The “PPI Hawker”: An innovative method for Patient and Public Involvement (PPI) in health research

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Smith This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.19589/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jun, 2020 Read the published version in Research Involvement and Engagement → Version 2 posted 4 You are reading this latest preprint version Show more versions Abstract Background: Patient and Public Involvement (PPI) in health research entails doing research ‘with’ the public. Successful PPI requires a diversity of patients’ perspectives and experiences. In Singapore, including the public’s voice in research is still in its infancy and different ways of involving the public have to be explored. Our aims were to describe a PPI initiative that enables members of the public to share their ideas and opinions about health research, and to assess the feasibility, accessibility and utility of the initiative. Methods: Building on the concept of the PPI Café used in the west we designed a “PPI Hawker” for Singapore. Here Hawker Centres rather than cafes are used frequently for eating and socialising, providing a one-stop destination for a wide section of society. The PPI facilitators approached people sitting at tables and joined them to discuss questions of relevance to a local research study. Observations and reflexive field notes were used to evaluate the “PPI Hawker’s” feasibility, acceptability and utility in the Singaporean community. Results: In three “PPI Hawkers” we approached 96 people and 72 (75%) engaged in discussions about the design of a population-based research study. The majority (75%) of participants willingly discussed all of the questions posed to them by the researchers, indicating the feasibility of PPI. The PPI participants came from the three major ethnic groups in Singapore and appeared to be broad in age, suggesting “PPI Hawkers” are easily accessible. Both participants and researchers recognised the utility of the “PPI Hawker”, reflecting on people’s willingness to talk about the research issues, engaging in informative conversations and posing relevant questions. Conclusion: The “PPI Hawkers” succeeded in engaging the public in conversations about a local population-based study. The public brought to the researchers’ attention a variety of previously unheard perspectives about the research. Each event fostered connectivity between professionals and the public, generating among researchers a more positive perception of the power of public involvement. “PPI Hawkers” provide an opportunity for co-informed conduct of research studies with diverse members of the public. They create a focus within a community setting for researchers to engage with the public. The resources needed (costs and preparatory time) are relatively few. Not only do “PPI Hawkers” have potential in Singapore, but also for the rest of Asia. Health Economics & Outcomes Research community-based methods collaborative research empowerment health research participatory research patient and public involvement and engagement Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Patient and public involvement (PPI) in research is defined as research that is carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them. Although PPI is a common component of health research in Western countries, such as the UK, Australia and Canada 1–5 , PPI is still in an early stage of development in Asian countries, including Singapore 6 . It is recognised that PPI enhances the quality and relevance of the research, and its impacts are greater when implemented early in the research cycle 7–9 . If Singapore wishes to remain at the forefront of Asian health research, public involvement in health research must be cultivated, with public perspectives being heard and their concerns addressed. Often when PPI is in its infancy, a few selected public collaborators are invited by the researchers to engage in a two-way conversation 10 . These same individuals may contribute repeatedly during the research process and also return for future studies led by the same team. Whilst this model of involvement is strong on continuity, it generates concerns about tokenism. There is a risk that the public contributor remains as a “thinker at the edges” 11,12 . Other PPI initiatives strive for greater diversity in involvement, whilst some focus on greater levels of public impact 13,14 . Public involvement is a complex and diverse endeavour; each PPI approach has its merits and their appropriateness varies according to the characteristics of the study (for example, research question, study design, resources available and skills of lay-researchers 15–18 . Recent PPI developments have focussed on ways to include disadvantaged communities in these “privileged” spaces, recognising it is often vulnerable people who have the greatest health needs 10,19,20 . PPI Cafés are an example of such developments, whereby the characteristics of a “science café” and a PPI workshop were blended. A “science café” is where scientists and science professionals are invited to speak in a casual non-academic setting where everyone can learn and discuss the scientific issues of the day in science and technology, generally for the price of a cup of coffee or a glass of wine 21 . In contrast, PPI workshops a formal, organised training sessions for researchers wanting to learn how to involve lay people in their research activities and for members of the public wishing to familiarise themselves with research and PPI 22 . The PPI Cafés borrow from the science café the casual setting and conversational style and from the PPI workshops learning objective to create an opportunity for the public to have learn about PPI as they contribute to the development and refinement of a real-life research project. The first PPI Café was piloted at the 2018 Imperial Festival 22 , a science festival for the public organised by researchers at Imperial College London. The public were invited to join the “baristas” (researchers, public facilitators and PPI facilitators) for a drink in a space customised to look like a café 22 . Tables were dedicated to different research studies, and at each table a facilitator introduced the research study before the researcher asked about their ‘guests’ perceptions and comments on specific issues. Guests were encouraged to write down their comments and leave them in a container in the centre of each table. In Singapore cafés are not as common as in Western countries, but hawker centres, also known as food courts, (shown in Fig.1) are used frequently for eating and socialising. In hawker centres, seating facilities are shared and a complete meal can be enjoyed at one table with each course taken from different vendors. This differs from the Western context, where only food and drink purchased from that vendor can be consumed on the premises exclusive to the vendor. Hawker centres are also more accessible, both physically and financially, to a wider sector of society than cafés. Described as “Singapore in a nutshell” 23 , they provide a one-stop destination for everyone, offering a wide choice of high-quality food at inexpensive prices (meals are priced at S$3-4 and a local drink costs about S$1.5 24 ). Open from 7 AM to 10 PM and managed by the National Environment Agency, hawker centres are typically found near public housing estates or transport hubs. The 15,000 food stalls 25 serve the majority of the 5.64 M people living across the country 26 . Hawker centres are so integral to Singaporean life that in March 2019, the Singaporean government nominated hawker culture for UNESCO listing of the Intangible Cultural Heritage of Humanity 27 . Figure 1 Photograph of Serangoon Gardens Market & Food Centre. Photo Credit: Cynthia Chew 28 To date there has been little attention to the inclusion of PPI in research conducted in Asian countries. Currently in Singapore the role of the public is almost exclusively limited to taking part in research. While the benefits of public involvement and co-production are well established in the literature 7,29–41 , methods for an Asian context have yet to be explored. Here we describe the “PPI Hawker”, an adaptation of the PPI Cafés used in Western cultures. The “PPI Hawker” was designed to enable the Singaporean public to share their personal perspectives relevant to a local population-based study (described in Box 1) in an informal environment throughout the country. This article shares our experiences of developing and conducting “PPI Hawkers”. Methods Towards an Asian friendly PPI Café Conceptually, the “PPI Hawker” was designed to be similar to the PPI Café. We envisioned the “PPI Hawker” would reduce the hierarchies between researchers and the public, enabling a two-way conversation, which could facilitate the sharing of knowledge and improved relevance of research studies. Through short and informal conversations, the “PPI Hawker” was created to bring together members of the community (past, current, and future patients and their caregivers) with researchers, reducing the boundaries between non-experts and experts. The design of “PPI Hawkers” would encourage recognition of complementary expertise by positioning lived experiences and personal perspectives at the same level as expert knowledge. Like for the PPI Café, organising the discussion in a setting familiar to the public would facilitate discussion, encouraging ideas to be explored in spontaneous conversation, building trust between lay people and researchers. Designing and testing the feasibility of the “PPI Hawker” To progress the design of the “PPI Hawker”, we formed a development team with a coordinator, two PPI Leads with experience of conducting PPI Cafés in the UK, a researcher from the population-based study (Box 1) and a Singaporean resident. The coordinator was a Spanish doctoral student, exploring the potential for PPI in Singapore (LLP) and the two PPI Leads were from Imperial College London’s Patient Experience Research Centre (PERC), UK with extensive experience of PPI. Other members of the team were an Asian post-doctoral researchers from the study population-based study and a Singaporean resident, an engineer who was interested in PPI. Adaptation of the PPI Café to the Singapore context required more than just change in location: the multi-ethnic community required us to consider how we would facilitate, and record discussions conducted in several languages. We decided to work organised in such a way as to maximise the local languages available for discussion (Mandarin Chinese, Cantonese, Malay and Tamil). Note taking was always in English as this is the lingua franca, that is the language adopted as a common language between speakers whose native languages are different. By documenting in English, the one common language between the speakers of many different languages in Singapore, our documentation was accessible to all facilitators and researchers. In taking the PPI Café (Fig.2) into the Singaporean context we wished to retain the informal atmosphere but to use the more open, non-institutional and public space of a Hawker Centre. We transferred the idea of using members of the public as facilitators, involving researcher from project, offering participants refreshments (but not making them ourselves), and facilitating in pairs. We dispensed with displaying research materials, but we added the use of cue cards to aid round table discussion (Fig.3). Participants were also able to refer to a card briefly summarising the study’s aims and methods, to reinforce the initial oral explanation. One facilitator introduced and guided each conversation, using their local language skills whilst the second facilitator documented the discussion. Figure 3 Design of the “PPI Hawker”, building on the PPI Café Figure 2 Example of cue card containing a question and prompts for the “PPI Hawkers” Having piloted the first “PPI Hawker” as a team of five, we subsequently worked as four (“PPI Hawker” coordinator, researcher from the study, and two public facilitators). The first public facilitator was the same one as in the development team; the second one was an early career scientist who wanted to develop her communication skills with the public and who studied in the same university where LLP is conducting her doctoral studies. None of them had been previously involved in research and they facilitated the “PPI Hawker” on a volunteer non-paid basis. The public facilitators were selected for their language skills (speaking English, and one or more local official languages: Mandarin, Malay and Tamil), their comfort engaging with the public and an interest in research. They were briefed on the research study objectives and the issues the researchers wanted the public to consider. Before going to the Hawker Centres the team used role play to familiarise themselves with the cue cards and how to focus discussion on those topics. Although LLP coordinated the event, all four facilitators had equal roles and voice during the whole event. A step-by-step guide to the “PPI Hawker“ The ten stages in organisation of the “PPI Hawker” are summarised in Fig.4. Such an event starts with a group of researchers willing to seek the lay perspectives in a “PPI Hawker” and to collaborate with a group of facilitators for it. A facilitator familiar with PPI would then work with the study team to come up with topics and questions about which a public perspectives would be valued (Step 1). The facilitation team is then formed, including a representative from the research study and at least two members of the public able to converse in local dialects and comfortable talking to new people (Step 2). Deciding on a suitable venue for the event attention must be paid to the ambience, a relaxed atmosphere in a place frequented by a diverse population and the time envisaged for the “PPI Hawker” (Step 3). As a team the facilitators need to refine the phrasing of the questions (Step 4) and then practice using role play how best to approach people in the hawker (Step 5). When the “PPI Hawker” event takes place it is advisable for the facilitators to work in pairs (Step 6) to approach people already sitting at a table, either alone or in a group, to introduce them to the study and the aim of the “PPI Hawker”. In our case, the coordinator paired with a lay facilitator, whilst the researcher paired with the second lay facilitator. Once verbal consent is obtained, the discussion of the PPI questions begins with one facilitator