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Why Study Public Health?

Why Is Public Health Important?

The field of public health plays a critical role in the promotion of health, prevention of disease, and empowerment of individuals to manage illness and disabilities. Every scientific finding, awareness campaign, and new policy has the potential to positively impact the lives of millions of people around the world . A unique blend of research, inquiry, and action, public health brings together people from across disciplines, backgrounds, and perspectives to discover the root causes of health problems and develop long-lasting, innovative solutions that improve everyone’s quality of life.

While the field of medicine traditionally aims to treat diseases and injuries, public health aims to proactively prevent them and keep populations healthy. In doing so, public health practitioners discover and share health interventions that ensure health and equity now and far into the future.    

What Will You Learn in a Public Health Degree Program?

In a public health degree program, you’ll learn how the conditions in the places where people live, learn, work, grow, and play affect their health outcomes. You’ll learn how public health professionals collaborate to uncover these conditions and build interventions that address them. Depending on your interests and passions, your coursework in Michigan Public Health’s six departments can explore the science behind the spread and control of disease, environmental impacts on human health, how policy and data can transform the health of populations, and the ways diet and nutrition shape our lives and our health. 

What Can You Do with a Public Health Degree?

A public health degree gives you the professional foundation and transferable skills you need to understand and work on a wide range of issues in a variety of industries and fields, including issues you see in the news every day, from COVID-19 to health care policy, firearm safety, and racism. Those with public health degrees keep communities healthy, protect workers, prevent and address pandemics, pursue social justice, drive public policy, spearhead disaster relief, ensure access to healthcare, and so much more. Public health professionals are at the forefront of research, practice, and service in nonprofits, community organizations, higher education, government, private industry, and health care. Discover jobs and careers in public health by learning more about our alumni .

Why Michigan Public Health?

As the #5 ranked school of public health in the US, we educate and train tomorrow’s public health leaders. Michigan Public Health students prepare to pursue positive, transformative change through engaging learning opportunities with top faculty, access to innovative laboratory and field settings, and community-based and entrepreneurial training. Our graduates join a community of 18,000 alumni and enter the world prepared to meet the challenges of a shifting landscape and anticipate where new challenges might arise.

What our students say about why they chose public health 

'Ready to do her part' in shaping a future with environmental health policy

Kate O’Brien, MPH ’24

Fulbright Scholar takes aim at sustainable food systems in Indonesia

Lala Fadila, MPH ’24

Internship in Kenya enriches Global Health Epidemiology personal journey

Christopher Floyd, BS ’21, MPH ’24

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Why I Chose Public Health

By Katie Freeland, MPH Global Health student

As an individual who has been raised in a privileged setting of private schools my entire life, I’ve had the opportunity to live in comfort. My parents have been able to provide for me, and I’ve never really had a lot of hardships. I realize that I am very blessed in this sense. I also realize that most of the world’s population is not as lucky as I am.

Before you get annoyed, I’m honestly not stating these things to brag or to sound callous. I’m stating them because I realize that I can use these opportunities to hopefully bring education, resources, and peace to individuals and groups of people–the marginalized–who have not been afforded the advantages that I have.

As a sophomore in high school, I had already figured out that I wanted to study communications and photography in college, and that’s exactly what I did. While studying at Southern Adventist University, I never changed my major (an amazing accomplishment in itself), and I was even able to gain a larger global perspective (and truly discover my love for traveling) when I spent nine months studying abroad in Florence, Italy my junior year.

In October 2012, less than a year after graduating with my B.S. in mass communication, I went on a life-changing mission trip to Haiti with Southern. I went as a photographer but I ended up doing so much more than taking pictures. I was able to help organize community clinics, helped gather and distribute supplies, and saw a total of nearly 200 children at the clinics. It was then I realized that, while I enjoyed working as a copywriter at an advertising agency (my first job out of college), I wanted to be able to focus my communication skills in the field of public health, specifically with nonprofits that help victims of human trafficking.

Coming from a communications background, I believe this has set me up to have a broad spectrum of interests. The global health track will give me an eclectic opportunity to delve into many topics of interest to me. In the last year of my undergraduate career and the year following, I became very interested in women’s health, access to health care, and human trafficking, along with many other human rights interests.

Another unique experience I was able to have in my undergraduate career was working for the Advancement and Development department at Southern for nearly three years. There I was able to witness fundraising and grant-writing from a first-person perspective. While I didn’t get to write grants as part of my job, I find that advancing my education in a public health school setting will give me this opportunity that I didn’t get a chance to have.

In the 2010-2011 school year, I was able to work for Asian Aid, USA, an NGO that helps women and children in India, Bangladesh, and Nepal with health education, human trafficking protection and relief, and builds schools for those in need. While I worked from the marketing and communications side of things, I realized that I wanted to be able to get involved more with the development and planning process. This was a great introductory time in my life to show me that I wanted to get involved with public and global health.

My goal with receiving an MPH is to work for an NGO, preferably one involved with human trafficking education, advocacy, and aid in all levels of the development process from beginning to end, and I am excited to begin my first year of my program at Loma Linda University School of Public Health.

Why Public Health

Collaborate to Transform Lives

The purpose of public health is to protect the health and improve the quality of life for all people. Public health is both a field of inquiry and an arena for action. It engages people from many different disciplines who work together to uncover the root causes of complex health problems and develop practical and cost-effective solutions.

Work on Large-Scale, Long-Term Solutions

Medicine helps individuals one-on-one when they are sick. The goal of public health, in contrast, is to prevent illness and injury, and to do so across large numbers of people through programs and actions that can reach hundreds, thousands, or even millions of people at a time. It is that multiplier effect that attracts many interested in health care and medicine specifically to explore an advanced degree in public health. A career in public health enables you to produce new knowledge, create powerful ideas, and collaborate with others to institute innovative—and frequently lower cost—solutions that will improve the health of large numbers of people locally, nationally, and globally.

Pursue a Passion for Public Service

Some students at the Harvard T.H. Chan School of Public Health already have advanced degrees in medicine, research, business, or law, but are looking to sharpen skills in areas such as biostatistics and epidemiology, and to learn new skills in areas as varied as health systems innovation, environmental health, or nutrition. Others who have no prior graduate degree want an educational program that will equip them to pursue a passion for public service in a health-related field at a high level in the U.S. or globally. Still others are looking to pursue health-related research careers. Graduates of the Harvard Chan School go on to work in hospitals, academic institutions, government, nongovernmental organizations, start-ups, pharmaceutical companies, consulting firms, and private businesses, pursuing their goal to improve the health of millions.

Learn Why Some of Our Students Chose Public Health

In our “Why Public Health?” series, we ask Harvard School of Public Health students to talk about why they chose to enter the field. Click on a student below to watch their video.

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Why Choose Public Health?

You have passion for building bridges to a healthier world through science-based knowledge and community service. You and your like-minded peers can powerfully transform not only your community, but our world. Now, more than ever, public health graduates are positioned to fill a growing need for caring individuals with solution-based initiatives that are grounded in health equity. Public health researchers, policy makers, program leaders and educators play a critical role in improving the lives of our global society.

Find Your Fit.

Public health is grounded in empathy. Your work will address broad issues that affect the health and wellbeing of individuals, families and populations today — and for generations to come. These valuable programs lead to increased life expectancies, improved quality of life and the reduction of diseases.

Fields of Study

Our faculty, staff and students collaborate on public health research and practice projects, both independently and through school-established centers.

Whether you like to analyze data, conduct research, formulate policy or focus on communities by working directly with people, there is a place for you in public health.

Pitt Public Health is proud to be an accredited institution by the Council for Education on Public Health (CEPH). Learn more about what sets us apart. 

Picture Yourself at Pitt Public Health

As a student at Pitt Public Health, you'll find a diverse community situated alongside a world-class medical center, a vibrant urban campus and plenty of green space. You'll enjoy all the amenities of a large university — but with a student-to-faculty ratio that feels like a smaller college.

Find out all the ways Pitt students and the surrounding communities eat, play, and live life to the fullest in the city of Pittsburgh .

Participate in the school's decision-making processes by serving as a representative with one of our standing committees or student organizations .

Celebrate student accomplishments at our annual Dean's Day event by presenting a research project and competing for monetary prizes or become involved in our One Book, One Community initiative.

Our students come from across the globe. Find opportunities to engage with students and faculty from a multitude of disciplines and professions through ongoing collaborations with the University of Pittsburgh Medical Center.

What is Public Health and why is it important?

Studying Public Health at BCU equips you with the knowledge, understanding and skills required to carry out important public health work. But what actually is Public Health, and why is it so important? Student Naima shares why it's crucial to our society, as well as rewarding to be part of.

Firstly, what is Public Health?

Put simply, public health focuses on helping individuals and the community stay healthy, and preventing them from threats to their health. It involves both the prevention and improvement of peoples' health. Whilst public health is a clinical medical specialism, you do not need to be a doctor or nurse to work in public health.

