Patient and Public Involvement in HIV research: a mapping review and development of an online evidence map

doi:10.21203/rs.3.rs-4078072/v1

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Patient and Public Involvement in HIV research: a mapping review and development of an online evidence map

https://doi.org/10.21203/rs.3.rs-4078072/v1

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Introduction: Increasing evidence indicates the benefits of patient and public involvement (PPI) in medical research, and PPI is increasingly expected by funders and publishers. We conducted a mapping review of studies reporting examples of PPI implementation in HIV research, and developed an online evidence map to guide researchers in the planning of PPI in HIV research projects.

Methods: We systematically searched Medline and Embase up until March 16, 2023, including search terms with variations for PPI and HIV. We extracted information from identified studies in duplicate and analysed the data descriptively and qualitatively to describe types of PPI models and report benefits, challenges, and mitigation strategies. This study was co-initiated and co-led by people living with HIV. PPI was embedded into all parts of the research process, and we report and reflect on our own PPI experience in this study.

Results: We identified twelve studies reporting PPI in HIV research between 1992 and 2020. Most PPI examples informed clinical trials, but also qualitative research, questionnaire development, research priority setting and surveys. Only six studies described the number and characteristics of PPI members involved. We observed four PPI models, from a model that solely engaged PPI members for a specific task to a model whereby PPI representatives were integrated into the study team with decision-making authority. Benefits reported included wider dissemination of research results, better understanding of research material and results, and higher levels of trust and learning between researcher and communities. Most reported challenges were lack of specific resources for PPI, levels of knowledge and expertise, risk of disclosure, and diversity of the PPI team. We embedded PPI from study inception onwards, which probably pre-empted some of the challenges reported in the reviewed examples.

Conclusions: This mapping review summarizes published examples of PPI in HIV research for various phases of research. There is clear need to strengthen the reporting on PPI processes in HIV research, e.g., by following the GRIPP2 guidelines, and to develop guidance on its hands-on implementation. The resulting online evidence map is a starting point to guide researchers on how to integrate PPI in their own research.

Patient and Public Involvement

HIV/AIDS

mapping review

evidence map

Involving people with lived experience of or affected by a medical condition in research processes – not as ‘subjects’ or ‘participants’, but as members of research teams – is known as Patient and Public Involvement, or PPI. PPI has a variety of benefits for both researchers and members of the public and is increasingly expected by medical journals and research funders. Historically, PPI has been strongly associated with HIV research, largely thanks to early HIV activism. However, published HIV research rarely reports on if and how PPI was used in studies. This makes it difficult to evaluate the impact of PPI on research processes, and limits available information for researchers seeking guidance on how to use PPI.

Here we searched and reviewed publications that report on PPI in HIV research, considering how and for which research phases PPI was applied, and perceived benefits and challenges, as well as how researchers overcame those challenges. The most frequently reported benefits included wider dissemination of research results, better understanding of consent forms, research materials, and results, higher levels of trust and learning between researcher and communities, and increased socio-cultural competency of the research team. Barriers to PPI were a lack of resources (time/money), uneven levels of research knowledge by PPI members, a lack of diversity among the PPI team, and the risk of disclosure and stigma that may contribute to people living with HIV not being willing to participate. Based on this review, we identified four models of PPI and created an online evidence map to help researchers use PPI in their studies.

People with lived experience of medical conditions can provide valuable input into research endeavours to ensure that they are relevant and adapted to their needs. Patient and Public Involvement (PPI) is the process whereby patients and members of the public work alongside researchers, from the definition of research priorities, grant writing, study conceptualization, research tool development, results interpretation, through to dissemination [1–3]. Increasing evidence highlights how PPI can improve research in terms of patient relevant outcomes, project implementation, acceptability of the proposed intervention and participant recruitment and engagement [4, 5]. Further, funders and publishers increasingly require PPI as an integral part of medical research and funding assessment boards. Historically, the field of HIV research has championed innovative PPI efforts, spurred largely by the activism of people living with HIV (PLWH) [6, 7]. However, despite increasing evidence and its history in HIV, PPI activities are rarely reported [8]. The lack of practical guidance on PPI with concrete examples may lead to suboptimal use of PPI and increased risk of tokenism [9–11].