managing the discussion and the other documenting the conversation (Step 7). As hawker centres are generally frequented by large crowds, not everyone will be approached, instead the facilitators select based on whether people are already engaged in conversation, appear to be leaving soon or are from the demographic group targeted. Figure 4 The ten stages in organisation of the “PPI Hawker” [1] To document the conversations, one of the researchers listed down the main points discussed for each of the questions. After each “PPI Hawker”, the main issues brought up by participants were summarised each facilitator reflected on their interactions with the public, documenting difficulties encountered, for example engaging the public in conversation around a particular aspect of the research (Step 8). The findings were presented to the research team orally and in a report for them to discuss and agree what adjustments should or could be made to the study (Step 9). When conducting “PPI Hawkers” the note taking is not routinely verbatim. However in this development and feasibility phase we captured exactly what members of the public offered as feedback on their experience of taking part in the “PPI Hawker”. Facilitators also noted of the number of people sitting at each participating table, together with their observations on demographic characteristics (gender, age and ethnicity) and the attitudes of everyone taking part; this data was used for assessing feasibility but not shared with the population-based study’s researchers. Ethical considerations In the UK, application for apply for ethical approval to involve the public in the planning or the design stage of research is not necessary 43 . Since Singapore does not yet have guidelines for PPI in research, we followed INVOLVE guidelines from the UK. We did not record any identifying information from “PPI Hawker” participants 44 . Criteria for evaluation Before piloting the “PPI Hawker”, we agreed on the desirable characteristics against which we could evaluate the initiative: Feasibility was defined by the capacity to engage members of the public in discussion. Our goals were: at least 50% people approached agreeing to participate, to engage a minimum of 20 participants in each session, at least 10 individuals responding to each of the questions posed by the researchers (the questions from each session are listed in Appendices 1 and 2). This criteria was based on sample sizes commonly used in qualitative research 45,46 . Acceptability of the “PPI Hawker” was judged by our success engaging with a cross section of the general adult population of Singapore, the target audience for the population based study. We sought representation from diverse ages (20-80) and all major ethnic groups (Chinese, Malay and Indian). To monitor this facilitators made notes about the perceived age of “PPI Hawker” participants and their ethnic group. Acceptability was also assessed by the informal feedback and comments made by participants. Utility was the extent to which the public generated ideas were incorporated into the study design by the population-based study’s researcher Utility was assessed by the researchers’ responses to presentations and written reports about the views elicited by the “PPI Hawkers”. [1] In preparing for this series of 10 stages, attention has been paid to the UK Standards for Public Involvement in Research 42 Results The conduct of three “PPI Hawkers” The “PPI Hawker” Pilot We conducted three “PPI Hawkers”, the first as a pilot to see if we needed to improve on the design. This “PPI Hawker” was held in November 2018, in Serangoon Gardens Market and Food Centre (Fig.1) and it soon became apparent that inviting participants to join our table as they queued to buy themselves refreshments from the hawker stalls was not going to work (Fig.2). Everyone approached refused to join our table, but instead invited us to join theirs. After a quick discussion, we decided to approach people already sitting and asking if we could join their table. With this amendment, 28 members of the public participated, but all declined the offer of a free drink. Our preliminary “PPI Hawker” highlighted the need to be clearer when introducing the concept of PPI and describing the overall aims of the research study to be discussed. The need for this additional information became apparent when some members of the public thought we were trying to recruit them to the study rather than ask for their ideas and opinions. The pilot reinforced the need to work in pairs, with one person documenting the insights shared by members of the public whilst the other facilitated the discussion. To increase the clarity and utility of the documentation we developed a coding system that we cod use in subsequent events. The conduct of two further “PPI Hawkers” Our first “PPI Hawker” engaged mostly Chinese, so to achieve greater ethnic diversity the two subsequent events were conducted in locations frequented by more Malay and Indian residents (Malay and Indian represent 13 and 9% of Singapore’s population respectively, 74% being Chinese 26 ). With our revised method (Fig.2), we were able to approach a further fifty-nine members of the public of whom we engaged forty-four (24 Indian, 13 Malay and 7 Chinese), in short conversations (around 15 minutes per table) sitting at 33 tables (16 in Admiralty and 17 in Tekka Centre). Achieving our goals The “PPI Hawkers” exceeded our predefined goals for feasibility, acceptability and utility. Feasibility: Capacity to engage members of the public At each “PPI Hawker” more than twenty members of the public were engaged, and within each session most individuals (85%) responded to each of the questions posed (these are listed in Appendices 1 and 2). The “PPI Hawker” concept was well received by the public; 96 members of the public were approached, whilst 72 took part in one of the three sessions. In other words, 75% of those approached at their tables agreed to engage in a conversation with us. Acceptability: The public’s perspective of the “PPI Hawker” We involved members of all three ethnic groups in Singapore and spoke to adults who appeared to be from a wide age range, confirming accessibility of the “PPI Hawker”. From the public’s feedback the opportunity to take part in the “PPI Hawker” conversations was appreciated, supporting “PPI Hawker”’s acceptability. Most members of the public we spoke to were “ happy to give [us their] opinion ” and to informally share with us their thoughts on the “PPI Hawker”. Participants enjoyed “feeling helpful ” contributing to something that would benefit their community. They felt that by meeting in the familiar space of the hawker centres, researchers lost “ their authoritarian attitude ”. Moreover, they recognised that “ researchers don’t know [our needs and wants], we have to tell them ”. The format of the “PPI Hawker” as an involvement method for Singaporeans was widely supported; participants valued its concise and one-off nature, because of the pressures on their time and no wish to talk about research on a regular basis. One member of the public finished their conversation with us by thanking us for meeting the public: “ You are doing a very good thing for people [coming to ask for people’s perspectives at the hawker centre]. I have to appreciate ”. Utility: Population-based study’s researchers’ feedback Results of the “PPI Hawker” were presented to the study’s Steering Group, composed of the 6 Study Principal Investigators, the Operations Manager, the Recruitment Manager and occasionally other researchers from the team. The Steering Group’s response to the feedback from the public about their population-based study was encouraging, and they expressed the need to continue with the “PPI Hawkers” to also understand the views of populations from different neighbourhoods. The researcher involved as a facilitator commented on how “ The public’s opinion are very diverse, and I learnt that if you spend the time to listen to public, there are many things that you can learn. People are generally willing to help, and their feedback will only make our research stronger! ” With subsequent “PPI Hawkers” her appreciation of their value was strengthened by observing the hidden knowledge within different communities. She commented: “ An eye opener, certainly I could see the totally different perspective from those of lower socio-economic classes about research health screening ”. The discussion of the feedback from participants prompted refinements to the “PPI Hawker” including more consistency in the terminology used. For example, while some facilitators had used the word “confidentiality” others had used “anonymity” when discussing data sharing issues. This inconsistency made the PPI feedback less useful as it was not always possible to know which term the pubic were responding to. As a result, we agreed facilitator’s should only use the terminology on the cue cards and would always explain any technical terms before engaging in discussion. Examples of how PPI impacted on the design of the population-based study can be found in the box 2 below. Researchers considered the feedback provided by “PPI Hawker” participants for all questions and intend to incorporate some aspects for each of the issues discussed. Some of those have already been operationalised, as discussed in box 2. Discussion Summary In three “PPI Hawkers” we were able to engage 72 members of the public in discussions about issues the researchers of a population-based study wanted the public’s perspective. This novel approach of involving lay people on research-related matters achieved an engagement rate of 75%. Participants came from the three main ethnic groups in Singapore and appeared to be broad in age. Since the hawker centres are spaces visited by almost all Singaporeans, this PPI method facilitates engagement with a broad sector of society in different neighbourhoods. Using short one-off conversations in their mother tongue in a familiar environment the majority of participants were willing to discuss all of the questions posed by the researchers. Researchers recognised the utility of the “PPI Hawker”, reflecting on people’s willingness to consider research issues, engaging in informative conversations and ask relevant questions. During these conversations, facilitators observed the traditional barriers between experts and non-experts being broken down, leading to mutual respect and sharing of ideas. PPI facilitator’s experience Facilitators observed how the informal setting allowed members of the public to talk openly and freely share personal experiences. This relaxed environment allowed us to approach audiences unfamiliar with research, where they felt able to contribute and also to ask questions about other topics beyond those suggested by the researchers. Facilitators were encouraged by their experiences of the “PPI Hawkers”, and highlighted the feasibility and accessibility of this method of involvement in the Singaporean context. The reflexive notes of the “PPI Hawker” team were universally encouraging, sometimes describing characteristics that exceeded expectations: “I was surprised by how most people were receptive and keen to discuss the project with us. Singaporeans are often zealous in the protection of their privacy and are reluctant to share their opinions. However, those we interacted with were willing to talk at length about the issues, curious about the research, and seemed to enjoy the experience” (“PPI Hawker” co-ordinator). One facilitators recorded how the public’s initial hesitancy to be involved was quickly transformed into engagement: “People were apprehensive when we first approached them (like we were going to sell something/ask them for something/like we were disturbing quiet, family time) but once it was clear we just wanted their OPINIONS, the conversation flowed quite effortlessly. I was surprised to see them have so much to say, so much to contribute to each of the questions asked. The public are not as oblivious or ill-informed as some may think, they may not be researchers but everything that was said made perfect sense and was of great value. We could not have predicted those responses or gotten a more honest feel for their perception of research in general or the barriers and facilitators to research if we did not sit down and talk to them in person, in a natural setting as we did today.” (Public facilitator, reflecting on sessions #2 and #3) Advantages of the “PPI Hawker” The “PPI Hawkers” have the potential to be used more widely for PPI in Singapore, and potentially in other Asian contexts. This approach to PPI has identified two major attributes: Firstly, the “PPI Hawker” reduces communication barriers, making it easier for researchers to interact with the public and vice versa. The process of the public inviting researchers to join them at their own tables appeared to enable the public more control over the encounter, and guide the amount and direction of the discussion. These conversations become opportunities to share knowledge and work together to improve the research design. We observed within the “PPI Hawker” dialogue, reciprocity, openness and respect, enabling thoughtful communication between the facilitators and the public. Secondly the “PPI Hawker” reduces the barriers between experts and the public, flattening or reversing the pyramid of hierarchy 47 . Conventionally lay people are reluctant to challenge perceived expertise 48,49 , but the round table discussions appeared to generate mutual trust, and a willingness for the non-expert to comment, critique and challenge the research. Such exchange is often difficult to achieve in very hierarchical societies, like Singapore 48,50 but the “PPI Hawker” appears to achieve this by the development of a collective consciousness. Effective and efficient use of resources PPI is often characterised as a time and energy intensive activity, and it can be this that deters researchers’ enthusiasm and engagement for PPI 6 . The “PPI Hawker” addresses some of these concerns as it does not require the administrative burden or the expenses of sending out invitations, hiring a venue or transport for participants. However, it does require time for the initial planning (a one-off activity), and then the conduct of each “PPI Hawker” and the collating of ideas. In our experience the time spent planning preparing and training for the project-specific PPI was 10 person hours in total. Each “PPI Hawker” required 2 hours of facilitators time (including