Below, find out Naima's eight reasons to why it's so important, and why we constantly need more people working within the public health sector.

1. Fighting diseases

Public Health studies plays a major role in fighting off the biggest killers of humans. Public Health professionals, who have either studied a Public Health degree or Health Studies related course, are constantly battling against diabetes, cancer, heart disease and dementia to maintain the health and well-being of the population.

2. Prevention before cure

Another fundamental quality of Public Health is its preventative nature. Prevention is far more effective and far less expensive than cure.  Public Health helps detect health issues as early as possible and responds appropriately to avoid the development of disease.

3. Longer lives

Public Health is important due to aiding and prolonging life. Through the prevention of health issues, individuals can spend more of their years in good health.

4. Diversity and equality

Public Health is important because its constantly striving to close the inequality gap between people and encourage equal opportunities for children, all ethnicities and genders.  It also takes into account the health of the whole population, rather than focusing on health at an individual level.

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5. Hazard awareness

Public Health is important as it ensures everyone is aware of health hazards through educational programmes, campaigns and through influencing government policies. An example of this is the nationwide Stop Smoking campaigns, which provides resources for individuals to learn about the effects of smoking as well as plans for them to stop smoking.

6. Health is a human right

Health is a human right and Public Health professionals ensure no one is disadvantaged, regardless of their socio-economic background.

7. A voice for the people

Public Health is important because you become the voice for individuals who have no voice and simply put, your influence on the improvement of someone’s health can be a great satisfaction.

What should you do next?

Come to a postgraduate open event.

Our campuses have a real buzz about them, at our Open Events, you’ll have the chance to experience it for yourself. See where you could be attending lectures, getting on with independent study and meeting fellow postgrads for a coffee.

Download our postgraduate guide

Our Postgraduate Guide provides details of all our postgraduate taught and research courses. It also provides information about the research environment at Birmingham City University

Apply for a course

So, you’re interested in applying for postgraduate study? Here’s a step-by-step guide covering all you need to know to apply. Unlike undergraduate degrees where you will apply via UCAS, you can apply straight to the University for a postgraduate degree.

Get advice on your personal statement

Not sure what's required of you in a postgraduate personal statement? Don't worry, our guide has top tips, examples from real students and all the guidance you'll need.

View our on-demand webinars

Taking a postgraduate course is a big investment in your future, and you’ll want to be sure that you’re choosing the right course and the right university. Our on-demand webinars will provide you with useful information and answers to any questions you may have.

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Writing Guide

Writing serves as a useful skill for anyone in the field of public health — students and professionals alike. Public health students must enroll in writing-intensive courses that require essays and research papers. Once students graduate, they put their skills to use writing reports on community health. They may compose presentations, research studies, or press releases, depending on their jobs. Those who stay in academia continue to write research papers throughout their careers.

Students should begin cultivating a clear and concise writing style long before they graduate.

They should also learn how to use standardized citations. Understanding how to properly cite sources will help students as they conduct research and publish their findings. Citations also help students and researchers avoid plagiarism.

This guide explains how to write a public health report, a research paper, and an exam essay. The page also advises students on how to conduct research online and find trustworthy sources. Students can review citation style guides and public health writing samples.

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Types of writing public health students will do in school, personal statements.

When applying to a public health program, schools often require students to submit personal statements. Schools may either ask students to write a general personal essay answer a certain prompt. Usually, prompts center around applicants’ interest in public health or about the public health field in general. Students might come across a prompt similar to this one: “Identify a public health issue in the U.S., and how you would work to rectify it as a public health professional.” Alternately, students may encounter this common topic: “What drove you to pursue a career in public health?”

Schools look for essays that are honest, well-written, and well-organized. Students should get the reader’s attention with an anecdote illustrating their commitment to public health. Was it an experience with adversity or discrimination that prompted you to pursue this career? Did you learn about the importance of public health while volunteering or traveling? Include those details in the story.

Students should also demonstrate their current knowledge of public health. They may write about their career goals as well. However, students should avoid writing exaggerations, falsehoods, or superlatives. People who read admissions essays can typically sense when applicants are stretching the truth. If the school makes the personal statement optional, students should still consider writing one. A personal statement demonstrates commitment and hard work, and may help make up for flawed or weak admissions materials.

In some public health courses, professors require students to answer essay questions during exams. This can be intimidating since students do not usually know the prompt until they actually start the exam. Students have a limited amount of time to write the essay, typically one or two hours. Students should allot their time accordingly. Some students do not plan their work before they begin writing; this can lead to sloppy essays with weak supporting points, disorganized information, and tangents unrelated to the prompt.

For a 60-minute time frame, students may give themselves 10 minutes to brainstorm, plan, and outline.

During the brainstorming process, students should write their thesis statement.

Then they should jot down three points that support the thesis. These ideas will serve as the three body paragraphs. Students may give themselves five minutes to write the introduction, 30 minutes to write the body, and then five minutes to write the conclusion. They then have 10 minutes to proofread. Students often inadvertently miss this step, but proofreading may make or break the essay.

Students should begin planning long before the day of the essay. Students ought to review the material well enough to be prepared for any prompt. They should carefully look over their lecture notes to determine which points the professor emphasized during classes. These points will likely prove significant when it comes time for the exam. Students should also make sure that they actually answer the prompt instead of rushing and jumping to assumptions.

Research Papers

In a research paper, students examine the existing research, theories, case studies, and ideas about a particular topic. Students have several weeks to write research papers, which may seem like a huge amount of time. However, research papers demand a lot of work, so students should start early. Professors rarely assign strict, narrow prompts for research papers. Instead, they usually give students a topic or range of topics, and students choose their focus. Public health topics may include how poverty or race affects access to healthcare; opioid abuse; the social consequences of HIV/AIDS; childhood obesity; or maternal mortality in third world countries.

Students should start by brainstorming a list of points and ideas they will investigate. Then comes the most time-intensive and significant part of a research paper: the research itself. Students ought to use multiple different resources to help them craft their arguments. Options include online databases, academic journals, and their college library. Make sure you keep track of citations and sources as you go.

Students should also make sure their essays are well-structured. A well-written thesis unites the main points of the paper. Unlike essays, research papers usually include more than five paragraphs. Students may break down their arguments into different sections. A research paper must include a works cited or bibliography that credits all sources. The exact length of the paper and number of sources depends on the professor’s expectations.

Over the course of their academic careers, public health students write many kinds of essays. Professors often assign persuasive essays, in which the student must make a convincing argument; expository essays, in which the student explores and explains an idea; narrative essays, in which the student tells a story; comparative essays, in which the students analyzes two different viewpoints; and cause and effect essays, in which the student must explain the logic behind why certain events or phenomena occur.

• Narrative: In a narrative essay, the author tells a meaningful story. Studying public health, you probably won’t write many narratives. However, narrative essays can support an argument or prove a point. For instance, if you argue that every community should have a free clinic, you might tell a personal story about your experience growing up in a low-income neighborhood with no access to healthcare. Make sure your essay demonstrates a clear plot, follows an organized structure, and includes many details.
• Expository: When professors assign expository essays, they expect students to explain or describe a concept. These essays help professors evaluate whether students have a firm grasp on a topic. Expository essay often include five paragraphs: an introduction with a thesis statement, three main points backing that thesis statement, and a conclusion. Students should do plenty of planning and research before writing to ensure they adequately address the prompt and include enough evidence.
• Persuasive: Persuasive essays appear commonly in academic assignments. Students first develop an argument as a thesis statement. Then, they generate a cogent defense of that argument by researching supporting evidence. Students should be able to anticipate arguments against their thesis statement and include counterpoints. In persuasive essays, students not only demonstrate their knowledge of the course material, but also prove their critical thinking skills by developing their case.
• Comparative: A comparative essay requires students to compare and contrast two ideas, viewpoints, or things. For example, public health students may compare two texts, theories, public health systems, or positions on an issue. First of all, students should create a list of similarities and differences between the two items. After that, they can develop a thesis statement on whether the similarities outweigh the differences or vice versa. Finally, they should organize the essay. They can either defend their thesis statement by listing each point of comparison, or they can split the essay in half by discussing subject one and then subject two.
• Cause and Effect: These essays require students to explain how one event or theory leads to a specific consequence. For instance, a public health student might argue that abstinence-only education in public schools leads to a higher rate of teenage pregnancies. Students should remember that just because one event follows another, those two events do not necessarily influence one another. In other words, correlation does not equal causation. In the analysis portion of the essay, students must explain specific reasons why they think the two events are connected using data and other evidence.

Citations Guide for Public Health Students

In public health writing, just as any other discipline, students must cite their sources. If students use ideas, theories, or research without crediting the original source — even unintentionally — then they have plagiarised. An accusation of plagiarism could follow the student throughout their education and professional career. Professors may fail students who plagiarise, sinking their GPA. Plagiarism accusations can also ruin a student’s credibility. Fortunately, students can avoid plagiarism by properly giving credit for their data and ideas. Common citation styles include those listed below.

