Participatory learning and action (PLA) to improve health outcomes in high-income settings: a systematic review protocol

Introduction Participatory learning and action (PLA) is a form of group reflection and learning with documented efficacy in low-income countries to improve social and health outcomes. PLA represents both a learning philosophy and a practical framework that could be applied to a variety of contexts. To date, PLA has not been widely implemented within high-income countries (HICs) to improve health and health-related outcomes. We aim to synthesise the literature currently available by means of a systematic review to form a foundation for future applications of PLA methodology in HICs. Methods and analysis Two reviewers will independently search predefined terms in the following electronic bibliographic databases: MEDLINE, EMBASE, CINAHL and Cochrane Library. The search terms will encompass PLA and PDSA (Plan-Do-Study-Act) projects, as well as studies using the Triple/Quadruple Aim model. We will include randomised controlled trials that incorporate online or face-to-face components using the PLA/PDSA methodology. Our data will be extracted into a standardised prepiloted form with subsequent narrative review according to the SWiM (Synthesis Without Meta-Analysis) guidelines. Ethics and dissemination No ethics approval is required for this study. The results of this study will be submitted for publication in a leading peer-reviewed academic journal in this field. Additionally, a report will be produced for the funders of this review, which can be viewed for free on their website. PROSPERO registration number CRD42020187978.

Line 32: The triple aim -should be 'population health' rather than 'health population'. Introduction: I think the introduction section is very long and slightly confusing, especially the first 2 paragraphs in page 6which seem to be PLA application in LICs and very specific examples. Also Page 7 -lines 9 -28 seems like a section from a discussion on findings rather than an introduction to this protocol.
Page 8: Methods and Analysis: Line 3: The authors mention published studieswill this include conference proceedings, thesis, book chapters, systematic reviews, reports etc., or only peer-reviewed original studies? Line 11: The authors mention health or social issueswhat are the social issues they will consideras the search terms (Table 1) do not cover any of the usual social issues that are usually considered as determinants for health such as education, employment, economic stability, neighbourhood and employment, community cohesion and safety etc., Alsosocial outcomes are not mentioned in the abstract. Line 15: The authors are including only RCTswhich is fine, however they do not mention qualitative studies, quality improvement studies etc., which would include PDSAs, as the authors mention using this and triple + quadruple aims as search terms. If they are not to be included, then a short explanation of why, would be useful. Line 18: The authors mention looking for studies between 2000 and 2020, it would be useful to know why this particular time period? Line 18: The authors also mention not including studies that are not written in English. Again, this needs a short explanation and included as a limitation. Table 1: I am unsure why the authors are searching by the term "women's group*". Also, the outcomes do not cover health worker experienceswhich is included in the quadruple aim nor the social outcomes mentioned in Page 8, Line 11. Line 59: EndNoteshould be referenced and should say EndNote reference management software. Line 59: The authors mention removing duplicates, would be useful to know how they intend to do thiswill this be using EndNote?
Page 9: Methods and Analysis: Line 7: The authors mention 'that there is little literature'this contradicts their claim in Page 10, Line 23, where they say 'a number of trials exist'. Line 11: I am unsure what the authors mean by 'Therefore, we will take care to compare studies with disparate aims'. Will be useful for this to be clarified.
Page 10: Discussion: Line 42: The authors mention inclusion of both RCTs and trials (I am assuming this to indicate non-randomised trials) -But inclusion criteria says they will only include RCTs. The authors need to clarify this or change inclusion criteria.

GENERAL COMMENTS
Analysis of PLA efficiency within HICS is an interesting concept. The paper is well-written and thoughtful. However, it is a proposal of research, not a reporting of research itself. As such, I am unsure if this meets the standards for acceptance. We have added in two sentences to explain this difference as suggested -thank you for the suggested reference, this has been incorporated. Line 32: The triple aim -should be 'population health' rather than 'health population'. We have implemented this suggestion, thank you. Introduction: I think the introduction section is very long and slightly confusing, especially the first 2 paragraphs in page 6which seem to be PLA application in LICs and very specific examples. Thank you for this feedback. We have cut down these two paragraphs and edited for claritythe examples given should now make more sense in the context of a broadening scope of PLA applications Also Page 7 -lines 9 -28 seems like a section from a discussion on findings rather than an introduction to this protocol. Thank you for this. We have removed the specific discursive elements to provide a more general idea of how LIC implementation of PLA approaches varies with respect to online or in-person approaches Methods and Analysis:

VERSION 1 -AUTHOR RESPONSE
The authors mention published studieswill this include conference proceedings, thesis, book chapters, systematic reviews, reports etc., or only peer-reviewed original studies?
Thank you. We have now clarified that randomized controlled trials and other observational studies in peer reviewed journals will be included in our study.
The authors mention health or social issueswhat are the social issues they will consideras the search terms (Table 1) do not cover any of the usual social issues that are usually considered as determinants for health such as education, employment, economic stability, neighbourhood and employment, community cohesion and safety etc., Alsosocial outcomes are not mentioned in the abstract.
Thank you. We have amended the search term to include the social outcome and we added the social outcomes to the abstract to confirm that we will review both health and social outcomes.
The authors are including only RCTswhich is fine, however they do not mention qualitative studies, quality improvement studies etc., which would include PDSAs, as the authors mention using this and triple + quadruple aims as search terms. If they are not to be included, then a short explanation of why, would be useful.
Thank you. We amended this to include RCTs and other observational studies.
The authors mention looking for studies between 2000 and 2020, it would be useful to know why this particular time period?
Thank you. We have explained our reasoning in the paper.
The authors also mention not including studies that are not written in English. Again, this needs a short explanation and included as a limitation.
Thank you. We have explained the use of a language restriction and acknowledged this as a limitation of the study I am unsure why the authors are searching by the term "women's group*". Also, the outcomes do not cover health worker experienceswhich is included in the quadruple aim nor the social outcomes mentioned in Page 8, Line 11.
Thank you. We didn't remove 'women's group' as a search term as often the term women's group have been used for many of these interventions, so the worry is if we remove the term that we miss some of the interventions we want to review. We have not included health worker experiences as a search term as this does not form the focus of our research question. However, we have included 'quadruple aim' as a search term to include studies that incorporate the remainder of the model, which are within the focus of this study.
EndNoteshould be referenced and should say EndNote reference management software.
Thank you. We have utilised Covidence as review management software and EndNote as reference management software, and we referenced it appropriately. Numbering of subsequent references have been updated