Illustration 2 Working with PPI contributors to optimise the intervention based on PBA user feedback

STREAM (Screen and TREAt for Malnutrition) is a NIHR funded programme (RP-PG-0614-20,004) involving the development and evaluation of interventions to support screening and treatment of malnutrition risk within primary care, among older adults living in the community. Two interventions were developed: an online training tool for Health Care Professionals and a booklet-based intervention for older adults (aged over 65 years) to motivate and support change in eating patterns. The interventions were developed following the Person-Based Approach (PBA) to intervention development, alongside PPI input.

The STREAM project team included three PPI contributors, two of whom were involved from early stages of funding application with the third joining after funding was secured. All PPI contributors are fully integrated within the research team and are invited to attend all management meetings and input on all aspects of the intervention, alongside other members of the intervention development group including clinicians, psychologists, nutritionists, dieticians, nurses, and gerontologists. Our PPI contributors have been involved in various tasks, including:

• Developing intervention objectives

• Defining target user characteristics and intervention guiding principles

• Developing qualitative interview guides, participant information sheets, and consent forms

• Interpreting key messages from qualitative research and systematic reviews

• Intervention planning and design

• Commenting on all draft intervention materials

• Planning the feasibility trial of the intervention

Older adults’ reactions to and experiences of using the draft booklets were explored using qualitative think aloud interviews. The design and content of the booklets were optimised through an iterative process, with later participants viewing booklets that were revised based on earlier participants’ feedback. Data from qualitative participants were discussed with and considered alongside feedback from our intervention development team.

Early contributions from our PPI were crucial for enabling us to efficiently develop and refine first drafts of the booklets that provided nutritional advice more relevant to the experiences of older adults. In particular, our PPI contributors provided advice on enhancing the relevance of eating well in older adulthood (e.g. maintaining energy, strength and independence) and improving the communication of key messages (e.g. language, complementary imagery, branding).

Our qualitative research enabled us to seek further feedback from a wider range of target users who had additional, varied experiences contributing to their appetite and eating patterns (e.g. recent bereavements, health conditions, hospital stays etc.). It was clear from this qualitative research that the key messages within the booklet were received poorly by some participants. For example, advice on how much food and drink older adults needed to consume was perceived to be unrealistic and overwhelming, undermining any further engagement with the intervention. In discussion with our PPI contributors and intervention development team, we experimented with various language tweaks (e.g. rephrasing ‘meals’ as ‘bites’). After these tweaks, the key messages were received favourably by participants.

For STREAM, PPI contribution was critical for facilitating early intervention planning and development, and considering how best to optimise booklets based on user feedback. However, without additional qualitative research, we likely would not have identified and addressed the potential for poor engagement with the key intervention messages ahead of a feasibility trial.