a 30-minutes briefing in advance). The final collation of comments and summarising them for the research team required a further 8 hours of the coordinator’s time and 1 hour for each of the other facilitators’ time. Limitations and strengths of the “PPI Hawker” A challenge for PPI globally is the need to hear a wide diversity of perspectives. Increasingly more groups have been empowered and are being heard, but some groups still remain at the margins. Reluctance to participate in PPI 6 is known to be more challenging to those with poor research knowledge, lower literacy and limited oral skills, characteristics often seen within those sub-populations who have the greatest health needs. We found the presence of the public facilitators was particularly helpful with developing trust, for example with the Indian population an introduction in Tamil defused feelings of being caught in an unfamiliar situation to inclusion in a conversation in which they were central. “PPI Hawkers” offer a helpful solution to this challenge, but they are not without their limitations. For example, it is recognised that long-term involvement throughout the different stages of a research project increases the impact of PPI 7 but the “PPI Hawker” is a one-off encounter. Not collecting personal and demographic data from participants makes it difficult to characterise them exactly. For example, we wanted an ethnic mix and used appearance to identify the ethnic group of participants. Using appearance may not always be adequate, for example if one wishes to target people of a specific age, sexuality, marital status or income group. Lastly, the “PPI Hawker” may not be appropriate for all types of research, including studies about sensitive topics or complex studies where substantial background and explanation are needed before the public are able to comment. Finally, alongside positive aspects of the “PPI Hawker”, some negative views were also noted. Around a quarter of members of the public approached wanted to be “left alone”, others wished to discuss topics not related to the research study (for example, digressing to complain about the government). However, only one individual responded with some aggression, sharing their dogmatic beliefs about medicine. None of our offers of a drink were accepted, and occasionally a participant expressed mild offense when offered a free drink, they considered it as too small a token of appreciation, because it was something that they could easily afford for themselves. We have demonstrated the feasibility of the “PPI Hawkers”, a novel approach suitable in a non-western culture, complementing widely used PPI Cafes and User Groups. Although our experience is currently confined to Singapore we anticipate that this model of involvement would be applicable to other Asian countries where the traditional concept of public food markets are also commonplace. As a potential refinement of the “PPI Hawkers” may be the use of some advanced publicity of the event, rather than descending unannounced on diners. This may have reduced the suspicion some people expressed and confirm our legitimacy. We are also keen to explore in the future whether the “PPI Hawker” could be an avenue for dissemination of research findings, an under-developed aspect of PPI 51 . Research findings continue to be shared conventionally, disseminated in academic environments (for example, conference presentations, journal papers and academic books) and far less through channels easily accessible for the public (for example, public exhibitions, podcasts and blogs). “PPI Hawkers” may be an effective way to increase the public’s awareness of the findings of health-related research that could impact on their lives. The feasibility of this needs further exploration and piloting. Conclusion This study has demonstrated how the “PPI Hawker” aligns with the ethos of public involvement in research. It has the potential to be the major model for PPI initiatives in Singapore, facilitating knowledge exchange in community spaces accessible to a wider number of people. Further feasibility studies are needed to confirm the “PPI Hawkers” utility when used to discuss studies in different topic areas and with different methods, but preliminary findings are encouraging. List of Abbreviations PPI: Patient and Public Involvement PERC: Patient Experience Research Centre Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding LLP is funded through the NTU-SINGA doctoral scholarship programme. Authors' contributions LLP was the coordinator of the “PPI Hawkers”. She designed and conducted the three “PPI Hawker” sessions, and she analysed the comments coming out of it. She maintained the relationship with the PPI Facilitators and the researchers from the population-based research study throughout. HES was a major contributor in developing the evaluation and writing the manuscript. All authors read and approved the final manuscript. Acknowledgements We would like to acknowledge all the facilitators of the three “PPI Hawker” sessions, in particular our two public facilitators. We would also like to thank the researchers of the population-based research study who gave us the chance to design and trial the “PPI Hawker”. References Consumers’ Health Forum of Australia. A Model Framework for Consumer and Community Participation in Health and Medical Research. December 2004. https://www.healthissuescentre.org.au/images/uploads/resources/NHMRC-framework-consumer-participation-research.pdf. Staley K, Associates T, Sandvei M, Horder M. ‘A problem shared…’ The challenges of public involvement for researchers in Denmark and the UK. April 2019:22. Manafo E, Petermann L, Mason-Lai P, Vandall-Walker V. Patient engagement in Canada: a scoping review of the ‘how’ and ‘what’ of patient engagement in health research. Health Research Policy and Systems . 2018;16(1). doi:10.1186/s12961-018-0282-4 Department of Health. 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April 2009. doi:10.1111/j.1369-7625.2009.00532.x nternational Association for Public Participation. Public Participation Pillars. https://cdn.ymaws.com/www.iap2.org/resource/resmgr/Communications/A3_P2_Pillars_brochure.pdf. Greenhalgh T, Hinton L, Finlay T, et al. Frameworks for supporting patient and public involvement in research: Systematic review and co‐design pilot. Health Expectations . April 2019:hex.12888. doi:10.1111/hex.12888 Gallivan J, Kovacs Burns K, Bellows M, Eigenseher C. The many faces of patient engagement. J Participat Med . 2012;4(e32). https://participatorymedicine.org/journal/evidence/research/2012/12/26/the-many-faces-of-patient-engagement/. Staley K. There is no paradox with PPI in research. Journal of Medical Ethics . 2013;39(3):186-187. doi:10.1136/medethics-2012-100512 Greenhalgh T. Citizens. In: How to Implement Evidence-Based Healthcare . John Wiley & Sons; 2018. Tritter JQ, McCallum A. The snakes and ladders of user involvement: Moving beyond Arnstein. Health Policy . 2006;76(2):156–168. Lam B, Zamenopoulos T, Kelemen M, Hoo Na J. Unearth Hidden Assets through Community Co-design and Co-production. The Design Journal . 2017;20:12-14. doi:10.1080/14606925.2017.1352863 Condon L, Bedford H, Ireland L, et al. Engaging Gypsy, Roma, and Traveller Communities in Research: Maximizing Opportunities and Overcoming Challenges. Qualitative Health Research . January 2019:104973231881355. doi:10.1177/1049732318813558 Cafe Scientifique. Cafe Scientifique: How it works. Cafe Scientifique. http://cafescientifique.org/home-page/how-it-works. Accessed April 11, 2020. Luna Puerta L, Imperial Patient Experience Research Centre (PERC). The potential for public involvement in health research in Singapore: Reflections on culture and practice. Patient Experience Research Centre . February 2019. http://wwwf.imperial.ac.uk/blog/perc/2019/02/04/public-involvement-hawker-singapore/. Accessed September 24, 2018. National Heritage Board. Hawker Culture in Singapore. Our Heritage. https://www.oursgheritage.sg/hawker-culture-in-singapore/. Published August 29, 2017. Accessed September 24, 2019. Ng D. Profit margins for hawker fare? As low as 20 to 30 cents. Channel News Asia. https://www.channelnewsasia.com/news/cnainsider/profit-margins-for-hawker-centre-fare-as-low-as-20-to-30-cents-10948414. Published November 20, 2018. Accessed September 24, 2019. Seetoh K. Hawker Centres Singapore. Are there too many? Makansutra . June 2018. Department of Statistics Singapore. Singapore Population. Singstat. https://www.singstat.gov.sg/modules/infographics/population. Published 2019. Accessed September 24, 2019. Zaccheus M. Singapore submits Unesco bid to recognise hawker culture. Straits Times. Chew C. Chomp Chomp Food Centre, Singapore. The Food Pornographer . November 2014. http://thefoodpornographer.com/2014/11/chomp-chomp-food-centre-singapore/. NIHR. Going the Extra Mile: Improving the Nation’s Health and Wellbeing through Public Involvement in Research . London: INVOLVE; 2015. Mockford C, Staniszewska S, Griffiths F, Herron-Marx S. The impact of patient and public involvement on UK NHS health care: a systematic review. International Journal for Quality in Health Care . 2012;24(1):28-38. doi:10.1093/intqhc/mzr066 Oliver SR, Rees RW, Clarke-Jones L, et al. A multidimensional conceptual framework for analysing public involvement in health services research. Health Expectations . 2008;11(1):72-84. doi:10.1111/j.1369-7625.2007.00476.x Thompson J, Bissell P, Cooper C, Armitage CJ, Barber R. Credibility and the ‘professionalized’ lay expert: Reflections on the dilemmas and opportunities of public involvement in health research. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine . 2012;16(6):602-618. doi:10.1177/1363459312441008 Smith E, Ross F, Donovan S, et al. Service user involvement in nursing, midwifery and health visiting research: A review of evidence and practice. Nursing Studies . 2008;45(2):298–315. Brett J, Staniszewska S, Mockford C, et al. A Systematic Review of the Impact of Patient and Public Involvement on Service Users, Researchers and Communities. Patient . 2014;7(4):387-395. doi:10.1007/s40271-014-0065-0 Petit-Zeman S, Locock L. Bring on the evidence. Nature . 13AD;501(5):160-162. doi:10.1111/j.1369-7625.2012.00795.x Boote J, Baird W, Sutton A. Public involvement in the systematic review process in health and social care: A narrative review of case examples. Health Policy . 2011;102(2-3):105-116. doi:10.1016/j.healthpol.2011.05.002 Ennis L, Wykes T. Impact of patient involvement in mental health research: longitudinal study. British Journal of Psychiatry . 2013;203(05):381-386. doi:10.1192/bjp.bp.112.119818 Barber R, Beresford P, Boote J, Cooper C, Faulkner A. Evaluating the impact of service user involvement on research: a prospective case study: Evaluating the impact of service user involvement on research. International Journal of Consumer Studies . 2011;35(6):609-615. doi:10.1111/j.1470-6431.2011.01017.x Lowes L, Robling MR, Bennert K, et al. Involving lay and professional stakeholders in the development of a research intervention for the DEPICTED Study. Health Expectations . 2011;14(3):250-260. de Wit M, Beurskens A, Piškur B, Stoffers E, Moser A. Preparing researchers for patient and public involvement in scientific research: Development of a hands-on learning approach through action research. Health Expectations . 2018;21(4):752-763. doi:10.1111/hex.12671 Minogue V, Cooke M, Donskoy A-L, Vicary P, Wells B. Patient and public involvement in reducing health and care research waste. Research Involvement and Engagement . 2018;4(1). doi:10.1186/s40900-018-0087-1 NIHR Centre for Engagement and Dissemination, Public Involvement and Engagement Team, Health and Care Research Wales. UK Standards for Public Involvement. UK Standards for Public Involvement. https://sites.google.com/nihr.ac.uk/pi-standards/home. Health Research Authority, INVOLVE. Public Involvement in Research and Research Ethics Committee Review: A Joint Statement .; 2016. https://www.invo.org.uk/wp-content/uploads/2016/05/HRA-INVOLVE-updated-statement-2016.pdf. Accessed September 3, 2019. Nanyang Technological University Singapore. NTU-IRB Guidelines. Nanyang Technological University Singapore. https://research.ntu.edu.sg/rieo/IRB/Guidelines/Pages/Guidelines.aspx. Published December 17, 2019. Accessed April 12, 2020. Green J, Thorogood N. Qualitative Methods for Health Research . London: Sage; 2004. Aurini JD, Heath M, Howells S. The How To of Qualitative Research . SAGE; 2016. Woodgate RL, Zurba M, Tennent P. Advancing patient engagement: youth and family participation in health research communities of practice. Research Involvement and Engagement . 2018;4(1). doi:10.1186/s40900-018-0094-2 Margolin J-L. Singapore 40 years on. Slow road to democracy. Asia Europe Journal . 2005;3(1):95-115. doi:10.1007/s10308-004-0136-2 Sim JB, Print M. Citizenship education in Singapore: controlling or empowering teacher understanding and practice? Oxford Review of Education . 2009;35(6):705-723. doi:10.1080/03054980903141549 Thompson MR. Democracy with Asian Characteristics. The Journal of Asian Studies . 2015;74(04):875-887. doi:10.1017/S0021911815001187 Staniszewska S, Brett J, Simera I, et al. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. Research Involvement and Engagement . 