American Psychological Association (APA) Style

Students in the social sciences use APA style when writing their essays and research papers. Business and nursing students also commonly use APA style. APA prefers active voice over passive voice, as well as concise language over flowery words. Research papers written in APA style should include a title page, abstract, and a reference page. In-text citations list the author’s name, year of publication, and page number if applicable. Below is an example of how to cite a source using APA style.

In-text citation:

In Milwaukee, poor neighbourhoods were segregated by design (Desmond, 2017, p. 249).

On the works cited page:

Desmond, M. (2017). Evicted: Poverty and profit in the American city . London: Penguin Books.

Chicago Manual of Style (CMS)

History students and students of the natural sciences typically use Chicago, or Turabian, style in their research. Papers written in Chicago style include three sections: the title page, the main body, and a references page. This style also uses footnotes to source information and provide more context. In-text citations list the author’s name, the date of publication, and the page where the student found the data. Unlike APA style, though, the in-text citation does not use a “p.” before the page number. See the example below:

In Milwaukee, poor neighbourhoods were segregated by design (Desmond 2017, 249).

Desmond, Matthew. Evicted: Poverty and Profit in the American City . London: Penguin Books, 2017.

Modern Language Association (MLA) Format

Students of the humanities — including literature, foreign languages, and cultural studies — use MLA style in their research papers. Unlike APA and Chicago style, MLA style does not require students to add a title page. MLA papers also do not include an abstract. Students only need to include the paper itself and a works cited page that corresponds with in-text citations. When adding citations in the body of the text, MLA includes the author’s last name and the page number in parentheses. This style does not list the publication year. You can find an example of MLA citation below:

In Milwaukee, poor neighbourhoods were segregated by design (Desmond 249).

Associated Press (AP) Style

Journalists use Associated Press, or AP style, in their work. AP style standardizes grammar and spelling usage across news media and mass communications. Students rarely use AP style, unless they are writing an article in their subject area for a newspaper or magazine. AP style prioritizes brevity and conciseness above all else. Therefore, it includes several rules that differ from other writing styles. For instance, AP style eliminates the last comma in a list of items (for example: “She dressed in capris, a tank top and sandals”). Since students and professors do not use AP style for academic papers, AP style does not include a reference page like other style guides. Instead, AP style simply uses non-parenthetical in-text citations.

“People who live in low-income communities lack opportunities to exercise,” said Lydia Homerton, professor of public health at Hero College.

The Best Writing Style for Public Health Majors

Professionals in the public health field use APA, the most common style in the social sciences. Professors expect students to use APA style as well. Public health research follows a standardized system of citing sources, making it easier for students and professionals in the field to conduct further research. Students should add a title page and abstract before the essay, as well as a list of references in the back.

Common Writing Mistakes Students Make

Active vs. passive voice.

When writing essays and research papers, students should use active voice and avoid passive voice. Learning the difference between passive and active constructions can be tricky. First of all, students should be able to identify the subject in a sentence. The subject is the noun performing an action. Take this sentence: “The woman catches the keys.” In this case, the woman is the subject of the sentence because she is the one performing the action, catching. The sentence “The woman catches the keys” is active because it focuses on the subject and the action. You can identify an active sentence by checking if the first noun is a subject performing an action.

By contrast, examine this sentence: “The keys were caught by the woman.” The first noun, “keys,” is not performing an action. Instead, it is being acted upon. The subject performing the action — the woman — is at the end of the sentence and not the beginning. This sentence uses passive voice instead of active voice. Some passive sentences do not include a subject at all. For example, “The keys were caught.”

Active voice makes writing more concise and easy to understand. Active sentences often include more information, especially about the subject performing an action. In research papers, students should use active voice whenever possible. However, sometimes it is clear that the author is the one performing the action, so active voice is not necessary. For instance, a researcher might write “the experiment was conducted Friday” instead of “I conducted the experiment Friday.”

Punctuation

Incorrect punctuation confuses readers. The wrong punctuation can change or obfuscate the meaning of a sentence, paragraph, or the entire essay. Publishers, professors, and other researchers often look down on papers with incorrect grammar, even if the content includes important or accurate research. Consequently, students should always use proper grammar in their essays.

The wrong punctuation can change or obfuscate the meaning of a sentence, paragraph, or the entire essay.

While students make many different errors with punctuation, most common errors revolve around colons and commas. Understand the difference between colons and semicolons. Both punctuation marks separate two parts of a sentence. Students should use colons when introducing a list. (“He ate lots of meat: pork, chicken, steak, veal, and duck.”) Colons can also introduce an appositive or new idea. (“She finally gave him the gift: a new computer.”) Semicolons, on the other hand, connect two complete, independent sentences. These sentences should be separate but related. (“He ate a lot of meat; he was ravenous.”)

Students should also take care to avoid comma splices. A comma splice occurs when writers connect two independent sentences using a comma. The following sentence includes a comma splice: “She danced with her boyfriend, he was very clumsy.” Instead, students could add an “and” to connect the two sentences. (“She danced with her boyfriend, and he was very clumsy.”) Alternately, writers could connect the sentences with a semicolon. (“She danced with her boyfriend; he was very clumsy.”) Lastly, writers could separate the two sentences with a period.

Proper grammar helps readers understand your essays. Proper grammar also gives your essay credibility. If you have a perfectly-argued essay, but your paper includes multiple grammar mistakes, the reader will likely be skeptical of the entire argument.

Understand the difference between there/their/they’re. “There” refers to a place. (“The dog is over there.”) Their shows possession. (“This is their house.”) “They’re” is a contraction for “they are.” (“They’re eating at the diner.”)

Also learn the difference between it’s and its. “It’s” is the contraction for “it is.” (“It’s hot outside.”) “Its” shows possession. (“The bird eats in its cage.”)

Make sure your sentences include proper subject-verb agreement. In other words, if the subject of a sentence is plural, the verb should also be plural. For example, use “The boy and his sisters are eating breakfast” instead of “The boy and his sisters is eating breakfast.”

Writing Resources for Public Health Students

• Guide to Improving Scientific Writing in Public Health : This guide from the World Health Organization and the Pan American Health Organization teaches students how to write about complicated scientific material in a way that’s easy for readers to understand. The guide includes tips on vocabulary and format.
• Argument, Structure, and Credibility in Public Health Writing : Written by a professor at Harvard’s School of Public Health, this essay breaks down how to make effective arguments in public health writing. The page includes flow charts and figures to help illustrate exactly how public health essays should be organized.
• Purdue Online Writing Lab APA Style Guide : Purdue’s Online Writing Lab includes style guides for all writing and citation styles, including APA. The style guides help students understand how to format papers, use in-text citations, and create reference pages.
• Award-Winning Health Articles : One of the best ways to improve your writing is to read good examples. This page lists nine award-winning public health writing samples.
• The Women’s and Children’s Health Policy Center Writing Skills Guide : This website links to several modules on writing public health documents. Lessons include policy briefs and memos.

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Home — Essay Samples — Life — Career Choice — Why I Chose Public Health: A Path to Fulfillment and Impact

Why I Chose Public Health: a Path to Fulfillment and Impact

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About this sample

Words: 696 |

Published: Sep 7, 2023

Words: 696 | Pages: 2 | 4 min read

Table of contents

A desire to address health disparities, promoting preventive health measures, furthering education and research, contributing to policy and advocacy, fulfillment and reward in public health, conclusion: a journey of purpose.

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Building Bridges between Health Care and Public Health: A Critical Piece of the Health Reform Infrastructure

Nicole lurie.

RAND Corporation, 1200 South Hayes St., Arlington, VA 22202-5050, Phone: 703-413-1100 x. 5127, Fax: 703-413-8111

Allen Fremont

RAND Corporation, 1776 Main Street, Santa Monica, CA 90401-3208, Tel: 310-393-0411 x.7569, Fax: 310-393-4818

Medicine and public health have been likened to trains on parallel tracks -- with windows facing opposite directions, looking out on the same landscape. As described by HHS Secretary Donna Shalala, those on the medical train see the individual trees: the subtle differences in size, color, age and health. Those aboard the public health train see the forest: populations of similar trees, growing together and weathering the same storms. 1 While the two have potentially complementary perspectives, efforts to improve care – as well as personal and population health – are hampered by lack of communication and coordination between medical and public health professionals and fragmented data systems. Differing perspectives and disconnected data have also hindered effectiveness of shared efforts between health professionals and other stakeholders, including community-based organizations and health plans. While the call for greater synergy between health care and public health is hardly new, emerging technologies and the urgent need for health reform create the opportunity and imperative for them to come together.