We conducted a mapping review of published PPI activities in HIV research to inform the creation of an online evidence map, intended as a continuously growing, hands-on, and easy-to-search online database for researchers applying PPI in HIV research.

Study design

Using a mapping review approach[12, 13], we systematically searched and reviewed publications reporting on PPI examples in HIV research. We registered our protocol on Open Science Framework (OSF) [14]. Based on the reported examples of PPI implementation found during the review, we developed an online evidence map.

Patient and Public Involvement

This study was initiated, designed, and conducted by an interdisciplinary team including PLWH as part of a larger project on PPI in the Swiss context. We report on our own PPI aim, methods, and activities according to the Guidance for Reporting Involvement of Patients and the Public (GRIPP2) checklist [15] (Fig. 1).

Table 1

Description of the role of PPI in our own study, based on the Guidance for Reporting Involvement of Patients and the Public (GRIPP2) checklist [15]
Aim of PPI in this study	● To co-produce a research project on PPI in HIV research with PLWH as members of the research team ● To draw on the expertise of PLWH at all stages of the research project ● To render research results accessible to wider HIV communities
Methods used for PPI in this study	● PLWH actively participated in all stages of the project: defining the initial research idea, defining the research questions and methods, acquiring funding, drafting the study protocol, interpreting the results, and writing the manuscript ● PPI and other contributors met bi-weekly to discuss the study progress
Result of PPI in this study	● PPI contributed to enriching the interpretation of the results ● PPI brought concrete experience concerning previous PPI activities in HIV research to the development of the online evidence map
Discussion on the extent to which PPI influenced this study overall	● PPI members contributed at all stages of the project, which was unlikely to have been initiated otherwise ● PPI contributed research ideas and perspectives beyond the scope of this study that may lead to further research projects
Critical perspective on the inclusion of PPI in this study	● PPI members sometimes lacked the necessary time to commit to research processes due to other professional activities. However, this is arguably the case in any research project including multiple partners ● Uneven levels of methodological expertise were apparent across study members including but not limited to PPI members ● PPI members in this study are not representative of populations affected by HIV in Switzerland (all were white, middle-class, cis-gender, and over 50, two were men and one a woman).

Search strategy and data sources

We systematically searched studies published before March 16, 2023, without language nor year restrictions, in Medline/PubMed and Embase, both via Ovid. Search terms included one of the following term on patient and public involvement: (“patient participation”/ or “community based participatory research”/) or (“patient participation” or “patient and public involvement” or “public and patient involvement” or “patient involvement” or “community based participatory research” or “stakeholder engagement” or “stakeholder involvement” or “community involvement” or “good participatory practice”), combined with one of the following terms for HIV (“HIV”/ or “Acquired Immunodeficiency Syndrome”/ or “HIV infections”/ or (HIV or “Human Immunodeficiency Virus” or “Acquired Immunodeficiency Syndrome”).

Study screening, eligibility, data extraction and analysis

We conducted screening and data extraction using Covidence (www.covidence.org). We included original articles that provided examples of PPI implementation in their HIV research projects. We excluded conference abstracts and examples of PPI in HIV care/service provision as our focus is on research. We screened abstracts and assessed full text eligibility in duplicate by two independent researchers. We then extracted data from each eligible study, in duplicate, including: The year and country where the study was conducted; the overall aim of study; the target study population; the characteristics of PPI members; reported challenges and mitigation strategies. We categorized the study design as prospective clinical study, qualitative research, survey, preclinical, or observational data analysis, and the project phases when PPI was involved into research project planning, research project implementation, closure (results interpretation), and post-closure (results dissemination) phase.

We performed qualitative content analysis and used the Alberta Health Services’ engagement spectrum [16] as a framework to inductively define four categories of PPI models, and reported challenges and mitigation strategies. We highlighted quotes of relevant text passages, created labels that reflect the content, and collaboratively and iteratively modified and refined the final types of PPI models, benefits, challenges, and mitigation strategies.

We thereafter created the online evidence map collaboratively with all co-authors as an iterative process over several meetings. To give concrete guidance to HIV researchers, we produced separate maps by type of research project (prospective clinical study, qualitative research, survey, preclinical, and observational data analysis).

Ethics statement

No ethical approval was required for this mapping review.