2017;3(1). doi:10.1186/s40900-017-0062-2 Supplementary Files Boxes.docx Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 16 Jun, 2020 Read the published version in Research Involvement and Engagement → Version 2 posted Editorial decision: Accept 05 May, 2020 Editor assigned by journal 04 May, 2020 Submission checks completed at journal 03 May, 2020 Editor invited by journal 03 May, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-10202","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Methodology","associatedPublications":[],"authors":[{"id":560903,"identity":"97339105-e377-447a-8220-7a115c6efd85","order_by":1,"name":"Lidia Luna Puerta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYBACPmYGgwMMBhI8/HChAwS0sIG1VNjISDbAVBPUwsBgwMBwJs3G4ADRWtiZNx742XaYx/h4A9vjj20Mcnw3Epg/fsHrMLaCg71ALWZnDrAbHGxjMJa8kcAmLYNXC4/BAV6QFqBKCaCWxA1ABrMEAS0H/4IcNv8BWEs9UAvzZ0JaDvOcSeMxkGAAa0kwuJHAIPmBgF8Oy1TY8EicSWyTOHNOwnDmmYdt0nh0MPDzH9788Y2BhD1/++FjEhVlNvJ8x5MPf/yBTw8CMDYACQkwg5mHOC3Iuom0ZRSMglEwCkYGAACfLUvULkLsJgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-8829-0492","institution":"Lee Kong Chian School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Lidia","middleName":"Luna","lastName":"Puerta","suffix":""},{"id":560904,"identity":"5e9cb201-0738-477d-bea0-587d815f8105","order_by":2,"name":"Helen E. Smith","email":"","orcid":"","institution":"Lee Kong Chian School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"E.","lastName":"Smith","suffix":""}],"badges":[],"createdAt":"2019-12-23 13:23:11","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.2.19589/v2","doiUrl":"https://doi.org/10.21203/rs.2.19589/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40900-020-00205-6","type":"published","date":"2020-06-16T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":1138945,"identity":"f5bb853f-801a-4cca-b689-68ab9e8a2a10","added_by":"auto","created_at":"2020-05-20 16:23:47","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":602153,"visible":true,"origin":"","legend":"Photograph of Serangoon Gardens Market \u0026 Food Centre. Photo Credit: Cynthia Chew 28","description":"","filename":"Figure1.JPEG","url":"https://assets-eu.researchsquare.com/files/rs-10202/v2/Figure1.JPEG"},{"id":1138947,"identity":"e074eb5e-66bc-4c7c-88f5-01673c7428ce","added_by":"auto","created_at":"2020-05-20 16:23:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2016610,"visible":true,"origin":"","legend":"Example of cue card containing a question and prompts for the “PPI Hawkers”","description":"","filename":"Figure2v9April2020.jpg","url":"https://assets-eu.researchsquare.com/files/rs-10202/v2/Figure2v9April2020.jpg"},{"id":1138948,"identity":"46a4c5df-1fc4-413f-9489-3780c413dc30","added_by":"auto","created_at":"2020-05-20 16:23:47","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4467155,"visible":true,"origin":"","legend":"Design of the “PPI Hawker”, building on the PPI Café","description":"","filename":"Figure3v9April2020.jpg","url":"https://assets-eu.researchsquare.com/files/rs-10202/v2/Figure3v9April2020.jpg"},{"id":1138949,"identity":"d12e58b3-2462-42de-8d95-f1d383c73bd9","added_by":"auto","created_at":"2020-05-20 16:23:47","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":4831953,"visible":true,"origin":"","legend":"The ten stages in organisation of the “PPI Hawker”","description":"","filename":"Figure430April2020.jpg","url":"https://assets-eu.researchsquare.com/files/rs-10202/v2/Figure430April2020.jpg"},{"id":13504526,"identity":"d8d4a97d-33bb-41ea-ac77-93aa66b39bd5","added_by":"auto","created_at":"2021-09-16 23:23:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1527711,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-10202/v2/dc491d17-437a-4f39-aee0-a28799ee48e8.pdf"},{"id":1138946,"identity":"a30b61e9-5a50-438b-8d79-327a99b82613","added_by":"auto","created_at":"2020-05-20 16:23:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16639,"visible":true,"origin":"","legend":"","description":"","filename":"Boxes.docx","url":"https://assets-eu.researchsquare.com/files/rs-10202/v2/Boxes.docx"},{"id":1138944,"identity":"a2ac366d-2f5c-426e-b36c-0dad6ae4c631","added_by":"auto","created_at":"2020-05-20 16:23:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18902,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-10202/v2/Appendix.docx"}],"financialInterests":"","formattedTitle":"The “PPI Hawker”: An innovative method for Patient and Public Involvement (PPI) in health research","fulltext":[{"header":"Background","content":"\u003cp\u003ePatient and public involvement (PPI) in research is defined as research that is carried out \u0026lsquo;with\u0026rsquo; or \u0026lsquo;by\u0026rsquo; members of the public rather than \u0026lsquo;to\u0026rsquo;, \u0026lsquo;about\u0026rsquo; or \u0026lsquo;for\u0026rsquo; them. Although PPI is a common component of health research in Western countries, such as the UK, Australia and Canada \u003csup\u003e1\u0026ndash;5\u003c/sup\u003e, PPI is still in an early stage of development in Asian countries, including Singapore \u003csup\u003e6\u003c/sup\u003e. It is recognised that PPI enhances the quality and relevance of the research, and its impacts are greater when implemented early in the research cycle \u003csup\u003e7\u0026ndash;9\u003c/sup\u003e. If Singapore wishes to remain at the forefront of Asian health research, public involvement in health research must be cultivated, with public perspectives being heard and their concerns addressed.\u003c/p\u003e\n\u003cp\u003eOften when PPI is in its infancy, a few selected public collaborators are invited by the researchers to engage in a two-way conversation \u003csup\u003e10\u003c/sup\u003e. These same individuals may contribute repeatedly during the research process and also return for future studies led by the same team. Whilst this model of involvement is strong on continuity, it generates concerns about tokenism.\u0026nbsp; There is a risk that \u0026nbsp;the public contributor remains as a \u0026ldquo;thinker at the edges\u0026rdquo; \u003csup\u003e11,12\u003c/sup\u003e. Other PPI initiatives strive for greater diversity in involvement, whilst some focus on greater levels of public impact \u003csup\u003e13,14\u003c/sup\u003e. Public involvement is a complex and diverse endeavour; each PPI approach has its merits and their appropriateness varies according to the characteristics of the study (for example, research question, study design, resources available and skills of lay-researchers \u003csup\u003e15\u0026ndash;18\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eRecent PPI developments have focussed on ways to include disadvantaged communities in these \u0026ldquo;privileged\u0026rdquo; spaces, recognising it is\u0026nbsp; often vulnerable people who have\u0026nbsp; the greatest health needs \u003csup\u003e10,19,20\u003c/sup\u003e. PPI Caf\u0026eacute;s are an example of such developments, whereby the characteristics of a \u0026ldquo;science caf\u0026eacute;\u0026rdquo; and a PPI workshop were blended. A \u0026ldquo;science caf\u0026eacute;\u0026rdquo; is where scientists and science professionals are invited to speak in a casual non-academic setting where everyone can learn and discuss the scientific issues of the day in science and technology, generally for the price of a cup of coffee or a glass of wine \u003csup\u003e21\u003c/sup\u003e. In contrast, PPI workshops a formal, organised training sessions for researchers wanting to learn how to involve lay people in their research activities and for members of the public wishing to familiarise themselves with research and PPI \u003csup\u003e22\u003c/sup\u003e. The PPI Caf\u0026eacute;s borrow from the science caf\u0026eacute; the casual setting and conversational style and from the PPI workshops learning objective to create an opportunity for the public to have learn about PPI as they contribute to the development and refinement of a real-life research project.\u003c/p\u003e\n\u003cp\u003eThe first PPI Caf\u0026eacute; was piloted at the 2018 Imperial Festival\u003csup\u003e22\u003c/sup\u003e, a science festival for the public organised by researchers at Imperial College London. The public were invited to join the \u0026ldquo;baristas\u0026rdquo; (researchers, public facilitators and PPI facilitators) for a drink in a space customised to look like a caf\u0026eacute; \u003csup\u003e22\u003c/sup\u003e. Tables were dedicated to different research studies, and at each table a facilitator introduced the research study before the researcher asked about their \u0026lsquo;guests\u0026rsquo; perceptions and comments on specific issues. Guests were encouraged to write down their comments and leave them in a container in the centre of each table.\u003c/p\u003e\n\u003cp\u003eIn Singapore caf\u0026eacute;s are not as common as in Western countries, but hawker centres, also known as food courts, (shown in Fig.1) are used frequently for eating and socialising. In hawker centres, seating facilities are shared and a complete meal can be enjoyed at one table with each course taken from different vendors. This differs from the Western context, where only food and drink purchased from that vendor can be consumed on the premises exclusive to the vendor. Hawker centres are also more accessible, both physically and financially, \u0026nbsp;to a wider sector of society than caf\u0026eacute;s. Described as \u0026ldquo;Singapore in a nutshell\u0026rdquo; \u003csup\u003e23\u003c/sup\u003e, they provide a one-stop destination for everyone, offering a wide choice of high-quality food at inexpensive prices (meals are priced at S$3-4 and a local drink costs about S$1.5 \u003csup\u003e24\u003c/sup\u003e). Open from 7 AM to 10 PM and managed by the National Environment Agency, hawker centres are typically found near public housing estates or transport hubs. The 15,000 food stalls \u003csup\u003e25\u003c/sup\u003e serve the majority of the 5.64 M people living across the country \u003csup\u003e26\u003c/sup\u003e. Hawker centres are so integral to Singaporean life that in March 2019, the Singaporean government nominated hawker culture for UNESCO listing of the Intangible Cultural Heritage of Humanity \u003csup\u003e27\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 1 Photograph of Serangoon Gardens Market \u0026amp; Food Centre. Photo Credit: Cynthia Chew \u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eTo date there has been little attention to the inclusion of PPI in research conducted in Asian countries. Currently in Singapore the role of the public is almost exclusively limited to taking part in research. While the benefits of public involvement and co-production are well established in the literature \u003csup\u003e7,29\u0026ndash;41\u003c/sup\u003e, methods for an Asian context have yet to be explored.\u0026nbsp; Here we describe the \u0026ldquo;PPI Hawker\u0026rdquo;, an adaptation of the PPI Caf\u0026eacute;s used in Western cultures. The \u0026ldquo;PPI Hawker\u0026rdquo; was designed to enable the Singaporean public to share their personal perspectives relevant to a local population-based study (described in Box 1) in an informal environment throughout the country. This article shares our experiences of developing and conducting \u0026ldquo;PPI Hawkers\u0026rdquo;.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eTowards an Asian friendly PPI Caf\u0026eacute;\u003c/h2\u003e\n\u003cp\u003eConceptually, the \u0026ldquo;PPI Hawker\u0026rdquo; was designed to be similar to the PPI Caf\u0026eacute;. We envisioned the \u0026ldquo;PPI Hawker\u0026rdquo; would reduce the hierarchies between researchers and the public, enabling a two-way conversation, which could facilitate the sharing of knowledge and improved relevance of research studies. Through short and informal conversations, the \u0026ldquo;PPI Hawker\u0026rdquo; was created to bring together members of the community (past, current, and future patients and their caregivers) with researchers, reducing the boundaries between non-experts and experts. The design of \u0026ldquo;PPI Hawkers\u0026rdquo; would encourage recognition of complementary expertise by positioning lived experiences and personal perspectives at the same level as expert knowledge. Like for the PPI Caf\u0026eacute;, organising the discussion in a setting familiar to the public would facilitate discussion, encouraging ideas to be explored in spontaneous conversation, building trust between lay people and researchers.\u003c/p\u003e\n\u003ch2\u003eDesigning and testing the feasibility of the \u0026ldquo;PPI Hawker\u0026rdquo;\u003c/h2\u003e\n\u003cp\u003eTo progress the design of the \u0026ldquo;PPI Hawker\u0026rdquo;, we formed a development team with a coordinator, two PPI Leads with experience of conducting PPI Caf\u0026eacute;s in the UK, a researcher from the population-based study (Box 1) and a Singaporean resident. The coordinator was a Spanish doctoral student, exploring the potential for PPI in Singapore (LLP) and the two PPI Leads were from Imperial College London\u0026rsquo;s Patient Experience Research Centre (PERC), UK with extensive experience of PPI. Other members of the team were an Asian post-doctoral researchers from the study population-based study and a Singaporean resident, an engineer who was interested in PPI.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdaptation of the PPI Caf\u0026eacute; to the Singapore context required more than just change in location: the multi-ethnic community required us to consider how we would facilitate, and record discussions conducted in several languages. We decided to work organised in such a way as to maximise the local languages available for discussion (Mandarin Chinese, Cantonese, Malay and Tamil). Note taking was always in English as this is the \u003cem\u003elingua franca, \u003c/em\u003ethat is the language adopted as a common language between speakers whose native languages are different.\u0026nbsp; By documenting in English, the one common language between the speakers of many different languages in Singapore, our documentation was accessible to all facilitators and researchers.\u003c/p\u003e\n\u003cp\u003eIn taking the PPI Caf\u0026eacute; (Fig.2) into the Singaporean context we wished to retain the informal atmosphere but to use the more open, non-institutional and public space of a Hawker Centre.\u0026nbsp; We transferred the idea of using members of the public as facilitators, involving researcher from project, offering participants refreshments (but not making them ourselves), and facilitating in pairs. We dispensed with displaying research materials, but we added the use of cue cards to aid round table discussion (Fig.3). Participants were also able to refer to a card briefly summarising the study\u0026rsquo;s aims and methods, to reinforce the initial oral explanation. One facilitator introduced and guided each conversation, using their local language skills whilst the second facilitator documented the discussion.\u003c/p\u003e\n\u003cp\u003eFigure 3 Design of the \u0026ldquo;PPI Hawker\u0026rdquo;, building on the PPI Caf\u0026eacute;\u003c/p\u003e\n\u003cp\u003eFigure 2 Example of cue card containing a question and prompts for the \u0026ldquo;PPI Hawkers\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eHaving piloted the first \u0026ldquo;PPI Hawker\u0026rdquo; as a team of five, we subsequently worked as four (\u0026ldquo;PPI Hawker\u0026rdquo; coordinator, researcher from the study, and two public facilitators). The first public facilitator was the same one as in the development team; the second one was an early career scientist who wanted to develop her communication skills with the public and who studied in the same university where LLP is conducting her doctoral studies. None of them had been previously involved in research and they facilitated the \u0026ldquo;PPI Hawker\u0026rdquo; on a volunteer non-paid basis. The public facilitators were selected for their language skills (speaking English, and one or more local official languages: Mandarin, Malay and Tamil), their comfort engaging with the public and an interest in research. They were briefed on the research study objectives and the issues the researchers wanted the public to consider. Before going to the Hawker Centres the team used role play to familiarise themselves with the cue cards and how to focus discussion on those topics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough LLP coordinated the event, all four facilitators had equal roles and voice during the whole event.