The view from the health care side

Progress toward improving healthcare quality and outcomes in the U.S. remains slow. Even within managed care plans, quality often remains unacceptably low, particularly for chronic disease and among certain minority and low-income enrollees. 2 While the reasons for this are complex, it is increasingly clear that the current configuration of health care delivery, with its emphasis on brief encounters with physicians or calls from disease managers, is insufficient. Patients are usually treated as isolated individuals, not as members of a community whose characteristics may affect their health.

Most health plans and providers look at populations they serve in broad demographic terms and administrative categories, such as by age, race, diagnosis, or payer, rather than in terms of the communities in which they live. While health plans are expected to manage the care and health of members, key decision makers typically have only limited data about the communities their members come from. Available data are usually presented in tables and charts that may obscure clusters or “hotspots” of low quality care concentrated within a few neighborhoods and typically ignore local factors that may contribute to those hotspots. Similarly, while physicians are implored to ‘treat their communities, 3 even providers in comprehensive “medical homes” with electronic medical records generally lack tools to help them see how and where groups of their patients may cluster. Consequently, regardless of their cultural competence or patient centeredness, busy providers (and insurers they contract with) often fail to recognize instances when characteristics of a local community, such as lack of grocery stores or safe places to exercise, may be impacting a significant subgroup of their patients.

The view from the public health side

The data available to public health professionals have also been far from optimal. While most health departments have detailed information about the demographic distributions of their populations, there is often little information available about health indicators for these populations and how these are distributed within jurisdictions. With the exception of information derived from vital records or from reportable infectious diseases, most information available to local public health providers is at the county level or higher, rather than the community level. This includes data about the risk factors for, and the burden of, chronic disease. While public health officials can sometimes obtain data from safety net providers on chronic conditions among their patients, they typically lack access to data from users of the rest of the health care system.

In short, fragmented clinical and public health data and gaps in how they are shared among health care and public health professionals means that each group typically lacks salient and actionable data to maximize health of the populations they serve. This leads to widely differing views of the problem, risks misinformed decisionmaking, and limits opportunities to identify how and where community and public health efforts might supplement the care of individual patients in the office setting or, conversely, how medical care can help address thorny public health problems.

Other views

This disconnect between medicine and public health stands in stark contrast to approaches now routinely used in basic science research, such as genomics and proteomics, where shared efforts and infrastructure across multiple disciplines and across public and private sectors are helping to accelerate growth and disseminate knowledge and tools to overcome complex challenges that previously seemed insurmountable. Similar breakthroughs are occurring in the social sciences. For example, new information technologies are facilitating integration of information about neighborhood environments, population characteristics, and their associated health outcomes, in ways that are rapidly advancing understanding of how neighborhoods impact health. That work, in turn, is increasing health care sector recognition of the importance of community level factors in primary and secondary prevention.

Bridging the gaps

We are optimistic about the potential to coordinate health care and population health approaches. While in medical care and public health, the large scale deployment of health information technology is not yet a reality, existing GIS and web technologies widely used in other fields can help link inpatient and outpatient care; health care and public health information; communities and the health care system in the ways that support a population health approach that is synergistic with patient-centered care. There is also a strong foundation of knowledge about use of GIS tools within both the health care and public health sectors on which to build. Studies of small area variation in hospital and physician markets and practices, for example, have advanced our understanding of health care financing and quality of care. Mapping important public health outcomes, such as variations in life expectancy and the burden of chronic disease have shown county level variation in these outcomes. Our own experience is that visual displays of data with maps and related decision tools can serve as a ‘universal language’ making complex data understandable-and actionable-for diverse stakeholders in the health care system, public health, and communities. They can also act as a ‘disruptive innovation,’ facilitating new insights into how community factors can influence health outcomes and highlighting specific opportunities for shared action between medical, public health, and other local stakeholders to address them as part of routine, comprehensive care.

Several efforts to analyze and map health care data highlight geographically aggregated health problems that require both personalized and population level action. For example, mapping hospitalizations for ambulatory care sensitive admissions such as for asthma or cellulitis, suggest geographic small areas in which community-level intervention is needed. 4 , 5 , 6 , 7 The National Health Plan Collaborative, a group of health insurers aiming to reduce disparities in care, has noted very small area variation in quality of care for racial/ethnic population groups. 8 By geocoding the addresses of enrollees and linking them to quality of care data, plans can use GIS tools to highlight ‘hot spots’ of poor quality, including information regarding racial/ethnic populations. Some have explored the role of local factors that can inform interventions, such as linguistic isolation or access to primary care providers.

Figure 1 illustrates how spatial displays of health care data can help target population level interventions. Panel 1 shows the residential location of all diabetics in a health plan. Based on a review of data, the plan had determined that Hispanic members with diabetes were less likely to receive LDL testing, and was contemplating sending a mass, Spanish-language mailing to all Hispanic members with diabetes, reminding of the importance of lipid testing. Using simple GIS approaches, the plan first mapped the distribution of its diabetics in a predominantly Hispanic region. It then focused in on a small area or “hotspot” with a large number of Hispanic diabetic members who had not received LDL testing. Then, by incorporating census-derived information, the plan was able to quickly determine that the neighborhoods in which most of these members lived was not particularly low income, as was initially assumed, but it was linguistically isolated. As a result, the plan determined that it was more efficient to focus resources on a language-appropriate intervention in that particular area. It also had new information it could share with the local health department, and local community groups who were also working to improve diabetic health outcomes in the area. In short, leveraging and mapping data on risk factor control within the delivery system can help identify and prioritize local geographic areas for action, foster collaboration between the health care system, public health departments, and local community groups while helping all stakeholders more efficiently focus their resources in areas of greatest need.

However, any given health plan (or provider) has data on only a small proportion of the population; combining data from multiple payors or providers in an area is likely to paint a more accurate picture. In California’s Right Care Initiative 9 leading health plans, provider groups, public health officials, and regulators, are using mapping and decision tools to identify low quality “hotspots” in communities served by participating plans. Once identified, additional analyses of local factors and resources will be used to plan and coordinated share action among diverse stakeholders, including competing plans, in ways that might not be feasible otherwise.

Without a doubt, efforts to integrate health care and public health must go well beyond mapping. Suggestions for doing so have been well articulated by others. Meanwhile, health reform legislation can facilitate some immediate steps. For example, all federally collected health-related data should be geo-enabled to facilitate mapping. Second, health care claims, including those from Medicare and Medicaid programs, should be geocoded and aggregated at the smallest possible level that preserves individual confidentiality. HHS might provide guidance on the kinds of data would be most useful to geocode (e.g. hospital discharges or quality measures). Health departments, business coalitions or others might request that such data be aggregated across all payors and providers, both public and private, in their jurisdictions. These steps could help foster and sustain local experimentation in using mapping and related decision tools to identify populations and locations with the greatest needs, and to develop ‘promising practices’ and incentive structures for getting the health care system, public health system and others working together.

The planned investments in health IT will likely lead to further innovation in ways to linking public health and health care data, including through automated disease reporting. Related comparative effectiveness research, at the delivery, system, and community level, can then examine whether models that integrate individual and population level care do indeed achieve better outcomes at lower cost. All this will likely take several years to implement, however. In the meantime, greater use of available GIS tools available that can integrate and display diverse types of data from many sources can help begin realigning the tracks in ways that will give those on the medical and public health trains a similar view.

Financial Disclosures: None reported.

Contributor Information

Nicole Lurie, RAND Corporation, 1200 South Hayes St., Arlington, VA 22202-5050, Phone: 703-413-1100 x. 5127, Fax: 703-413-8111.

Allen Fremont, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401-3208, Tel: 310-393-0411 x.7569, Fax: 310-393-4818.

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• Grad School
• Sample Essays
• The Public Health Student

What if people lived healthier lives, practiced preventive medicine, and took precautions against illness and disease? My days in the physical therapy department often made me think about the prevention of injuries as well as the injuries themselves. I was already doubting my future career choice as a physical therapist. Although I loved the science of it and helping people, the lack of variety within the field and its limited options for growth bothered me. I needed a career that helped a large number of people, emphasized prevention and primary care rather than tertiary care, and would continually challenge and motivate me to improve. Knowing that I really did not want to pursue physical therapy as I had originally planned, my thoughts wandered to the area of public health, particularly health management.

My first true introduction to the public health arena came in a class offered through the Big U School of Public Health. As I listened to experts speak about contemporary health issues, I was intrigued. The world of "capitation," "rationing of care," and Medicaid fascinated me as I saw the range of problems that public health professionals were trying to solve in innovative ways. This one semester class provided me with a basic but thorough understanding of the issues faced in health care today. In the last two years I have continued to learn about public health both through coursework and work in the field.

Because field experience is such a valuable learning tool, I searched for a research assistant position that would allow me to view public health at a different level. I worked on a project at a county health clinic in Englewood, a low-income, minority community. The program attempted to increase treatment compliance rates for adolescents diagnosed with tuberculosis who must complete a six-month medical program. Working for the county exposed me to a different side of health care that I had previously seen. Service and organization were not assets of the county and yet its role in the public health "ecosystem" was and is critical. Its job of immunizing thousands and interacting with all members of the community is often forgotten, but is important for keeping an entire community healthy.

