What are the key ingredients for effective public involvement in health care improvement and policy decisions? A randomized trial process evaluation

Context: In the past 50 years, individual patient involvement at the clinical consultation level has received considerable attention. More recently, patients and the public have increasingly been involved in collective decisions concerning the improvement of health care and policymaking. However, rigorous evaluation guiding the development and implementation of effective public involvement interventions is lacking. This article describes those key ingredients likely to affect public members' ability to deliberate productively with professionals and influence collective health care choices.

Method: We conducted a trial process evaluation of public involvement in setting priorities for health care improvement. In all, 172 participants (including 83 patients and public members and 89 professionals) from 6 Health and Social Services Centers in Canada participated in the trial. We video-recorded 14 one-day meetings, and 2 nonparticipant observers took structured notes. Using qualitative analysis, we show how public members influenced health care improvement priorities.

Findings: Legitimacy, credibility, and power explain the variations in the public members' influence. Their credibility was supported by their personal experience as patients and caregivers, the provision of a structured preparation meeting, and access to population-based data from their community. Legitimacy was fostered by the recruitment of a balanced group of participants and by the public members' opportunities to draw from one another's experience. The combination of small-group deliberations, wider public consultation, and a moderation style focused on effective group process helped level out the power differences between professionals and the public. The engagement of key stakeholders in the intervention design and implementation helped build policy support for public involvement.

Conclusions: A number of interacting active ingredients structure and foster the public's legitimacy, credibility, and power. By paying greater attention to them, policymakers could develop and implement more effective public involvement interventions.