\u003c/p\u003e\n\u003ch5\u003e\u003cem\u003eA step-by-step guide to the \u0026ldquo;PPI Hawker\u0026ldquo;\u003c/em\u003e\u003c/h5\u003e\n\u003cp\u003eThe ten stages in organisation of the \u0026ldquo;PPI Hawker\u0026rdquo; are summarised in Fig.4. Such an event starts with a group of researchers willing to seek the lay perspectives in a \u0026ldquo;PPI Hawker\u0026rdquo; and to collaborate with a group of facilitators for it. A facilitator familiar with PPI would then work with the study team to come up with topics and questions about which a public perspectives would be valued (Step 1). The facilitation team is then formed, including a representative from the research study and at least two members of the public able to converse in local dialects and comfortable talking to new people (Step 2). Deciding on a suitable venue for the event attention must be paid to the ambience, a relaxed atmosphere in a place frequented by a diverse population and the time envisaged for the \u0026ldquo;PPI Hawker\u0026rdquo; (Step 3). As a team the facilitators need to refine the phrasing of the questions (Step 4) and then practice using role play how best to approach people in the hawker (Step 5).\u003c/p\u003e\n\u003cp\u003eWhen the \u0026ldquo;PPI Hawker\u0026rdquo; event takes place it is advisable for the facilitators to work in pairs (Step 6) to approach people already sitting at a table, either alone or in a group, to introduce them to the study and the aim of the \u0026ldquo;PPI Hawker\u0026rdquo;. In our case, the coordinator paired with a lay facilitator, whilst the researcher paired with the second lay facilitator. Once verbal consent is obtained, the discussion of the PPI questions begins with one facilitator managing the discussion and the other documenting the conversation (Step 7). As hawker centres are generally frequented by large crowds, not everyone will be approached, instead the facilitators select based on whether people are already engaged in conversation, appear to be leaving soon or are from the demographic group targeted.\u003c/p\u003e\n\u003cp\u003eFigure 4 The ten stages in organisation of the \u0026ldquo;PPI Hawker\u0026rdquo;\u003ca href=\"#_ftn1\" name=\"_ftnref1\"\u003e\u003cstrong\u003e[1]\u003c/strong\u003e\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eTo document the conversations, one of the researchers listed down the main points discussed for each of the questions. After each \u0026ldquo;PPI Hawker\u0026rdquo;, the main issues brought up by participants were summarised each facilitator reflected on their interactions with the public, documenting difficulties encountered, for example engaging the public in conversation around a particular aspect of the research (Step 8).\u003c/p\u003e\n\u003cp\u003eThe findings were presented to the research team orally and in a report for them to discuss and agree what adjustments should or could be made to the study (Step 9).\u003c/p\u003e\n\u003cp\u003eWhen conducting \u0026ldquo;PPI Hawkers\u0026rdquo; the note taking is not routinely verbatim. However in this development and feasibility phase we captured exactly what members of the public offered as feedback on their experience of taking part in the \u0026ldquo;PPI Hawker\u0026rdquo;. Facilitators also noted of the number of people sitting at each participating table, together with their observations on demographic characteristics (gender, age and ethnicity) and the attitudes of everyone taking part; \u0026nbsp;this data was used for assessing feasibility but not shared with the population-based study\u0026rsquo;s researchers.\u003c/p\u003e\n\u003ch5\u003eEthical considerations\u003c/h5\u003e\n\u003cp\u003eIn the UK, application for\u0026nbsp; apply for ethical approval to involve the public in the planning or the design stage of research is not necessary\u003csup\u003e43\u003c/sup\u003e. Since Singapore does not yet have guidelines for PPI in research, we followed INVOLVE guidelines from the UK. We did not record any identifying information from \u0026ldquo;PPI Hawker\u0026rdquo; participants \u003csup\u003e44\u003c/sup\u003e.\u003c/p\u003e\n\u003ch5\u003e\u003cem\u003eCriteria for evaluation\u003c/em\u003e\u003c/h5\u003e\n\u003cp\u003eBefore piloting the \u0026ldquo;PPI Hawker\u0026rdquo;, we agreed on the desirable characteristics against which we could evaluate the initiative:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eFeasibility was defined by the capacity to engage members of the public in discussion. Our goals were:\u003c/li\u003e\n\u003cli\u003eat least 50% people approached agreeing to participate,\u003c/li\u003e\n\u003cli\u003eto engage a minimum of 20 participants in each session, at least 10 individuals responding to each of the questions posed by the researchers (the questions from each session are listed in Appendices 1 and 2). This criteria was based on sample sizes commonly used in qualitative research \u003csup\u003e45,46\u003c/sup\u003e.\u003c/li\u003e\n\u003cli\u003eAcceptability of the \u0026ldquo;PPI Hawker\u0026rdquo; was judged by our success engaging with a cross section of the general adult population of Singapore, the target audience for the population based study. We sought representation from diverse ages (20-80) and all major ethnic groups (Chinese, Malay and Indian). To monitor this facilitators made notes about the perceived age of \u0026ldquo;PPI Hawker\u0026rdquo; participants and their ethnic group. Acceptability was also assessed by the informal feedback and comments made by participants.\u003c/li\u003e\n\u003cli\u003eUtility was the extent to which the public generated ideas were incorporated into the study design by the population-based study\u0026rsquo;s researcher Utility was assessed by the researchers\u0026rsquo; responses to presentations and written reports about the views elicited by the \u0026ldquo;PPI Hawkers\u0026rdquo;.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"#_ftnref1\" name=\"_ftn1\"\u003e[1]\u003c/a\u003e In preparing for this series of 10 stages, attention has been paid to the UK Standards for Public Involvement in Research\u003csup\u003e42\u003c/sup\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003ch4\u003eThe conduct of three \u0026ldquo;PPI Hawkers\u0026rdquo;\u003c/h4\u003e\n\u003ch5\u003eThe \u0026ldquo;PPI Hawker\u0026rdquo; Pilot\u003c/h5\u003e\n\u003cp\u003eWe conducted three \u0026ldquo;PPI Hawkers\u0026rdquo;, the first as a pilot to see if we needed to improve on the design. This \u0026ldquo;PPI Hawker\u0026rdquo; was held in November 2018, in Serangoon Gardens Market and Food Centre (Fig.1) and it soon became apparent that inviting participants to join our table as they queued to buy themselves refreshments from the hawker stalls was not going to work (Fig.2). Everyone approached refused to join our table, but instead invited us to join theirs. After a quick discussion, we decided to approach people already sitting and asking if we could join their table. With this amendment, 28 members of the public participated, but all declined the offer of a free drink.\u003c/p\u003e\n\u003cp\u003eOur preliminary \u0026ldquo;PPI Hawker\u0026rdquo; highlighted the need to be clearer when introducing the concept of PPI and describing the overall aims of the research study to be discussed. The need for this additional information became apparent when some members of the public thought we were trying to recruit them to the study rather than ask for their ideas and opinions. The pilot reinforced the need to work in pairs, with one person documenting the insights shared by members of the public whilst the other facilitated the discussion. To increase the clarity and utility of the documentation we developed a coding system that we cod use in subsequent events.\u003c/p\u003e\n\u003ch5\u003eThe conduct of two further \u0026ldquo;PPI Hawkers\u0026rdquo;\u003c/h5\u003e\n\u003cp\u003eOur first \u0026ldquo;PPI Hawker\u0026rdquo; engaged mostly Chinese, so to achieve greater ethnic diversity the two subsequent events were conducted in locations frequented by more Malay and Indian residents (Malay and Indian represent 13 and 9% of Singapore\u0026rsquo;s population respectively, 74% being Chinese \u003csup\u003e26\u003c/sup\u003e). With our revised method (Fig.2), we were able to approach a further fifty-nine members of the public of whom we engaged forty-four (24 Indian, 13 Malay and 7 Chinese), in short conversations (around 15 minutes per table) sitting at 33 tables (16 in Admiralty and 17 in Tekka Centre).\u003c/p\u003e\n\u003ch4\u003eAchieving our goals\u003c/h4\u003e\n\u003cp\u003eThe \u0026ldquo;PPI Hawkers\u0026rdquo; exceeded our predefined goals for feasibility, acceptability and utility.\u0026nbsp;\u003c/p\u003e\n\u003ch5\u003eFeasibility: Capacity to engage members of the public\u003c/h5\u003e\n\u003cp\u003eAt each \u0026ldquo;PPI Hawker\u0026rdquo; more than twenty members of the public were engaged, and within each session most individuals (85%) responded to each of the questions posed (these are listed in Appendices 1 and 2). The \u0026ldquo;PPI Hawker\u0026rdquo; concept was well received by the public; 96 members of the public were approached, whilst 72 took part in one of the three sessions. In other words, 75% of those approached at their tables agreed to engage in a conversation with us.\u003c/p\u003e\n\u003ch5\u003eAcceptability: The public\u0026rsquo;s perspective of the \u0026ldquo;PPI Hawker\u0026rdquo;\u003c/h5\u003e\n\u003cp\u003eWe involved members of all three ethnic groups in Singapore and spoke to adults who appeared to be from a wide age range, confirming accessibility of the \u0026ldquo;PPI Hawker\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eFrom the public\u0026rsquo;s feedback the opportunity to take part in the \u0026ldquo;PPI Hawker\u0026rdquo; conversations was appreciated, supporting \u0026ldquo;PPI Hawker\u0026rdquo;\u0026rsquo;s acceptability. Most members of the public we spoke to were \u0026ldquo;\u003cem\u003ehappy to give [us their] opinion\u003c/em\u003e\u0026rdquo; and to informally share with us their thoughts on the \u0026ldquo;PPI Hawker\u0026rdquo;. Participants enjoyed\u003cem\u003e \u0026ldquo;feeling helpful\u003c/em\u003e\u0026rdquo; contributing to something that would benefit their community. They felt that by meeting in the familiar space of the hawker centres, researchers lost \u0026ldquo;\u003cem\u003etheir authoritarian attitude\u003c/em\u003e\u0026rdquo;. Moreover, they recognised that \u0026ldquo;\u003cem\u003eresearchers don\u0026rsquo;t know [our needs and wants], we have to tell them\u003c/em\u003e\u0026rdquo;. The format of the \u0026ldquo;PPI Hawker\u0026rdquo; as an involvement method for Singaporeans was widely supported; participants valued its concise and one-off nature, because of the pressures on their time and no wish to talk about research on a regular basis. One member of the public finished their conversation with us by thanking us for meeting the public: \u0026ldquo;\u003cem\u003eYou are doing a very good thing for people [coming to ask for people\u0026rsquo;s perspectives at the hawker centre]. I have to appreciate\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e\n\u003ch5\u003eUtility: Population-based study\u0026rsquo;s researchers\u0026rsquo; feedback\u003c/h5\u003e\n\u003cp\u003eResults of the \u0026ldquo;PPI Hawker\u0026rdquo; were presented to the study\u0026rsquo;s Steering Group, composed of the 6 Study Principal Investigators, the Operations Manager, the Recruitment Manager and occasionally other researchers from the team. The Steering Group\u0026rsquo;s response to the feedback from the public about their population-based study was encouraging, and they expressed the need to continue with the \u0026ldquo;PPI Hawkers\u0026rdquo; to also understand the views of populations from different neighbourhoods. The researcher involved as a facilitator commented on how \u0026ldquo;\u003cem\u003eThe public\u0026rsquo;s opinion are very diverse, and I learnt that if you spend the time to listen to public, there are many things that you can learn. People are generally willing to help, and their feedback will only make our research stronger!\u003c/em\u003e\u0026rdquo; With subsequent \u0026ldquo;PPI Hawkers\u0026rdquo; her appreciation of their value was strengthened by observing the hidden knowledge within different communities. She commented: \u0026ldquo;\u003cem\u003eAn eye opener, certainly I could see the totally different perspective from those of lower socio-economic classes about research health screening\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eThe discussion of the feedback from participants prompted refinements to the \u0026ldquo;PPI Hawker\u0026rdquo; including more consistency in the terminology used. For example, while some facilitators had used the word \u0026ldquo;confidentiality\u0026rdquo; others had used \u0026ldquo;anonymity\u0026rdquo; when discussing data sharing issues. This inconsistency made the PPI feedback less useful as it was not always possible to know which term the pubic were responding to. As a result, we agreed facilitator\u0026rsquo;s should only use the terminology on the cue cards and would always explain any technical terms before engaging in discussion.\u003c/p\u003e\n\u003cp\u003eExamples of how PPI impacted on the design of the population-based study can be found in the box 2 below. Researchers considered the feedback provided by \u0026ldquo;PPI Hawker\u0026rdquo; participants for all questions and intend to incorporate some aspects for each of the issues discussed. Some of those have already been operationalised, as discussed in box 2.