My work at the county health clinic as well as my knowledge of some areas of public health led me to accept an internship in Washington D.C. this past summer. The internship provided me with a greater understanding of a federal public health agency’s operations and allowed me to contribute in a variety of ways to the XYZ Department in which I worked. Most importantly I worked on "policy issues" which involved identifying and summarizing problems that were out of the ordinary as well as documenting resolved issues in order to establish protocols to increase the department’s efficiency. In addition I served on a scientific review panel which was responsible for editing a seventy-page proposed regulation before its submission.

Along with my duties at XYZ, I attended seminars and met with public health leaders at different functions and events. All these activities confirmed my growing interest in preventive medicine, outcomes and effectiveness, and quality of care, particularly within the private/managed care sector. These are my strongest interests because I believe they are fundamental to our nation’s health. We must achieve efficiency and access without sacrificing quality.

The University of ____ would help me achieve my goals of furthering my public health education through the specialized coursework offered as part of its health administration program. [The client provides specifics here about the program’s specific appeal and strengths]

Since rejecting physical therapy as a career possibility my interest in public health has only grown. I welcome the challenge of serving a large community and participating in such a dynamic and challenging field. What if an aspirin a day could prevent heart attacks? What if abandoning unnecessary procedures saved thousands of dollars, which then allowed a hospital to treat other patients needing care? What if every person was guaranteed care and that care was good? I would like to find answers for these questions during my career as a public health graduate student and professional.

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Guest Essay

Doctors Need a Better Way to Treat Patients Without Their Consent

By Sandeep Jauhar

Dr. Jauhar is a cardiologist in New York who writes frequently about medical care and public health.

Not long ago, I took care of a middle-aged man at my hospital who had severe heart failure requiring life support. When he was disconnected from machines after a few days of treatment, he began to display psychotic symptoms, including delusional thinking, tangential speech and paranoia. He had a long history of untreated schizophrenia, I learned, which had estranged him from family members and friends, with whom he had virtually no contact.

My patient demanded to leave the hospital. However, sending him home was going to be a problem. He could not take care of himself. There was little chance he would take his medications, including a blood thinner to dissolve a clot in his heart before it caused a stroke. He was even less likely to take psychiatric drugs that he did not believe he needed.

My colleagues and I didn’t know what to do, so we called the treating psychiatrist. The psychiatrist immediately declared that our patient lacked the capacity to discharge himself from the hospital. The patient could not grasp the implications of this choice, for instance, or properly weigh its risks and benefits. The psychiatrist said the patient should remain in the hospital to receive psychiatric treatment, even against his will.

The psychiatrist’s opinion made sense to me. Patients with untreated schizophrenia have a higher rate of death than those who undergo treatment. Hopefully treatment would restore my patient’s judgment to the point where he would take his medications when he went home — or even decide not to take them, but to make that risky decision in the full appreciation of the likely consequences. (If autonomy means anything, it means that patients have the right to make bad decisions, too.) Treating him, even over his objections, seemed to be in his best interests.

However, according to New York law — and the law of other states — such involuntary treatment would require a court order. As doctors, we would have to plead our case before a judge. But was a judge without medical or psychiatric expertise the best person to decide this man’s fate?

In this case and also more generally, I think the answer is no. The law ought to be changed to keep such decisions in hospitals — in the hands of doctors, medical ethicists and other relevant experts.

Doctors don’t always have to resort to the courts to treat patients without their consent. There are some notable exceptions, such as during a life-threatening emergency (if a competent patient has not previously refused such treatment) or when there is a pressing societal interest (such as requiring patients with communicable tuberculosis to take antibiotics).

But judicial review has been the cornerstone of “treatment over objection,” as it’s known, for the past four decades or so. Appellate courts in the 1980s ruled that judicial hearings in such cases are needed to safeguard patients’ rights. For example, in 1983, in Rogers v. Commissioner of Department of Mental Health, the Massachusetts Supreme Judicial Court declared that a judge could override medical judgments favoring involuntary psychiatric treatment.

The underlying motivation behind judicial review was and remains laudable: to avoid the sort of paternalistic abuses that have characterized too much of medical history. Doctors often used to withhold bad news from patients, to cite just a small example. Involuntary treatment, even with benevolent intentions, reeks of such paternalism.

But though medical practice is by no means perfect, times have changed. The sort of abuse dramatized in the 1975 movie “One Flew Over the Cuckoo’s Nest,” with its harrowing depiction of forced electroconvulsive therapy, is far less common. Doctors today are trained in shared decision-making. Safeguards are now in place to prevent such maltreatment, including multidisciplinary teams in which nurses, social workers and bioethicists have a voice.

In addition to being less necessary to prevent abuse than they once were, courts are by nature poorly suited for making decisions about treatment over objection. For one thing, they are slow: Having to go to court often results in delays, sometimes up to a week or more, which can harm patients who need care urgently.

Moreover, judges have neither the experience nor the expertise to properly evaluate psychological states, assess decision-making capacity or determine whether a proposed treatment’s benefits outweigh its risks. It is no surprise that by some estimates 95 percent or more of requests for treatment over objection are approved by judges, who invariably haven’t met the patient and must rely on information provided by the treating medical team.

A better system for determining whether a patient should be treated over his or her objection would be a hospital hearing in which a committee of doctors, ethicists and other relevant experts — all of whom would be independent of the hospital and not involved in the care of the patient — engaged in conversation with the medical team and the patient and patient’s family. Having hearings on site would expedite decisions and minimize treatment delays. The committee would make the final decision.

Of course, such a committee would have to be granted immunity from legal liability (as with judges in our current system), so that experts would be willing to serve and speak candidly. Patients’ interests could be safeguarded by requiring the committee to publish its reasoning. Periodic audits by a regulatory body could ensure that the committee’s deliberations were meeting medical and ethical standards.

In the event that the committee could not reach a consensus on the best course of action (or if there were allegations of wrongdoing), then the parties involved could appeal to a judge. But that would be the exception rather than the rule.

In the case of my patient with heart failure, the decision ultimately didn’t have to go before a judge. Multiple discussions involving the patient, the hospital ethics and palliative care teams, social workers, nurses, psychiatrists and other doctors — discussions that in many respects served the function of a formal committee of the sort I’m proposing — yielded an agreement with the patient that his interests would be best served by sending him home with hospice care.

Capacity must be judged relative to the decision being made, and it became clear over the course of hospitalization that our patient understood the terminal nature of his condition and had the capacity to choose hospice care. Forced treatment was unlikely to significantly improve his psychiatric symptoms before the natural progression of heart failure caused his death.

So he was discharged home. It was the best decision under the circumstances, one reached by expert deliberation, not legal procedure. He passed away a few weeks later without, fortunately, ever setting foot in court.

Sandeep Jauhar ( @sjauhar ) is a doctor at Northwell Health in New York and the author, most recently, of “ My Father’s Brain : Life in the Shadow of Alzheimer’s.”

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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• Open access
• Published: 13 May 2024

What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review

• Olivia R. Phillips 1 , 2   na1 ,
• Cerian Harries 2 , 3   na1 ,
• Jo Leonardi-Bee 1 , 2 , 4   na1 ,
• Holly Knight 1 , 2 ,
• Lauren B. Sherar 2 , 3 ,
• Veronica Varela-Mato 2 , 3 &
• Joanne R. Morling 1 , 2 , 5  

Research Involvement and Engagement volume  10 , Article number:  48 ( 2024 ) Cite this article

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There is increasing interest in using patient and public involvement (PPI) in research to improve the quality of healthcare. Ordinarily, traditional methods have been used such as interviews or focus groups. However, these methods tend to engage a similar demographic of people. Thus, creative methods are being developed to involve patients for whom traditional methods are inaccessible or non-engaging.

To determine the strengths and limitations to using creative PPI methods in health and social care research.

Electronic searches were conducted over five databases on 14th April 2023 (Web of Science, PubMed, ASSIA, CINAHL, Cochrane Library). Studies that involved traditional, non-creative PPI methods were excluded. Creative PPI methods were used to engage with people as research advisors, rather than study participants. Only primary data published in English from 2009 were accepted. Title, abstract and full text screening was undertaken by two independent reviewers before inductive thematic analysis was used to generate themes.

Twelve papers met the inclusion criteria. The creative methods used included songs, poems, drawings, photograph elicitation, drama performance, visualisations, social media, photography, prototype development, cultural animation, card sorting and persona development. Analysis identified four limitations and five strengths to the creative approaches. Limitations included the time and resource intensive nature of creative PPI, the lack of generalisation to wider populations and ethical issues. External factors, such as the lack of infrastructure to support creative PPI, also affected their implementation. Strengths included the disruption of power hierarchies and the creation of a safe space for people to express mundane or “taboo” topics. Creative methods are also engaging, inclusive of people who struggle to participate in traditional PPI and can also be cost and time efficient.

