):329–39.

    Article  Google Scholar 

  44. 44.

    Wallerstein N, Duran B. The theoretical, historical, and practical roots of CBPR. In: Wallerstein N, Minkler M, editors. Community-based participatory research for health: from process to outcomes. San Francisco, CA: John Wiley & Sons; 2010. p. 25–46.

    Google Scholar 

  45. 45.

    Wallerstein N, Duran B. Using community-based participatory research to address health disparities. Health Promot Pract. 2006;7:312–23.

    Article  Google Scholar 

  46. 46.

    Woolf SH, Zimmerman E, Haley A, Krist AH. Authentic engagement of patients and communities can transform research, practice, and policy. Health Aff. 2016;35(4):590–4.

    Article  Google Scholar 

  47. 47.

    Young IM. Inclusion and democracy. Oxford, UK: Oxford University Press; 2000.

    Google Scholar 

  48. 48.

    Young IM. Communication and the Other: beyond deliberative democracy. In: Benhabib S, editor. Democracy and difference: contesting the boundaries of the political. Princeton, NJ: Princeton University Press; 1996. p. 120–36.

    Chapter  Google Scholar 

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Acknowledgements

The author would like to thank Natalia Evertsz and Jessica Snir for their assistance with transcription and coding of interview data.

Funding

At the time of this study, BP was supported by an Australian Research Council (ARC) Discovery Early Career Researcher Award (Award No. DE170100414). The contents of this article are solely the responsibility of the author and do not reflect the views of the ARC. The ARC had no involvement in the design or conduct of this study, or in writing this manuscript.

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BP conceived of the paper: its topic, aims, and arguments. BP was responsible for writing the first draft of the paper and revising the work critically for intellectual content. BP gave final approval of the version to be published. BP read and approved the final manuscript.

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Correspondence to Bridget Pratt.

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Pratt, B. Achieving inclusive research priority-setting: what do people with lived experience and the public think is essential?. BMC Med Ethics 22, 117 (2021). https://doi.org/10.1186/s12910-021-00685-5

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Keywords

  • Ethics
  • Inclusion
  • Power
  • Priority-setting
  • Engagement
  • Partnership
  • Health research
  • Patient and public involvement