\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch2\u003eSummary\u003c/h2\u003e\n\u003cp\u003eIn three \u0026ldquo;PPI Hawkers\u0026rdquo; we were able to engage 72 members of the public in discussions about issues the researchers of a population-based study wanted the public\u0026rsquo;s perspective. This novel approach of involving lay people on research-related matters achieved an engagement rate of 75%. Participants came from the three main ethnic groups in Singapore and appeared to be broad in age. Since the hawker centres are spaces visited by almost all Singaporeans, this PPI method facilitates engagement with a broad sector of society in different neighbourhoods. Using short one-off conversations in their mother tongue in a familiar environment the majority of participants were willing to discuss all of the questions posed by the researchers. Researchers recognised the utility of the \u0026ldquo;PPI Hawker\u0026rdquo;, reflecting on people\u0026rsquo;s willingness to consider research issues, engaging in informative conversations and ask relevant questions. During these conversations, facilitators observed the traditional barriers between experts and non-experts being broken down, leading to mutual respect and sharing of ideas.\u003c/p\u003e\n\u003ch6\u003ePPI facilitator\u0026rsquo;s experience\u003c/h6\u003e\n\u003cp\u003eFacilitators observed how the informal setting allowed members of the public to talk openly and freely share personal experiences. This relaxed environment allowed us to approach audiences unfamiliar with research, where they felt able to contribute and also to ask questions about other topics beyond those suggested by the researchers. Facilitators were encouraged by their experiences of the \u0026ldquo;PPI Hawkers\u0026rdquo;, and highlighted the feasibility and accessibility of this method of involvement in the Singaporean context.\u003c/p\u003e\n\u003cp\u003eThe reflexive notes of the \u0026ldquo;PPI Hawker\u0026rdquo; team were universally encouraging, sometimes describing characteristics that exceeded expectations:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I was surprised by how most people were receptive and keen to discuss the project with us. Singaporeans are often zealous in the protection of their privacy and are reluctant to share their opinions. However, those we interacted with were willing to talk at length about the issues, curious about the research, and seemed to enjoy the experience\u0026rdquo; (\u0026ldquo;PPI Hawker\u0026rdquo; co-ordinator).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne facilitators recorded how the public\u0026rsquo;s initial hesitancy to be involved was quickly transformed into engagement:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;People were apprehensive when we first approached them (like we were going to sell something/ask them for something/like we were disturbing quiet, family time) but once it was clear we just wanted their OPINIONS, the conversation flowed quite effortlessly. I was surprised to see them have so much to say, so much to contribute to each of the questions asked. The public are not as oblivious or ill-informed as some may think, they may not be researchers but everything that was said made perfect sense and was of great value. We could not have predicted those responses or gotten a more honest feel for their perception of research in general or the barriers and facilitators to research if we did not sit down and talk to them in person, in a natural setting as we did today.\u0026rdquo; (Public facilitator, reflecting on sessions #2 and #3)\u003c/p\u003e\n\u003ch2\u003eAdvantages of the \u0026ldquo;PPI Hawker\u0026rdquo;\u003c/h2\u003e\n\u003cp\u003eThe \u0026ldquo;PPI Hawkers\u0026rdquo; have the potential to be used more widely for PPI in Singapore, and potentially in other Asian contexts. This approach to PPI has identified two major attributes:\u003c/p\u003e\n\u003cp\u003eFirstly, the \u0026ldquo;PPI Hawker\u0026rdquo; reduces communication barriers, making it easier for researchers to interact with the public and vice versa. The process of the public inviting\u0026nbsp; researchers to join them at their own tables appeared to enable the public more control over the encounter, and guide the amount and direction of the discussion. These conversations become opportunities to share knowledge and work together to improve the research design. We observed within the \u0026ldquo;PPI Hawker\u0026rdquo; dialogue, reciprocity, openness and respect, enabling thoughtful communication between the facilitators and the public.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSecondly the \u0026ldquo;PPI Hawker\u0026rdquo; reduces the barriers between experts and the public, flattening or reversing the pyramid of hierarchy \u003csup\u003e47\u003c/sup\u003e. Conventionally lay people are reluctant to challenge perceived expertise \u003csup\u003e48,49\u003c/sup\u003e, but the round table discussions appeared to generate mutual trust, and a willingness for the non-expert to comment, critique and challenge the research. Such exchange is often difficult to achieve in very hierarchical societies, like Singapore \u003csup\u003e48,50\u003c/sup\u003e but the \u0026ldquo;PPI Hawker\u0026rdquo; appears to achieve this by the development of a collective consciousness.\u003c/p\u003e\n\u003ch2\u003eEffective and efficient use of resources\u003c/h2\u003e\n\u003cp\u003ePPI is often characterised as a time and energy intensive activity, and it can be this that deters researchers\u0026rsquo; enthusiasm and engagement for PPI \u003csup\u003e6\u003c/sup\u003e. The \u0026ldquo;PPI Hawker\u0026rdquo; addresses some of these concerns as it does not require the administrative burden or the expenses of sending out invitations, hiring a venue or transport for participants. However, it does require time for the initial planning (a one-off activity), and then the conduct of each \u0026ldquo;PPI Hawker\u0026rdquo; and the collating of ideas. In our experience the time spent planning preparing and training for the project-specific PPI was 10 person hours in total. Each \u0026ldquo;PPI Hawker\u0026rdquo; required 2 hours of facilitators time (including a 30-minutes briefing in advance). The final collation of comments and summarising them for the research team required a further 8 hours of the coordinator\u0026rsquo;s time and 1 hour for each of the other facilitators\u0026rsquo; time.\u003c/p\u003e\n\u003ch2\u003eLimitations and strengths of the \u0026ldquo;PPI Hawker\u0026rdquo;\u003c/h2\u003e\n\u003cp\u003eA challenge for PPI globally is the need to hear a wide diversity of perspectives. Increasingly more groups have been empowered and are being heard, but some groups still remain at the margins. Reluctance to participate in PPI \u003csup\u003e6\u003c/sup\u003e\u0026nbsp; is known to be more challenging to those with poor research knowledge, lower literacy and limited oral skills, characteristics often seen within those sub-populations who have the greatest health needs. We found the presence of the public facilitators was\u0026nbsp; particularly helpful with developing trust, for example with the Indian population an introduction in Tamil defused feelings of being caught in an unfamiliar situation to inclusion in a conversation in which they were central.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;PPI Hawkers\u0026rdquo; offer a helpful solution to this challenge, but they are not without their limitations. For example, it is recognised that long-term involvement throughout the different stages of a research project increases the impact of PPI \u003csup\u003e7\u003c/sup\u003e but the \u0026ldquo;PPI Hawker\u0026rdquo; is a one-off encounter. Not collecting personal and demographic data from participants makes it difficult to characterise them exactly. \u0026nbsp;For example, we wanted an ethnic mix and used appearance to identify the ethnic group of participants. Using appearance may not always be adequate, for example if one wishes to target people of a specific age, sexuality, marital status or income group. Lastly, the \u0026ldquo;PPI Hawker\u0026rdquo; may not be appropriate for all types of research, including studies about sensitive topics or complex studies where substantial background and explanation are needed before the public are able to comment.\u003c/p\u003e\n\u003cp\u003eFinally, alongside positive aspects of the \u0026ldquo;PPI Hawker\u0026rdquo;, some negative views were also noted. Around a quarter of members of the public approached wanted to be \u0026ldquo;left alone\u0026rdquo;, others wished to discuss topics not related to the research study (for example, digressing to complain about the government). However, only one individual responded with some aggression, sharing their dogmatic beliefs about medicine. None of our offers of a drink were accepted, and occasionally a participant\u0026nbsp; expressed mild offense when offered a free drink, they considered it as too small a token of appreciation, because it was something that they could easily afford for themselves.\u003c/p\u003e\n\u003cp\u003eWe have demonstrated the feasibility of the \u0026ldquo;PPI Hawkers\u0026rdquo;, a novel approach suitable in a non-western culture, complementing widely used PPI Cafes and User Groups. Although our experience is currently confined to Singapore we anticipate that this model of involvement would be applicable to other Asian countries where the traditional concept of public food markets are also commonplace.\u003c/p\u003e\n\u003cp\u003eAs a potential refinement of the \u0026ldquo;PPI Hawkers\u0026rdquo; may be the use of some advanced publicity of the event, \u0026nbsp;rather than descending unannounced on diners. This may have reduced the suspicion some people expressed and confirm our legitimacy. We are also keen to explore in the future whether the \u0026ldquo;PPI Hawker\u0026rdquo; could be an avenue for dissemination of research findings, an under-developed aspect of PPI \u003csup\u003e51\u003c/sup\u003e. Research findings continue to be shared conventionally, disseminated in academic environments (for example, conference presentations, journal papers and academic books) and far less through channels easily accessible for the public (for example, public exhibitions, podcasts and blogs). \u0026ldquo;PPI Hawkers\u0026rdquo; may be an effective way to increase the public\u0026rsquo;s awareness of the findings of health-related research that could impact on their lives. The feasibility of this needs further exploration and piloting.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study has demonstrated how the \u0026ldquo;PPI Hawker\u0026rdquo; aligns with the ethos of public involvement in research. It has the potential to be the major model for PPI initiatives in Singapore, facilitating knowledge exchange in community spaces accessible to a wider number of people. Further feasibility studies are needed to confirm the \u0026ldquo;PPI Hawkers\u0026rdquo; utility when used to discuss studies in different topic areas and with different methods, but preliminary findings are encouraging.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cp\u003ePPI: Patient and Public Involvement\u003c/p\u003e\n\u003cp\u003ePERC: Patient Experience Research Centre\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eLLP is funded through the NTU-SINGA doctoral scholarship programme.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors' contributions\u003c/h2\u003e\n\u003cp\u003eLLP was the coordinator of the \u0026ldquo;PPI Hawkers\u0026rdquo;. She designed and conducted the three \u0026ldquo;PPI Hawker\u0026rdquo; sessions, and she analysed the comments coming out of it. She maintained the relationship with the PPI Facilitators and the researchers from the population-based research study throughout. HES was a major contributor in developing the evaluation and writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to acknowledge all the facilitators of the three \u0026ldquo;PPI Hawker\u0026rdquo; sessions, in particular our two public facilitators.\u003c/p\u003e\n\u003cp\u003eWe would also like to thank the researchers of the population-based research study who gave us the chance to design and trial the \u0026ldquo;PPI Hawker\u0026rdquo;.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eConsumers\u0026rsquo; Health Forum of Australia. A Model Framework for Consumer and Community Participation in Health and Medical Research. December 2004. https://www.healthissuescentre.org.au/images/uploads/resources/NHMRC-framework-consumer-participation-research.pdf.\u003c/li\u003e\n\u003cli\u003eStaley K, Associates T, Sandvei M, Horder M. \u0026lsquo;A problem shared\u0026hellip;\u0026rsquo; The challenges of public involvement for researchers in Denmark and the UK. April 2019:22.\u003c/li\u003e\n\u003cli\u003eManafo E, Petermann L, Mason-Lai P, Vandall-Walker V. Patient engagement in Canada: a scoping review of the \u0026lsquo;how\u0026rsquo; and \u0026lsquo;what\u0026rsquo; of patient engagement in health research. \u003cem\u003eHealth Research Policy and Systems\u003c/em\u003e. 2018;16(1). doi:10.1186/s12961-018-0282-4\u003c/li\u003e\n\u003cli\u003eDepartment of Health. Best research for best health: a new national health research strategy. 2006. http://www.clinmed.rcpjournal.org/cgi/doi/10.7861/clinmedicine.6-5-435. 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Unearth Hidden Assets through Community Co-design and Co-production. \u003cem\u003eThe Design Journal\u003c/em\u003e. 2017;20:12-14. doi:10.1080/14606925.2017.1352863\u003c/li\u003e\n\u003cli\u003eCondon L, Bedford H, Ireland L, et al. Engaging Gypsy, Roma, and Traveller Communities in Research: Maximizing Opportunities and Overcoming Challenges. \u003cem\u003eQualitative Health Research\u003c/em\u003e. January 2019:104973231881355. doi:10.1177/1049732318813558\u003c/li\u003e\n\u003cli\u003eCafe Scientifique. Cafe Scientifique: How it works. Cafe Scientifique. http://cafescientifique.org/home-page/how-it-works. Accessed April 11, 2020.\u003c/li\u003e\n\u003cli\u003eLuna Puerta L, Imperial Patient Experience Research Centre (PERC). The potential for public involvement in health research in Singapore: Reflections on culture and practice. \u003cem\u003ePatient Experience Research Centre\u003c/em\u003e. February 2019. http://wwwf.imperial.ac.uk/blog/perc/2019/02/04/public-involvement-hawker-singapore/. Accessed September 24, 2018.\u003c/li\u003e\n\u003cli\u003eNational Heritage Board. Hawker Culture in Singapore. Our Heritage. https://www.oursgheritage.sg/hawker-culture-in-singapore/. Published August 29, 2017. Accessed September 24, 2019.