‘Creative PPI’ is an umbrella term encapsulating many different methods of engagement and there are strengths and limitations to each. The choice of which should be determined by the aims and requirements of the research, as well as the characteristics of the PPI group and practical limitations. Creative PPI can be advantageous over more traditional methods, however a hybrid approach could be considered to reap the benefits of both. Creative PPI methods are not widely used; however, this could change over time as PPI becomes embedded even more into research.

Plain English Summary

It is important that patients and public are included in the research process from initial brainstorming, through design to delivery. This is known as public and patient involvement (PPI). Their input means that research closely aligns with their wants and needs. Traditionally to get this input, interviews and group discussions are held, but this can exclude people who find these activities non-engaging or inaccessible, for example those with language challenges, learning disabilities or memory issues. Creative methods of PPI can overcome this. This is a broad term describing different (non-traditional) ways of engaging patients and public in research, such as through the use or art, animation or performance. This review investigated the reasons why creative approaches to PPI could be difficult (limitations) or helpful (strengths) in health and social care research. After searching 5 online databases, 12 studies were included in the review. PPI groups included adults, children and people with language and memory impairments. Creative methods included songs, poems, drawings, the use of photos and drama, visualisations, Facebook, creating prototypes, personas and card sorting. Limitations included the time, cost and effort associated with creative methods, the lack of application to other populations, ethical issues and buy-in from the wider research community. Strengths included the feeling of equality between academics and the public, creation of a safe space for people to express themselves, inclusivity, and that creative PPI can be cost and time efficient. Overall, this review suggests that creative PPI is worthwhile, however each method has its own strengths and limitations and the choice of which will depend on the research project, PPI group characteristics and other practical limitations, such as time and financial constraints.

Peer Review reports

Introduction

Patient and public involvement (PPI) is the term used to describe the partnership between patients (including caregivers, potential patients, healthcare users etc.) or the public (a community member with no known interest in the topic) with researchers. It describes research that is done “‘with’ or ‘by’ the public, rather than ‘to,’ ‘about’ or ‘for’ them” [ 1 ]. In 2009, it became a legislative requirement for certain health and social care organisations to include patients, families, carers and communities in not only the planning of health and social care services, but the commissioning, delivery and evaluation of them too [ 2 ]. For example, funding applications for the National Institute of Health and Care Research (NIHR), a UK funding body, mandates a demonstration of how researchers plan to include patients/service users, the public and carers at each stage of the project [ 3 ]. However, this should not simply be a tokenistic, tick-box exercise. PPI should help formulate initial ideas and should be an instrumental, continuous part of the research process. Input from PPI can provide unique insights not yet considered and can ensure that research and health services are closely aligned to the needs and requirements of service users PPI also generally makes research more relevant with clearer outcomes and impacts [ 4 ]. Although this review refers to both patients and the public using the umbrella term ‘PPI’, it is important to acknowledge that these are two different groups with different motivations, needs and interests when it comes to health research and service delivery [ 5 ].

Despite continuing recognition of the need of PPI to improve quality of healthcare, researchers have also recognised that there is no ‘one size fits all’ method for involving patients [ 4 ]. Traditionally, PPI methods invite people to take part in interviews or focus groups to facilitate discussion, or surveys and questionnaires. However, these can sometimes be inaccessible or non-engaging for certain populations. For example, someone with communication difficulties may find it difficult to engage in focus groups or interviews. If individuals lack the appropriate skills to interact in these types of scenarios, they cannot take advantage of the participation opportunities it can provide [ 6 ]. Creative methods, however, aim to resolve these issues. These are a relatively new concept whereby researchers use creative methods (e.g., artwork, animations, Lego), to make PPI more accessible and engaging for those whose voices would otherwise go unheard. They ensure that all populations can engage in research, regardless of their background or skills. Seminal work has previously been conducted in this area, which brought to light the use of creative methodologies in research. Leavy (2008) [ 7 ] discussed how traditional interviews had limits on what could be expressed due to their sterile, jargon-filled and formulaic structure, read by only a few specialised academics. It was this that called for more creative approaches, which included narrative enquiry, fiction-based research, poetry, music, dance, art, theatre, film and visual art. These practices, which can be used in any stage of the research cycle, supported greater empathy, self-reflection and longer-lasting learning experiences compared to interviews [ 7 ]. They also pushed traditional academic boundaries, which made the research accessible not only to researchers, but the public too. Leavy explains that there are similarities between arts-based approaches and scientific approaches: both attempts to investigate what it means to be human through exploration, and used together, these complimentary approaches can progress our understanding of the human experience [ 7 ]. Further, it is important to acknowledge the parallels and nuances between creative and inclusive methods of PPI. Although creative methods aim to be inclusive (this should underlie any PPI activity, whether creative or not), they do not incorporate all types of accessible, inclusive methodologies e.g., using sign language for people with hearing impairments or audio recordings for people who cannot read. Given that there was not enough scope to include an evaluation of all possible inclusive methodologies, this review will focus on creative methods of PPI only.

We aimed to conduct a qualitative systematic review to highlight the strengths of creative PPI in health and social care research, as well as the limitations, which might act as a barrier to their implementation. A qualitative systematic review “brings together research on a topic, systematically searching for research evidence from primary qualitative studies and drawing the findings together” [ 8 ]. This review can then advise researchers of the best practices when designing PPI.

Public involvement

The PHIRST-LIGHT Public Advisory Group (PAG) consists of a team of experienced public contributors with a diverse range of characteristics from across the UK. The PAG was involved in the initial question setting and study design for this review.

Search strategy

For the purpose of this review, the JBI approach for conducting qualitative systematic reviews was followed [ 9 ]. The search terms were (“creativ*” OR “innovat*” OR “authentic” OR “original” OR “inclu*”) AND (“public and patient involvement” OR “patient and public involvement” OR “public and patient involvement and engagement” OR “patient and public involvement and engagement” OR “PPI” OR “PPIE” OR “co-produc*” OR “co-creat*” OR “co-design*” OR “cooperat*” OR “co-operat*”). This search string was modified according to the requirements of each database. Papers were filtered by title, abstract and keywords (see Additional file 1 for search strings). The databases searched included Web of Science (WoS), PubMed, ASSIA and CINAHL. The Cochrane Library was also searched to identify relevant reviews which could lead to the identification of primary research. The search was conducted on 14/04/23. As our aim was to report on the use of creative PPI in research, rather than more generic public engagement, we used electronic databases of scholarly peer-reviewed literature, which represent a wide range of recognised databases. These identified studies published in general international journals (WoS, PubMed), those in social sciences journals (ASSIA), those in nursing and allied health journals (CINAHL), and trials of interventions (Cochrane Library).

Inclusion criteria

Only full-text, English language, primary research papers from 2009 to 2023 were included. This was the chosen timeframe as in 2009 the Health and Social Reform Act made it mandatory for certain Health and Social Care organisations to involve the public and patients in planning, delivering, and evaluating services [ 2 ]. Only creative methods of PPI were accepted, rather than traditional methods, such as interviews or focus groups. For the purposes of this paper, creative PPI included creative art or arts-based approaches (e.g., e.g. stories, songs, drama, drawing, painting, poetry, photography) to enhance engagement. Titles were related to health and social care and the creative PPI was used to engage with people as research advisors, not as study participants. Meta-analyses, conference abstracts, book chapters, commentaries and reviews were excluded. There were no limits concerning study location or the demographic characteristics of the PPI groups. Only qualitative data were accepted.

Quality appraisal

Quality appraisal using the Critical Appraisal Skills Programme (CASP) checklist [ 10 ] was conducted by the primary authors (ORP and CH). This was done independently, and discrepancies were discussed and resolved. If a consensus could not be reached, a third independent reviewer was consulted (JRM). The full list of quality appraisal questions can be found in Additional file 2 .

Data extraction

ORP extracted the study characteristics and a subset of these were checked by CH. Discrepancies were discussed and amendments made. Extracted data included author, title, location, year of publication, year study was carried out, research question/aim, creative methods used, number of participants, mean age, gender, ethnicity of participants, setting, limitations and strengths of creative PPI and main findings.

Data analysis

The included studies were analysed using inductive thematic analysis [ 11 ], where themes were determined by the data. The familiarisation stage took place during full-text reading of the included articles. Anything identified as a strength or limitation to creative PPI methods was extracted verbatim as an initial code and inputted into the data extraction Excel sheet. Similar codes were sorted into broader themes, either under ‘strengths’ or ‘limitations’ and reviewed. Themes were then assigned a name according to the codes.

The search yielded 9978 titles across the 5 databases: Web of Science (1480 results), PubMed (94 results), ASSIA (2454 results), CINAHL (5948 results) and Cochrane Library (2 results), resulting in 8553 different studies after deduplication. ORP and CH independently screened their titles and abstracts, excluding those that did not meet the criteria. After assessment, 12 studies were included (see Fig.  1 ).

