The PPI Culture Change (PPI-CC) model. Towards conceptualizing culture change as an impact from PPI in healthcare and health research

Background: Impact evaluation of patient and public involvement (PPI) commonly assumes that PPI occurs within separate domains, namely clinical practice, organizational development, or research, and must be evaluated within these domains. This fragmented approach misaligns with the nature of strategic PPI, which are formal strategies, often co-designed with patients and relatives, integrating initiatives across all three domains into one coherent strategy.

 

 The fragmentation obscures how strategic PPI must be evaluated and generates impact.

Culture change may represent a meaningful metric for understanding the impact of strategic PPI. The purpose of PPI strategies is often to bring about culture change, and culture change is often described as a prerequisite for becoming successful with the PPI agenda. To avoid it remaining a vague aspiration, we need to develop a clearer understanding of what culture change means in practice. This includes how it manifests, whom it impacts, when and why it occurs, and how such change can be evaluated within complex systems like healthcare and health research.

 

Approach: This project was initiated by a patient and public panel. We conducted a scoping review to explore culture-related outcomes from PPI initiatives across clinical, organizational, and research domains, and based on this, to develop a framework that conceptualizes and operationalizes culture change as an impact metric.

Guided by a dynamic cultural understanding, studies were screened and relevant outcomes extracted. To make sense of the multidimensional nature of the data, we worked abductively with the empiric findings and complexity and organizational culture theory. This led us to develop the PPI Culture Change (PPI-CC) model, which conceptualizes how PPI impact culture change across micro, meso, and macro levels.

The model was refined through consultation with an expert panel of 17 stakeholders – patients, relatives, clinicians, leaders, researchers, and project staff.

 

Results: 1,658 studies were screened, and 22 met inclusion criteria. We identified 132 culture-related outcomes, organized into 15 categories and five subcategories across three levels.

The micro level (User socialization process) includes outcomes reflecting how users engage in continuous cultural negotiations of accepted ways of thinking, behaving, and speaking when participating in PPI. The meso level (Organizational commitment) includes outcomes reflecting how organizations embed and sustain PPI through structural and procedural mechanisms. The macro level (Regulatory assumptions) includes outcomes reflecting broader societal, institutional, and political assumptions that regulate how PPI is perceived and engaged with.

 

The PPI-CC model conceptualizes these three levels as mutually reinforcing and interdependent, rather than hierarchical or linear. It proposes that culture change is an iterative, non-linear process that evolves through feedback loops, learning, and adaptation across levels, where changes at one level influence and shape others.

 

Implications: The PPI-CC model provides a framework for understanding how strategic PPI impacts culture change. It calls for moving beyond fragmented evaluation of isolated domains towards integrated, system-level evaluation, and for viewing evaluation as not a one-time exercise but a continuous learning process that reveals what we, as individuals, groups, organizations, and systems, are doing well, where we fall short, and where we can improve.