\u003c/li\u003e\n\u003cli\u003eNg D. Profit margins for hawker fare? As low as 20 to 30 cents. Channel News Asia. https://www.channelnewsasia.com/news/cnainsider/profit-margins-for-hawker-centre-fare-as-low-as-20-to-30-cents-10948414. Published November 20, 2018. Accessed September 24, 2019.\u003c/li\u003e\n\u003cli\u003eSeetoh K. Hawker Centres Singapore. Are there too many? \u003cem\u003eMakansutra\u003c/em\u003e. June 2018.\u003c/li\u003e\n\u003cli\u003eDepartment of Statistics Singapore. Singapore Population. Singstat. https://www.singstat.gov.sg/modules/infographics/population. Published 2019. Accessed September 24, 2019.\u003c/li\u003e\n\u003cli\u003eZaccheus M. Singapore submits Unesco bid to recognise hawker culture. Straits Times.\u003c/li\u003e\n\u003cli\u003eChew C. Chomp Chomp Food Centre, Singapore. \u003cem\u003eThe Food Pornographer\u003c/em\u003e. November 2014. http://thefoodpornographer.com/2014/11/chomp-chomp-food-centre-singapore/.\u003c/li\u003e\n\u003cli\u003eNIHR. \u003cem\u003eGoing the Extra Mile: Improving the Nation\u0026rsquo;s Health and Wellbeing through Public Involvement in Research\u003c/em\u003e. London: INVOLVE; 2015.\u003c/li\u003e\n\u003cli\u003eMockford C, Staniszewska S, Griffiths F, Herron-Marx S. The impact of patient and public involvement on UK NHS health care: a systematic review. \u003cem\u003eInternational Journal for Quality in Health Care\u003c/em\u003e. 2012;24(1):28-38. doi:10.1093/intqhc/mzr066\u003c/li\u003e\n\u003cli\u003eOliver SR, Rees RW, Clarke-Jones L, et al. A multidimensional conceptual framework for analysing public involvement in health services research. \u003cem\u003eHealth Expectations\u003c/em\u003e. 2008;11(1):72-84. doi:10.1111/j.1369-7625.2007.00476.x\u003c/li\u003e\n\u003cli\u003eThompson J, Bissell P, Cooper C, Armitage CJ, Barber R. Credibility and the \u0026lsquo;professionalized\u0026rsquo; lay expert: Reflections on the dilemmas and opportunities of public involvement in health research. \u003cem\u003eHealth: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine\u003c/em\u003e. 2012;16(6):602-618. doi:10.1177/1363459312441008\u003c/li\u003e\n\u003cli\u003eSmith E, Ross F, Donovan S, et al. Service user involvement in nursing, midwifery and health visiting research: A review of evidence and practice. \u003cem\u003eNursing Studies\u003c/em\u003e. 2008;45(2):298\u0026ndash;315.\u003c/li\u003e\n\u003cli\u003eBrett J, Staniszewska S, Mockford C, et al. A Systematic Review of the Impact of Patient and Public Involvement on Service Users, Researchers and Communities. \u003cem\u003ePatient\u003c/em\u003e. 2014;7(4):387-395. doi:10.1007/s40271-014-0065-0\u003c/li\u003e\n\u003cli\u003ePetit-Zeman S, Locock L. Bring on the evidence. \u003cem\u003eNature\u003c/em\u003e. 13AD;501(5):160-162. doi:10.1111/j.1369-7625.2012.00795.x\u003c/li\u003e\n\u003cli\u003eBoote J, Baird W, Sutton A. Public involvement in the systematic review process in health and social care: A narrative review of case examples. \u003cem\u003eHealth Policy\u003c/em\u003e. 2011;102(2-3):105-116. doi:10.1016/j.healthpol.2011.05.002\u003c/li\u003e\n\u003cli\u003eEnnis L, Wykes T. Impact of patient involvement in mental health research: longitudinal study. \u003cem\u003eBritish Journal of Psychiatry\u003c/em\u003e. 2013;203(05):381-386. doi:10.1192/bjp.bp.112.119818\u003c/li\u003e\n\u003cli\u003eBarber R, Beresford P, Boote J, Cooper C, Faulkner A. Evaluating the impact of service user involvement on research: a prospective case study: Evaluating the impact of service user involvement on research. \u003cem\u003eInternational Journal of Consumer Studies\u003c/em\u003e. 2011;35(6):609-615. doi:10.1111/j.1470-6431.2011.01017.x\u003c/li\u003e\n\u003cli\u003eLowes L, Robling MR, Bennert K, et al. Involving lay and professional stakeholders in the development of a research intervention for the DEPICTED Study. \u003cem\u003eHealth Expectations\u003c/em\u003e. 2011;14(3):250-260.\u003c/li\u003e\n\u003cli\u003ede Wit M, Beurskens A, Pi\u0026scaron;kur B, Stoffers E, Moser A. Preparing researchers for patient and public involvement in scientific research: Development of a hands-on learning approach through action research. \u003cem\u003eHealth Expectations\u003c/em\u003e. 2018;21(4):752-763. doi:10.1111/hex.12671\u003c/li\u003e\n\u003cli\u003eMinogue V, Cooke M, Donskoy A-L, Vicary P, Wells B. 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Published December 17, 2019. Accessed April 12, 2020.\u003c/li\u003e\n\u003cli\u003eGreen J, Thorogood N. \u003cem\u003eQualitative Methods for Health Research\u003c/em\u003e. London: Sage; 2004.\u003c/li\u003e\n\u003cli\u003eAurini JD, Heath M, Howells S. \u003cem\u003eThe How To of Qualitative Research\u003c/em\u003e. SAGE; 2016.\u003c/li\u003e\n\u003cli\u003eWoodgate RL, Zurba M, Tennent P. Advancing patient engagement: youth and family participation in health research communities of practice. \u003cem\u003eResearch Involvement and Engagement\u003c/em\u003e. 2018;4(1). doi:10.1186/s40900-018-0094-2\u003c/li\u003e\n\u003cli\u003eMargolin J-L. Singapore 40 years on. Slow road to democracy. \u003cem\u003eAsia Europe Journal\u003c/em\u003e. 2005;3(1):95-115. doi:10.1007/s10308-004-0136-2\u003c/li\u003e\n\u003cli\u003eSim JB, Print M. Citizenship education in Singapore: controlling or empowering teacher understanding and practice? \u003cem\u003eOxford Review of Education\u003c/em\u003e. 2009;35(6):705-723. doi:10.1080/03054980903141549\u003c/li\u003e\n\u003cli\u003eThompson MR. Democracy with Asian Characteristics. \u003cem\u003eThe Journal of Asian Studies\u003c/em\u003e. 2015;74(04):875-887. doi:10.1017/S0021911815001187\u003c/li\u003e\n\u003cli\u003eStaniszewska S, Brett J, Simera I, et al. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. \u003cem\u003eResearch Involvement and Engagement\u003c/em\u003e. 2017;3(1). doi:10.1186/s40900-017-0062-2\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"research-involvement-and-engagement","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"riae","sideBox":"Learn more about [Research Involvement and Engagement](http://researchinvolvement.biomedcentral.com/)","snPcode":"40900","submissionUrl":"https://submission.nature.com/new-submission/40900/3","title":"Research Involvement and Engagement","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"community-based methods, collaborative research, empowerment, health research, participatory research, patient and public involvement and engagement","lastPublishedDoi":"10.21203/rs.2.19589/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.19589/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Patient and Public Involvement (PPI) in health research entails doing research ‘with’ the public.\u0026nbsp;Successful PPI requires a diversity of patients’ perspectives and experiences. In Singapore, including the public’s voice in research is still in its infancy and different ways of involving the public have to be explored. Our aims were to\u0026nbsp;describe\u0026nbsp;a PPI initiative that enables members of the public to share their ideas and opinions about health research, and to assess the feasibility, accessibility and utility of the initiative.\u0026nbsp;\u003c/p\u003e\u003cp\u003eMethods: Building on the concept of the PPI Café\u0026nbsp;used in the west\u0026nbsp;we designed a\u0026nbsp;“PPI Hawker”\u0026nbsp;for Singapore.\u0026nbsp;Here Hawker Centres rather than cafes are used frequently for eating and socialising, providing a one-stop destination for a wide section of society. The PPI facilitators approached people sitting at tables and joined them to discuss questions of relevance to a local research study.\u0026nbsp;Observations and reflexive field notes were used to evaluate\u0026nbsp;the “PPI Hawker’s” feasibility,\u0026nbsp;acceptability and utility\u0026nbsp;in the Singaporean community. \u003c/p\u003e\u003cp\u003eResults: In three “PPI Hawkers” we\u0026nbsp;approached 96 people and 72 (75%) engaged\u0026nbsp;in discussions about the design of\u0026nbsp;\u0026nbsp;a population-based research study. The majority\u0026nbsp;(75%)\u0026nbsp;of participants willingly discussed all of the questions posed to them by the researchers, indicating the feasibility of PPI. The PPI participants came from the three major ethnic groups in Singapore and\u0026nbsp;appeared to be\u0026nbsp;broad in age, suggesting “PPI Hawkers” are easily accessible. Both participants and researchers recognised the utility of the “PPI Hawker”, reflecting on people’s willingness to talk about the research issues, engaging in informative conversations and posing relevant questions. \u003c/p\u003e\u003cp\u003eConclusion: The\u0026nbsp;“PPI Hawkers” succeeded in engaging the public in conversations about a local population-based study. The\u0026nbsp;public brought to the researchers’ attention a variety of previously unheard perspectives about the research. Each event fostered connectivity between professionals and the public, generating among researchers a more positive perception of the power of public involvement. “PPI Hawkers”\u0026nbsp;provide an opportunity for\u0026nbsp;co-informed conduct\u0026nbsp;of research studies with diverse members of the public. They create a focus within a community setting for researchers to engage with the public. The resources needed (costs and preparatory time) are relatively\u0026nbsp;few. Not only do “PPI Hawkers” have\u0026nbsp;potential in Singapore, but also for the rest of Asia.\u003c/p\u003e","manuscriptTitle":"The “PPI Hawker”: An innovative method for Patient and Public Involvement (PPI) in health research","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-05-20 16:23:46","doi":"10.21203/rs.2.19589/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-05-05T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-05-04T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-05-03T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-05-03T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"research-involvement-and-engagement","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"riae","sideBox":"Learn more about [Research Involvement and Engagement](http://researchinvolvement.biomedcentral.com/)","snPcode":"40900","submissionUrl":"https://submission.nature.com/new-submission/40900/3","title":"Research Involvement and Engagement","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2019-12-31 17:23:46","doi":"10.21203/rs.2.19589/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-04-03T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-01-26T12:00:00+00:00","index":3,"fulltext":"Recommendation: Minor Revision\nForm responses:\n---\n\nComments to Author:\n---\nThank you for the opportunity to review your article. I enjoyed reading and learning about the PPI Hawker. Overall, I thought the paper was well-written and an interesting addition to the field. As a POR researcher, I will consider using a PPI Hawker/Cafe strategy in future studies. My main concerns with this publication are in regards to a lack of detail in some sections (particularly the methodology). It wasn't until I got to the end of the publication and read the methods, results, discussion, etc. that I had a clear idea of how the PPI hawkers were organized. My specific comments are provided below.\n\nTitle:\n- State what PPI stands for in full...\n\nAbstract:\n- Define what a PPI Hawker and PPI Cafe are in the background\n- If PPI stands for 'public involvement' why is there the additional P?\n- How many people were approached to be in the study?\n- You use the terms 'co-designed' and 'co-conducted' - I would argue that the participants were not involved in the design and conduct of the study rather informed the study. Suggest changing to 'co-informed'\n- Need a statement about how the PPI hawkers are relevant to Asain countries and the little attention to PPI in Asia to date\n\nMethods:\nDesigning and testing feasibility section:\n- Figures 2 \u0026 3 should be switched - right now have figure 3 comes before figure 2\n- Figure 3 is blurry so I am unable to read it\n- This section is meant to describe how the PPI Hawkers were set up, but at the end of the section I am still confused. Was the Hawker closed for this event so everyone there was participating in the PPI hawker? How many people did you have organizing it and how many participants at each Hawker? Were the food shops still open or was this done after hours? How were the facilitators chosen? Who were the pairs? Who led the whole event? Who were the researchers and how were they involved? How did you find and recruit facilitators? Were these paid positions? Had they been involved in research before?\nWhat were the coordinators and researchers roles during the Hawker sessions? Were these conversations all held separately? How many questions were there? Did everyone just respond to one question? How was informed consent gained? Did you have ethics to do this? Were you approaching different numbers of people at each table? Were all the same questions asked? How long were the individual conversations? Did the facilitators switch role? Were there only two facilitators?\n\nResults:\n- Did you collect any demographic information? You mention age a few times but no ages provided.\n- Who was in the Steering Group and how were they involved?\n- Box 1 is helpful - I wonder if there should also be a short blurb somewhere about the population-based research study that people were being asked about to provide more context...\n- The public perspective on the PPI hawker - how did they provide feedback? Just informally?\n- I think more information on the facilitators, coordinators, researcher are needed - in the methods section... who are the people conducting this study..\n\nDeclarations:\n-- Why are ethics and consent not applicable? Because you weren't recording any of their data and just collecting broad observations? I think a statement of why ethics and informed consent is not needed needs to be stated in the methods* Level of interest: **An article of importance in its field**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2020-01-21T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major Revision\nForm responses:\n---\n\nComments to Author:\n---\n\nThis paper gives a detailed account of PPI projects based on the traditional concept of public food marketsh, commonplace in Singapore and other parts of Asia, known as Hawkers. This novel approach complements widely used PPI Cafes and User Groups.