PRISMA flowchart of the study selection process

Study characteristics

The included studies were published between 2018 and 2022. Seven were conducted in the UK [ 12 , 14 , 15 , 17 , 18 , 19 , 23 ], two in Canada [ 21 , 22 ], one in Australia [ 13 ], one in Norway [ 16 ] and one in Ireland [ 20 ]. The PPI activities occurred across various settings, including a school [ 12 ], social club [ 12 ], hospital [ 17 ], university [ 22 ], theatre [ 19 ], hotel [ 20 ], or online [ 15 , 21 ], however this information was omitted in 5 studies [ 13 , 14 , 16 , 18 , 23 ]. The number of people attending the PPI sessions varied, ranging from 6 to 289, however the majority (ten studies) had less than 70 participants [ 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Seven studies did not provide information on the age or gender of the PPI groups. Of those that did, ages ranged from 8 to 76 and were mostly female. The ethnicities of the PPI group members were also rarely recorded (see Additional file 3 for data extraction table).

Types of creative methods

The type of creative methods used to engage the PPI groups were varied. These included songs, poems, drawings, photograph elicitation, drama performance, visualisations, Facebook, photography, prototype development, cultural animation, card sorting and creating personas (see Table  1 ). These were sometimes accompanied by traditional methods of PPI such as interviews and focus group discussions.

The 12 included studies were all deemed to be of good methodological quality, with scores ranging from 6/10 to 10/10 with the CASP critical appraisal tool [ 10 ] (Table  2 ).

Thematic analysis

Analysis identified four limitations and five strengths to creative PPI (see Fig.  2 ). Limitations included the time and resource intensity of creative PPI methods, its lack of generalisation, ethical issues and external factors. Strengths included the disruption of power hierarchies, the engaging and inclusive nature of the methods and their long-term cost and time efficiency. Creative PPI methods also allowed mundane and “taboo” topics to be discussed within a safe space.

Theme map of strengths and limitations

Limitations of creative PPI

Creative ppi methods are time and resource intensive.

The time and resource intensive nature of creative PPI methods is a limitation, most notably for the persona-scenario methodology. Valaitis et al. [ 22 ] used 14 persona-scenario workshops with 70 participants to co-design a healthcare intervention, which aimed to promote optimal aging in Canada. Using the persona method, pairs composed of patients, healthcare providers, community service providers and volunteers developed a fictional character which they believed represented an ‘end-user’ of the healthcare intervention. Due to the depth and richness of the data produced the authors reported that it was time consuming to analyse. Further, they commented that the amount of information was difficult to disseminate to scientific leads and present at team meetings. Additionally, to ensure the production of high-quality data, to probe for details and lead group discussion there was a need for highly skilled facilitators. The resource intensive nature of the creative co-production was also noted in a study using the persona scenario and creative worksheets to develop a prototype decision support tool for individuals with malignant pleural effusion [ 17 ]. With approximately 50 people, this was also likely to yield a high volume of data to consider.

To prepare materials for populations who cannot engage in traditional methods of PPI was also timely. Kearns et al. [ 18 ] developed a feedback questionnaire for people with aphasia to evaluate ICT-delivered rehabilitation. To ensure people could participate effectively, the resources used during the workshops, such as PowerPoints, online images and photographs, had to be aphasia-accessible, which was labour and time intensive. The author warned that this time commitment should not be underestimated.

There are further practical limitations to implementing creative PPI, such as the costs of materials for activities as well as hiring a space for workshops. For example, the included studies in this review utilised pens, paper, worksheets, laptops, arts and craft supplies and magazines and took place in venues such as universities, a social club, and a hotel. Further, although not limited to creative PPI methods exclusively but rather most studies involving the public, a financial incentive was often offered for participation, as well as food, parking, transport and accommodation [ 21 , 22 ].

Creative PPI lacks generalisation

Another barrier to the use of creative PPI methods in health and social care research was the individual nature of its output. Those who participate, usually small in number, produce unique creative outputs specific to their own experiences, opinions and location. Craven et al. [ 13 ], used arts-based visualisations to develop a toolbox for adults with mental health difficulties. They commented, “such an approach might still not be worthwhile”, as the visualisations were individualised and highly personal. This indicates that the output may fail to meet the needs of its end-users. Further, these creative PPI groups were based in certain geographical regions such as Stoke-on-Trent [ 19 ] Sheffield [ 23 ], South Wales [ 12 ] or Ireland [ 20 ], which limits the extent the findings can be applied to wider populations, even within the same area due to individual nuances. Further, the study by Galler et al. [ 16 ], is specific to the Norwegian context and even then, maybe only a sub-group of the Norwegian population as the sample used was of higher socioeconomic status.

However, Grindell et al. [ 17 ], who used persona scenarios, creative worksheets and prototype development, pointed out that the purpose of this type of research is to improve a certain place, rather than apply findings across other populations and locations. Individualised output may, therefore, only be a limitation to research wanting to conduct PPI on a large scale.

If, however, greater generalisation within PPI is deemed necessary, then social media may offer a resolution. Fedorowicz et al. [ 15 ], used Facebook to gain feedback from the public on the use of video-recording methodology for an upcoming project. This had the benefit of including a more diverse range of people (289 people joined the closed group), who were spread geographically around the UK, as well as seven people from overseas.

Creative PPI has ethical issues

As with other research, ethical issues must be taken into consideration. Due to the nature of creative approaches, as well as the personal effort put into them, people often want to be recognised for their work. However, this compromises principles so heavily instilled in research such as anonymity and confidentiality. With the aim of exploring issues related to health and well-being in a town in South Wales, Byrne et al. [ 12 ], asked year 4/5 and year 10 pupils to create poems, songs, drawings and photographs. Community members also created a performance, mainly of monologues, to explore how poverty and inequalities are dealt with. Byrne noted the risks of these arts-based approaches, that being the possibility of over-disclosure and consequent emotional distress, as well as people’s desire to be named for their work. On one hand, the anonymity reduces the sense of ownership of the output as it does not portray a particular individual’s lived experience anymore. On the other hand, however, it could promote a more honest account of lived experience. Supporting this, Webber et al. [ 23 ], who used the persona method to co-design a back pain educational resource prototype, claimed that the anonymity provided by this creative technique allowed individuals to externalise and anonymise their own personal experience, thus creating a more authentic and genuine resource for future users. This implies that anonymity can be both a limitation and strength here.

The use of creative PPI methods is impeded by external factors

Despite the above limitations influencing the implementation of creative PPI techniques, perhaps the most influential is that creative methodologies are simply not mainstream [ 19 ]. This could be linked to the issues above, like time and resource intensity, generalisation and ethical issues but it is also likely to involve more systemic factors within the research community. Micsinszki et al. [ 21 ], who co-designed a hub for the health and well-being of vulnerable populations, commented that there is insufficient infrastructure to conduct meaningful co-design as well as a dominant medical model. Through a more holistic lens, there are “sociopolitical environments that privilege individualism over collectivism, self-sufficiency over collaboration, and scientific expertise over other ways of knowing based on lived experience” [ 21 ]. This, it could be suggested, renders creative co-design methodologies, which are based on the foundations of collectivism, collaboration and imagination an invalid technique in the research field, which is heavily dominated by more scientific methods offering reproducibility, objectivity and reliability.

Although we acknowledge that creative PPI techniques are not always appropriate, it may be that their main limitation is the lack of awareness of these methods or lack of willingness to use them. Further, there is always the risk that PPI, despite being a mandatory part of research, is used in a tokenistic or tick-box fashion [ 20 ], without considering the contribution that meaningful PPI could make to enhancing the research. It may be that PPI, let alone creative PPI, is not at the forefront of researchers’ minds when planning research.

Strengths of creative PPI

Creative ppi disrupts power hierarchies.

One of the main strengths of creative PPI techniques, cited most frequently in the included literature, was that they disrupt traditional power hierarchies [ 12 , 13 , 17 , 19 , 23 ]. For example, the use of theatre performance blurred the lines between professional and lay roles between the community and policy makers [ 12 ]. Individuals created a monologue to portray how poverty and inequality impact daily life and presented this to representatives of the National Assembly of Wales, Welsh Government, the Local Authority, Arts Council and Westminster. Byrne et al. [ 12 ], states how this medium allowed the community to engage with the people who make decisions about their lives in an environment of respect and understanding, where the hierarchies are not as visible as in other settings, e.g., political surgeries. Creative PPI methods have also removed traditional power hierarchies between researchers and adolescents. Cook et al. [ 13 ], used arts-based approaches to explore adolescents’ ideas about the “perfect” condom. They utilised the “Life Happens” resource, where adolescents drew and then decorated a person with their thoughts about sexual relationships, not too dissimilar from the persona-scenario method. This was then combined with hypothetical scenarios about sexuality. A condom-mapping exercise was then implemented, where groups shared the characteristics that make a condom “perfect” on large pieces of paper. Cook et al. [ 13 ], noted that usually power imbalances make it difficult to elicit information from adolescents, however these power imbalances were reduced due to the use of creative co-design techniques.