The review

We identified a total of 1053 records across all databases. After removal of 156 duplicates and 897 studies during the title/abstract screening process, we included 37 studies in the full text screening. We further excluded 25 studies for the following reasons: only conference abstract available (n = 11), study examines PPI on a theoretical level without providing guidance (n = 9), not about HIV (n = 2), not about HIV research only HIV service provision (n = 3). The remaining twelve studies were extracted in detail [17–28].

Characteristics of included studies and PPI members

The included studies (Table 2) provide descriptions of PPI implementation examples used in their HIV research ranging from 1992 [19] to 2020 [20]. Most examples involved clinical trials [17, 19, 20, 22, 24, 26–29], but also qualitative research [23], research instrument/questionnaire development [25, 26], research priority setting [21], and surveys [19]. These projects reported on PPI for the research planning phase targeting breastfeeding mothers living with HIV in Malawi [18], men living with HIV in the military service in the United States [19], or Latina women at risk for HIV acquisition in the United States [22], among others. In some studies, PPI was included in all phases of research, such as studies involving youth living with HIV in Canada [23] or South Africa [17], diverse communities of PLWH in the UK [28], or with men who have sex with men and trans women in the UK [24]. Three studies included PPI for the post-closure phase [22, 25, 26]. Only six studies [18, 19, 21, 23, 25, 27] described in detail how many PPI members were involved and their characteristics.

Reported PPI models

The following models were identified: Model A, where only one to three PPI representatives are part of the study team and have decision-making capacity (2 examples [19, 28]); Model B, whereby a group of PPI representatives is consulted regularly throughout the study but are not part of the study team and have no decision-making capacity (4 examples [17, 25, 27, 28]); Model C, whereby one to three PPI representatives are part of the study team with decision-making capacity plus a group of PPI representatives is consulted regularly to increase the number and diversity of opinions (7 examples [17, 19, 22–24, 26, 28]); Model D, whereby PPI representatives are only consulted for a one-off task, for example input on the questionnaire or study protocol (5 examples [17, 18, 20, 21, 28]).

Reported benefits, challenges, and mitigation strategies

The most frequently reported benefits were wider dissemination of research results, better understanding of consent forms, research materials, and results, higher levels of trust, respect, and learning between researcher and communities, and increased socio-cultural competency of the research team. The challenges emerged around four key topics. First, limited resources, particularly time and funds for PPI activities, highlight the need for early PPI involvement for concrete planning of PPI and dedicated study staff for PPI activities. Second, differing levels of knowledge and expertise among PPI members and researchers was a recurring theme. This may be mitigated by offering training and defining clear terms and agreements. Third, risk of disclosure and stigma especially during publication and result dissemination, resulting in a need for publication strategies where individuals not wishing to be identified could still participate (e.g., collective co-authorship and pseudonyms). Fourth, many studies noted the lack of demographic diversity amongst PPI members.

The online evidence map

Figure 2 provides an excerpt of the map for prospective clinical studies. We provide information on how to include PPI in each of the four defined research phases, divided into sub-tasks, and provided an example from the review, including its reference. Finally, we added external links to additional local guidance documents. The map is available through the homepage of the Swiss HIV Cohort Study (SHCS) in an online format to continuously add further examples (http://www.shcs.ch/315-patient-and-public-involvement-ppi).

This mapping review of PPI in HIV research yielded twelve studies reporting a wide range of examples of PPI implementation. Four common PPI models emerged. A model whereby PPI members have decision-making capacity throughout the study (model A and C) conceivably aligns more strongly with PPI principles compared to occasional involvement (model B and D). Group-based models (model B and C) may encompass more diverse views. One-off PPI models might be more feasible and similarly effective in addressing specific problems that arise during a trial, such as recruitment issues, but may be more susceptible to tokenism. A mix of different models may be resource intensive yet more effective, maximising PPI's potential impact on a study. Given that the literature on theoretical aspects of PPI is extensive and PPI is increasingly encouraged by funders and publishers, we expected more published examples in HIV research. However, the limited numbers of studies included in this review probably represents underreporting of PPI examples rather than actual PPI use in HIV research.