\n\nHowever, the concept of Hawkers is alien at least in Europe. It is true that many indoor shopping centres in the West have food halls with seating in public areas, however, each is private to the individual business. This is unlike the Hawker concept where seating is shared and a complete meal can be enjoyed at one table with each course taken from different vendors.\n\nIn addition, in Europe only food and drink purchased from an individual vendor is allowed to be consumed on their premises, including any seating they maintain in public areas.\n\nUnfortunately, the paper does not explain the Hawker concept until well into the body of the paper and not at all in the abstract. If this paper is to be disseminated to any meaningful extent in the West the authors must fully explain the Hawker concept at the beginning of the paper and at the beginning of the abstract.\n\nThe authors could have benefited from some advanced publicity of their project rather than descending unannounced on diners with, to some extent, the resulting suspicion they document.\n--\nSent from myMail app for Android\n\n* Level of interest: **An article whose findings are important to those with closely related research interests**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I have no competing interests.**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2020-01-21T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major Revision\nForm responses:\n---\n\nComments to Author:\n---\nThis study describes and reports on the feasibility, acceptability, and utility of a PPI methodology (\"PPI Hawker\") developed by the study authors. This methodology is unique in that it has been developed for use in Singapore, a country in which PPI is still in its infancy. While I see the value of this manuscript (i.e., the importance of developing PPI methods that are appropriate for different geographic contexts), I have numerous concerns that need to be addressed before this manuscript is appropriate for publication. These include both the level of detail presented about the PPI Hawker, the criteria used for its evaluation, and the presentation of the results and discussion. I expand upon these concerns below.\n\nAbstract\n1. Define PPI in the opening of your background.\n2. I believe the objectives of this manuscript are to describe the design of the PPI initiative and to assess its feasibility, acceptability, and utility.\n3. Lines 27/28: you didn't measure age; provide a % to support \"majority\".\n4. Study design: Since you describe the PPI Hawker in the methods section of your manuscript I'd provide a 1-sentence overview of the PPI Hawker here.\n5. Lines 43/44: I think that \"meaningful co-design and co-conduct\" may be an overstatement - researchers are consulting the public when they use this approach. See for example Gallivan 2012 The many faces of patient engagement or IAP2 Participation Spectrum.\n\nPlain English Summary\n1. Lines 59-62: Great that you explain what a hawker centre is but also spell out what a PPI Hawker is - from what I've just read I'm guessing it is a PPI cafe held in a hakwer centre… Also, readers may not know what a PPI Cafe is so define/briefly explain this term so as to make manuscript more accessible.\n2. Include your study aims/objectives before you launch into the results (line 1 onwards). Also, if designing the PPI Hawker is part of your objectives then include some descriptive information about the PPI Hawker in your results.\n3. Lines 8/9: \"… members of the public but requires few…\" : replace \"but\" with \"and\".\n\nBackground\n1. Define PPI again (even though you already did in the abstract).\n2. Lines 28-33: I'm unsure what the authors mean by \"refined\" in this context. Consider here patient-researchers' influences on decisions-making (e.g. IAP2's spectrum of participation or Gallivan's paper mentioned above). Potential strengths of \"this model of involvement\" not only include continuity but also the potential for patient-researchers to have influence on the decisions that are made in a study (instead of acting as one-off consultants that are peripheral to the research team and whose input may or may not be incorporated by the research team). Each PPI approach has its merits - appropriateness of approaches varies by characteristics of the study (e.g., research question, available resources including time, etc.) and interests of patient-researchers.\n3. Lines 32/33: I think you can make the argument that your approach encourages diversity in opinions but I'm unsure about inclusivity (i.e., in the research process/team) since it involves one-off consultations. Unless you're using inclusivity to mean something else in which case make this clear (i.e., how are inclusive and diverse distinct concepts in this sentence?). Also, I think you mean diversity IN involvement not OF involvement.\n4. Lines 37/38: \"By merging characteristics of a \"science café\" and a PPI workshop\" : Characteristics such as? Provide more detail for readers unfamiliar with either.\n5. Lines 46/47: Remove comma after public.\n6. Lines 47-53: I'm unsure about the relevance of these other initiatives... I would use the space to expand upon the characteristics of a PPI cafe, science cafe and a PPI workshop. If you choose to keep these initiatives here then explicitly state the relevance of them to the PPI Hawker (maybe they're examples of PPI workshops you drew from in designing the PPI Hawker?).\n\nMethods:\n1. Lines 22/31: I really like the content of this paragraph. However, I think that a paragraph that describes the tangible characteristics of the PPI Hawker should precede it. Alternatively, you could state that conceptually you designed the Hawker to ... (and include the info you have in this paragraph). This would make it clear to the reader that you're describing your vision behind/ conceptualization of the PPI Hawker here. I prefer the second approach.\n2. Lines 35/36: You need to provide more detail on PPI cafes before the reader gets to this point so they have a context to ground themselves in.\n3. Lines 36/37: What is the population-based study? Describe it briefly below, even though the reader eventually obtains some of this information in Box 1. If you don't describe immediately below then inform reader where this info is found in your manuscript (i.e., Box 1).\n4. Lines 44/45: Briefly explain the term lingua franca using \"(i.e., )\" so text remains accessible to all readers.\n5. Lines 47-56: Figure 2 should come before Figure 3 in the text. Also - what happens to the information that participants share during the PPI Hawker? For example, do the notetakers try to write everything down verbatim or just main points? Do the researchers do any fact-checking with the participants to ensure that what they've captured in their notes is representative of what the participants said. How is what's written in the notes then synthesized (if it is at all) before it is given to the researchers? What do the researchers do with the information that they receive (read original notes? Analyze for themes or synthesize? Etc.). You don't have to answer these questions directly but you do need to include more detail about what happens after the information is gathered by the notetakers (and about what information is gathered). You might find this reference useful when thinking about this: Doria et al 2018. Sharpening the focus: differentiating between focus groups for patient engagement vs. qualitative research. Res Involv Engagem. 2018;4:19.\n6. Line 1: \"The development team of 5 PILOTED the first PPI Hawker PILOT: awkward.\n\nCriteria for evaluation\n1. Reading up to this point I still have no clue what a PPI Hawker event entails. Reading through the rest of your manuscript I realize that some of this information is in Figure 4 but please also add a paragraph that provides an overview of Figure 4 prior to this point. This paragraph should include a tangible/concrete description of the PPI Hawker. One in which you operationalize what occurs in a way that allows someone to replicate what you did or at least roughly know how to conduct a PPI Hawker - the steps they need to take and/or the integral features. Right now it's all very abstract. You do a great job of explaining the ideas/conceptualization behind the Hawker, now beef up your tangible description of it.\n2. I like how you describe how you defined each evaluation criterion. If you have a reference that guided your definitions and/or operationalizations include it. Consider providing some information around how you landed on your operationalizations of the criteria.\n3. Lines 21/22: Out of curiosity - why 10 and not a % of participants?\n4. Lines 23-36: I struggle with your statement about seeking representation from diverse ages because you did not ask participants their ages. Did you perhaps ask researchers to speculate whether participants fell into prespecified age categories within the age range of 20-80 and to write this information down (this approach is used in intercept surveys -- built environment and physical activity/mobility research)? Regardless, provide more information on how you ascertained \"diverse ages.\"\n\nResults\n1. I'm struggling with how the results are presented because they include a lot of discussion and don't intuitively line up with the stated criteria for evaluation of the PPI Hawker. There is also some speculation (or what I perceive to be speculation) about findings. Presentation of results should flow logically from criteria for evaluation. Please revise this section accordingly.\n2. I'm also not used to seeing the same figures referred to throughout methods and results. I find this a scattered and distracting approach. Usually a figure supports what you are stating in a paragraph. Or, said another way, you usually present a figure and expand upon it in an adjacent paragraph.\n3. Lines 56-2: Since recruitment rate is part of your evaluation criteria include here how many people total you approached.\n4. Lines 3-6: Did you actually ask participants this or are you speculating? I think this and the paragraph below are more appropriate for the discussion since they don't directly relate to your criteria for evaluation.\n5. Lines 33/34 and 38-41: How do you know that these populations were \"… from different neighbourhoods\"? How does the researcher know that the perspectives are coming from lower socio-economic classes? I don't believe you measured participants' neighbourhoods or socio-economic class.\n6. Box 1: As stated previously you need to provide some information about the population-based study (prior to this point) so the reader has some context to ground him/herself in. Also, as I touched on in a previous comment we need more detail about what the researchers did with participants' feedback. Did they incorporate all the feedback? A percentage of the feedback? Pick and choose what \"worked for them\"? It's great that the researchers incorporated what was said but the level of detail here about the process of documenting and incorporating ideas doesn't make a strong argument for this form of engagement being less tokenistic (I'm not convinced it is - this is an example of an approach that can be used to consult with the public on research).\n7. Lines 38/39: Public's perspective of the PPI Hawker should be include as a criteria for evaluation since you present it as a result (or moved to the discussion).\n\nDiscussion\n1. Lines 31-32: I think \"appeared to be\" is more appropriate than \"were\" broad in age.\n2. Lines 33-34: You have no way of knowing that you engaged with a broad sector of society (i.e., in different neighbourhoods) since you did not measure this. You did measure ethnicity.\n3. Lines 50-53: You did not get any info about participants' socio-economic status, literacy, oral skills, health needs etc. so I don't think you can imply that you reached these populations. Outside of ethnicity you don't really know who you reached.\n4. Lines 3-15: Typically resources are used as measures of feasibility ... so I wonder why this is a discussion point and not evaluation criterion.\n5. Lines 25-27: \"This may be impossible if one wishes to target people of a specific age, sexuality, marital status, or income group\" - Exactly. So then how do you know you had representation from diverse ages?\n6. Line 36: Consider using this reference (i.e., GRIPP2) to inform how your report on PPI in your manuscript.\n7. Lines 42-43: This Figure is more useful and appropriate when you introduce and describe the PPI Hawker.\n\nFigure 3: Maybe something has gone wrong on my end but I can't make out this figure's text.\n\nAppendices: Please refer to the appendices in the body of your manuscript (otherwise they jump out of nowhere).\n\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests' below**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-01-12T12:00:00+00:00","index":3,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-01-02T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2019-12-22T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-12-19T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-12-18T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-12-17T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-12-17T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2019-12-15T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"research-involvement-and-engagement","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"riae","sideBox":"Learn more about [Research Involvement and Engagement](http://researchinvolvement.biomedcentral.com/)","snPcode":"40900","submissionUrl":"https://submission.nature.com/new-submission/40900/3","title":"Research Involvement and Engagement","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d3c32d1e-5f74-4af3-8ed0-993d4de117ad","owner":[],"postedDate":"May 20th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":45939,"name":"Health Economics \u0026 Outcomes Research"}],"tags":[],"updatedAt":"2020-06-21T15:01:49+00:00","versionOfRecord":{"articleIdentity":"rs-10202","link":"https://doi.org/10.1186/s40900-020-00205-6","journal":{"identity":"research-involvement-and-engagement","isVorOnly":false,"title":"Research Involvement and Engagement"},"publishedOn":"2020-06-16 12:00:00","publishedOnDateReadable":"June 16th, 2020"},"versionCreatedAt":"2020-05-20 16:23:46","video":"","vorDoi":"10.1186/s40900-020-00205-6","vorDoiUrl":"https://doi.org/10.1186/s40900-020-00205-6","workflowStages":[]},"version":"v2","identity":"rs-10202","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-10202","version":["v2"]},"buildId":"xY3USe_2onMUXQTaeJKFU","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}