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.