We identified two other reviews about PPI in HIV research.[30, 31] First, a mixed-methods review on PPI for questionnaire instrument development in HIV research and care.[30] It identified 41 studies assessing 39 instruments. In 79% of the studies the involvement was restricted to consultation, comparable to our Model D. Second, a systematic review specifically assessing PPI for clinical trials found 108 eligible studies [31]. The review focused on stakeholders other than patients. Most often stakeholder involvement happened during the protocol development phase and study recruitment, only 13% informed the closure or post-closure research phase.

Reflecting on our own PPI activity, we embedded PPI from study inception onwards, which not only mitigated but probably pre-empted some of the challenges reported in the reviewed examples. Further, funders understood the importance of PPI; financial resources were therefore built into the initial protocol and funding application and not a challenge. While we encountered time-constraints for meetings and research members having varying areas of expertise, this was not specific to PPI members. Risk of disclosure was not an issue for PPI members here, since two are members of the SHCS Scientific Board, and the third also lives openly with HIV. However, in terms of diversity, we faced similar challenges described by others in this review. Including women, racialised and other marginalized communities, such as substance users, is an ongoing difficulty in all areas of HIV research that we still seem to find challenging [11, 32]. While a few included studies in this review outlined in detail how PPI members were approached and selected [25, 27], more guidance is needed in this aspect.

Our study has some shortcomings. First, our search was restricted to HIV research, and PPI examples only involving PLWH or people at risk of HIV, but not other stakeholders (the “Public” in PPI). Second, we excluded original studies that only mentioned PPI, e.g., in a standard PPI statement, without giving further details. We acknowledge that this article does not give a holistic picture of all PPI activities in HIV research, e.g., on the level of scientific boards or funders’ research proposal assessment boards. As a strength, this research project was co-created and co-led by PLWH, and involved a systematic search according to mapping review guidance and rigorous data extraction in duplicate.

In conclusion, this mapping review summarises published examples of PPI in HIV research for various phases of research. There is a clear need to strengthen the reporting on PPI processes in HIV research, e.g., by following the GRIPP2 guidelines. Better hands-on guidance for the implementation of PPI in HIV research is warranted. The resulting online evidence map is a starting point to guide future researchers on how to integrate and apply PPI in their own research.

Competing interests

The authors report no competing interests.

Authors’ contributions

DJP, DH, CP, JN, and AA conceptualized the study and obtained the funding. LA, AB, and AA conducted the search and data extraction, with input from DJP, ECR, DH, CP, MB, and JN. DJP and AA drafted the first version of the manuscript. All named authors regularly reviewed the draft manuscript, provided input, and approved the final version.

Acknowledgements

We thank Hannah Ewald PhD (University Library, University of Basel; Medical Information Specialist) and Sandra Kohlmaier PhD (Department Clinical Research, University Hospital Basel; PPI focal person) for their input on the search strategy, and Dunja Nicca PhD (Institute of Nursing Science, University of Basel; PPI expert) for their input on the study protocol.

Funding

This mapping review is part of a larger mixed methods study that aims to assess the attitudes and levels of knowledge of HIV research stakeholders in Switzerland on PPI and at providing concrete guidance on meaningful PPI for the SHCS and beyond. This overarching study is funded by the SHCS (project no #911) and Gilead Sciences. AA receives his salary from a postdoc.mobility grant of the Swiss National Science Foundation (P500PM_221961).

Data Availability Statement

All included studies and all generated data are presented in this manuscript.

Members of the Swiss HIV Cohort Study Young Researchers’ Group

Irene Abela, Frédérique Chammartin-Basnet, José Damas, Malte Kohns, Karoline Leuzinger, Annalisa Marinosci, Luisa Salazar-Vizcaya, Andrea Erba, Mailin Waldecker, Bernard Surial, Chloé Pasin, Marie Ballif, Alain Amstutz, Julia Notter

Members of the Swiss HIV Cohort Study

Abela I, Aebi-Popp K, Anagnostopoulos A, Battegay M, Bernasconi E, Braun DL, Bucher HC, Calmy A, Cavassini M, Ciuffi A, Dollenmaier G, Egger M, Elzi L, Fehr J, Fellay J, Furrer H, Fux CA, Günthard HF (President of the SHCS), Hachfeld A, Haerry D (deputy of "Positive Council"), Hasse B, Hirsch HH, Hoffmann M, Hösli I, Huber M, Jackson-Perry D, Kahlert CR (Chairman of the Mother & Child Substudy), Kaiser L, Keiser O, Klimkait T, Kouyos RD, Kovari H, Kusejko K (Head of Data Centre), Labhardt N, Leuzinger K, Martinez de Tejada B, Marzolini C, Metzner KJ, Müller N, Nemeth J, Nicca D, Notter J, Paioni P, Pantaleo G, Perreau M, Rauch A (Chairman of the Scientific Board), Salazar-Vizcaya L, Schmid P, Speck R, Stöckle M (Chairman of the Clinical and Laboratory Committee), Tarr P, Trkola A, Wandeler G, Weisser M, Yerly S.

PPI (Patient and Public Involvement) resources for applicants to NIHR research programmes [Internet]. [cited 2024 Jan 18]. Available from: https://www.nihr.ac.uk/documents/ppi-patient-and-public-involvement-resources-for-applicants-to-nihr-research-programmes/23437
Grotz J, Ledgard M, Poland F. NIHR. Patient and public involvement in health and social care research: a handbook for researchers 2014. 2020 [cited 2024 Jan 18]; Available from: https://link.springer.com/10.1007/978-3-030-55289-3
NIHR. Standards for public involvement in research—better public involvement for better health and social care research 2019.
Brett J, Staniszewska S, Mockford C, Herron-Marx S, Hughes J, Tysall C, et al. Mapping the impact of patient and public involvement on health and social care research: a systematic review. Health Expect. 2014 Oct;17(5):637–50.
Ryll B. From good to great: what patients can do for your medical research. Nat Med. 2020 Oct;26(10):1508–1508.
Sabin ML. How the Denver Principles changed health care for everyone. The Lancet. 2023 Jun 24;401(10394):2099–100.
Good participatory practice: Guidelines for biomedical HIV prevention trials (2011) [Internet]. [cited 2024 Jan 18]. Available from: https://www.unaids.org/en/resources/documents/2011/20110629_JC1853_GPP_Guidelines_2011%20OK
Lang I, King A, Jenkins G, Boddy K, Khan Z, Liabo K. How common is patient and public involvement (PPI)? Cross-sectional analysis of frequency of PPI reporting in health research papers and associations with methods, funding sources and other factors. BMJ Open. 2022 May 24;12(5):e063356.
Ocloo J, Matthews R. From tokenism to empowerment: progressing patient and public involvement in healthcare improvement. BMJ Qual Saf. 2016 Aug;25(8):626–32.
Jackson T, Pinnock H, Liew SM, Horne E, Ehrlich E, Fulton O, et al. Patient and public involvement in research: from tokenistic box ticking to valued team members. BMC Medicine. 2020 Apr 13;18(1):79.
Martin GP. Representativeness, legitimacy and power in public involvement in health-service management. Soc Sci Med. 2008 Dec;67(11):1757–65.
Pierce J. Research Guides: Systematic Reviews & Other Review Types: What is a Mapping Review? [Internet]. 2023 [cited 2023 Mar 13]. Available from: https://guides.temple.edu/c.php?g=78618&p=5094330
Miake-Lye IM, Hempel S, Shanman R, Shekelle PG. What is an evidence map? A systematic review of published evidence maps and their definitions, methods, and products. Systematic Reviews. 2016 Feb 10;5(1):28.
Glasstetter J, Jackson-Perry D, Haerry D, Pasin C, Ballif M, Cart-Richter E, et al. Meaningful Patient and Public Involvement in HIV research: Study protocol for a mapping review. 2023 Mar 20 [cited 2023 Mar 26]; Available from: https://osf.io/md37a
Staniszewska S, Brett J, Simera I, Seers K, Mockford C, Goodlad S, et al. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. BMJ. 2017 Aug 2;358:j3453.
Singh S, Burns KK, Rees J, Picklyk D, Spence J, Marlett N. Patient and family engagement in Alberta Health Services: Improving care delivery and research outcomes. Healthc Manage Forum. 2018 Mar 1;31(2):57–61.
Baron D, Essien T, Pato S, Magongo M, Mbandazayo N, Scorgie F, et al. Collateral benefits: how the practical application of Good Participatory Practice can strengthen HIV research in sub-Saharan Africa. J Int AIDS Soc. 2018 Oct;21 Suppl 7(Suppl Suppl 7):e25175.
Corneli AL, Piwoz EG, Bentley ME, Moses A, Nkhoma JR, Tohill BC, et al. Involving communities in the design of clinical trial protocols: the BAN Study in Lilongwe, Malawi. Contemp Clin Trials. 2007 Jan;28(1):59–67.
Carey MA, Smith MW. Enhancement of validity through qualitative approaches. Incorporating the patient’s perspective. Eval Health Prof. 1992 Mar;15(1):107–14.
Day S, Mathews A, Blumberg M, Vu T, Rennie S, Tucker JD. Broadening community engagement in clinical research: Designing and assessing a pilot crowdsourcing project to obtain community feedback on an HIV clinical trial. Clin Trials. 2020 Jun;17(3):306–13.
Denison JA, Pettifor A, Mofenson LM, Kasedde S, Marcus R, Konayuma KJ, et al. Youth engagement in developing an implementation science research agenda on adolescent HIV testing and care linkages in sub-Saharan Africa. AIDS. 2017 Jul 1;31 Suppl 3(Suppl 3):S195–201.
Flaskerud JH, Anderson N. Disseminating the results of participant-focused research. J Transcult Nurs. 1999 Oct;10(4):340–9.
Flicker S. Who benefits from community-based participatory research? A case study of the Positive Youth Project. Health Educ Behav. 2008 Feb;35(1):70–86.
Gafos M, South A, Hanley B, Brodnicki E, Hodson M, McCormack S, et al. “PROUD to have been involved”: an evaluation of participant and community involvement in the PROUD HIV prevention trial. Research Involvement and Engagement. 2020 Apr 17;6(1):13.
Lessard D, Engler K, Toupin I, I-Score Consulting Team, Routy JP, Lebouché B. Evaluation of a project to engage patients in the development of a patient-reported measure for HIV care (the I-Score Study). Health Expect. 2019 Apr;22(2):209–25.
Lessard D, Engler K, Vicente S, Bilodeau M, Lebouché B. Challenges of Patient Engagement in an HIV Clinical Research Program: A Qualitative Analysis of Stakeholder Accounts. J Patient Exp. 2020 Dec;7(6):925–30.
NIMH Multisite HIV/STD Prevention Trial for African American Couples Group. The role of Community Advisory Boards (CABs) in Project Eban. J Acquir Immune Defic Syndr. 2008 Sep 1;49 Suppl 1(Suppl 1):S68-74.
South A, Hanley B, Gafos M, Cromarty B, Stephens R, Sturgeon K, et al. Models and impact of patient and public involvement in studies carried out by the Medical Research Council Clinical Trials Unit at University College London: findings from ten case studies. Trials. 2016 Jul 29;17:376.
Boote J, Baird W, Beecroft C. Public involvement at the design stage of primary health research: a narrative review of case examples. Health Policy. 2010 Apr;95(1):10–23.
Lénárt A, Engler K, Lessard D, Toupin I, Rodríguez C, Lebouché B. The involvement of people living with HIV in the development of HIV-specific or inclusive health instruments: a mixed methods review. AIDS Care. 2020 Jul;32(7):801–10.
Day S, Blumberg M, Vu T, Zhao Y, Rennie S, Tucker JD. Stakeholder engagement to inform HIV clinical trials: a systematic review of the evidence. J Int AIDS Soc. 2018 Oct;21 Suppl 7(Suppl Suppl 7):e25174.
Rose DS. History of Patient and Public Involvement in England. In: Rose DS, editor. Mad Knowledges and User-Led Research [Internet]. Cham: Springer International Publishing; 2022 [cited 2024 Jan 18]. p. 65–90. (The Politics of Mental Health and Illness). Available from: https://doi.org/10.1007/978-3-031-07551-3_3

Table 2 is available in the Supplementary Files section.

The authors declare no competing interests.

Table2.docx

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Patient and Public Involvement in HIV research: a mapping review and development of an online evidence map

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Abstract

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Plain English Summary

Introduction

Methods

Study design

Patient and Public Involvement

Search strategy and data sources

Study screening, eligibility, data extraction and analysis

Ethics statement

Results

The review

Characteristics of included studies and PPI members

Reported PPI models

Reported benefits, challenges, and mitigation strategies

The online evidence map

Discussion

Declarations

References

Tables

Additional Declarations

Supplementary Files

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