The same reduction in power hierarchies was noted by Grindell et al. [ 17 ], who used the person-scenario method and creative worksheets with individuals with malignant pleural effusion. This was with the aim of developing a prototype of a decision support tool for patients to help with treatment options. Although this process involved a variety of stakeholders, such as patients, carers and healthcare professionals, creative co-design was cited as a mechanism that worked to reduce power imbalances – a limitation of more traditional methods of research. Creative co-design blurred boundaries between end-users and clinical staff and enabled the sharing of ideas from multiple, valuable perspectives, meaning the prototype was able to suit user needs whilst addressing clinical problems.

Similarly, a specific creative method named cultural animation was also cited to dissolve hierarchies and encourage equal contributions from participants. Within this arts-based approach, Keleman et al. [ 19 ], explored the concept of “good health” with individuals from Stoke-on Trent. Members of the group created art installations using ribbons, buttons, cardboard and straws to depict their idea of a “healthy community”, which was accompanied by a poem. They also created a 3D Facebook page and produced another poem or song addressing the government to communicate their version of a “picture of health”. Public participants said that they found the process empowering, honest, democratic, valuable and practical.

This dissolving of hierarchies and levelling of power is beneficial as it increases the sense of ownership experienced by the creators/producers of the output [ 12 , 17 , 23 ]. This is advantageous as it has been suggested to improve its quality [ 23 ].

Creative PPI allows the unsayable to be said

Creative PPI fosters a safe space for mundane or taboo topics to be shared, which may be difficult to communicate using traditional methods of PPI. For example, the hypothetical nature of condom mapping and persona-scenarios meant that adolescents could discuss a personal topic without fear of discrimination, judgement or personal disclosure [ 13 ]. The safe space allowed a greater volume of ideas to be generated amongst peers where they might not have otherwise. Similarly, Webber et al. [ 23 ], , who used the persona method to co-design the prototype back pain educational resource, also noted how this method creates anonymity whilst allowing people the opportunity to externalise personal experiences, thoughts and feelings. Other creative methods were also used, such as drawing, collaging, role play and creating mood boards. A cardboard cube (labelled a “magic box”) was used to symbolise a physical representation of their final prototype. These creative methods levelled the playing field and made personal experiences accessible in a safe, open environment that fostered trust, as well as understanding from the researchers.

It is not only sensitive subjects that were made easier to articulate through creative PPI. The communication of mundane everyday experiences were also facilitated, which were deemed typically ‘unsayable’. This was specifically given in the context of describing intangible aspects of everyday health and wellbeing [ 11 ]. Graphic designers can also be used to visually represent the outputs of creative PPI. These captured the movement and fluidity of people and well as the relationships between them - things that cannot be spoken but can be depicted [ 21 ].

Creative PPI methods are inclusive

Another strength of creative PPI was that it is inclusive and accessible [ 17 , 19 , 21 ]. The safe space it fosters, as well as the dismantling of hierarchies, welcomed people from a diverse range of backgrounds and provided equal opportunities [ 21 ], especially for those with communication and memory difficulties who might be otherwise excluded from PPI. Kelemen et al. [ 19 ], who used creative methods to explore health and well-being in Stoke-on-Trent, discussed how people from different backgrounds came together and connected, discussed and reached a consensus over a topic which evoked strong emotions, that they all have in common. Individuals said that the techniques used “sets people to open up as they are not overwhelmed by words”. Similarly, creative activities, such as the persona method, have been stated to allow people to express themselves in an inclusive environment using a common language. Kearns et al. [ 18 ], who used aphasia-accessible material to develop a questionnaire with aphasic individuals, described how they felt comfortable in contributing to workshops (although this material was time-consuming to make, see ‘Limitations of creative PPI’ ).

Despite the general inclusivity of creative PPI, it can also be exclusive, particularly if online mediums are used. Fedorowicz et al. [ 15 ], used Facebook to create a PPI group, and although this may rectify previous drawbacks about lack of generalisation of creative methods (as Facebook can reach a greater number of people, globally), it excluded those who are not digitally active or have limited internet access or knowledge of technology. Online methods have other issues too. Maintaining the online group was cited as challenging and the volume of responses required researchers to interact outside of their working hours. Despite this, online methods like Facebook are very accessible for people who are physically disabled.

Creative PPI methods are engaging

The process of creative PPI is typically more engaging and produces more colourful data than traditional methods [ 13 ]. Individuals are permitted and encouraged to explore a creative self [ 19 ], which can lead to the exploration of new ideas and an overall increased enjoyment of the process. This increased engagement is particularly beneficial for younger PPI groups. For example, to involve children in the development of health food products, Galler et al. [ 16 ] asked 9-12-year-olds to take photos of their food and present it to other children in a “show and tell” fashion. They then created a newspaper article describing a new healthy snack. In this creative focus group, children were given lab coats to further their identity as inventors. Galler et al. [ 16 ], notes that the methods were highly engaging and facilitated teamwork and group learning. This collaborative nature of problem-solving was also observed in adults who used personas and creative worksheets to develop the resource for lower back pain [ 23 ]. Dementia patients too have been reported to enjoy the creative and informal approach to idea generation [ 20 ].

The use of cultural animation allowed people to connect with each other in a way that traditional methods do not [ 19 , 21 ]. These connections were held in place by boundary objects, such as ribbons, buttons, fabric and picture frames, which symbolised a shared meaning between people and an exchange of knowledge and emotion. Asking groups to create an art installation using these objects further fostered teamwork and collaboration, both at an individual and collective level. The exploration of a creative self increased energy levels and encouraged productive discussions and problem-solving [ 19 ]. Objects also encouraged a solution-focused approach and permitted people to think beyond their usual everyday scope [ 17 ]. They also allowed facilitators to probe deeper about the greater meanings carried by the object, which acted as a metaphor [ 21 ].

From the researcher’s point of view, co-creative methods gave rise to ideas they might not have initially considered. Valaitis et al. [ 22 ], found that over 40% of the creative outputs were novel ideas brought to light by patients, healthcare providers/community care providers, community service providers and volunteers. One researcher commented, “It [the creative methods] took me on a journey, in a way that when we do other pieces of research it can feel disconnected” [ 23 ]. Another researcher also stated they could not return to the way they used to do research, as they have learnt so much about their own health and community and how they are perceived [ 19 ]. This demonstrates that creative processes not only benefit the project outcomes and the PPI group, but also facilitators and researchers. However, although engaging, creative methods have been criticised for not demonstrating academic rigour [ 17 ]. Moreover, creative PPI may also be exclusive to people who do not like or enjoy creative activities.

Creative PPI methods are cost and time efficient

Creative PPI workshops can often produce output that is visible and tangible. This can save time and money in the long run as the output is either ready to be implemented in a healthcare setting or a first iteration has already been developed. This may also offset the time and costs it takes to implement creative PPI. For example, the prototype of the decision support tool for people with malignant pleural effusion was developed using personas and creative worksheets. The end result was two tangible prototypes to drive the initial idea forward as something to be used in practice [ 17 ]. The use of creative co-design in this case saved clinician time as well as the time it would take to develop this product without the help of its end-users. In the development of this particular prototype, analysis was iterative and informed the next stage of development, which again saved time. The same applies for the feedback questionnaire for the assessment of ICT delivered aphasia rehabilitation. The co-created questionnaire, designed with people with aphasia, was ready to be used in practice [ 18 ]. This suggests that to overcome time and resource barriers to creative PPI, researchers should aim for it to be engaging whilst also producing output.

That useable products are generated during creative workshops signals to participating patients and public members that they have been listened to and their thoughts and opinions acted upon [ 23 ]. For example, the development of the back pain resource based on patient experiences implies that their suggestions were valid and valuable. Further, those who participated in the cultural animation workshop reported that the process visualises change, and that it already feels as though the process of change has started [ 19 ].

The most cost and time efficient method of creative PPI in this review is most likely the use of Facebook to gather feedback on project methodology [ 15 ]. Although there were drawbacks to this, researchers could involve more people from a range of geographical areas at little to no cost. Feedback was instantaneous and no training was required. From the perspective of the PPI group, they could interact however much or little they wish with no time commitment.

This systematic review identified four limitations and five strengths to the use of creative PPI in health and social care research. Creative PPI is time and resource intensive, can raise ethical issues and lacks generalisability. It is also not accepted by the mainstream. These factors may act as barriers to the implementation of creative PPI. However, creative PPI disrupts traditional power hierarchies and creates a safe space for taboo or mundane topics. It is also engaging, inclusive and can be time and cost efficient in the long term.

Something that became apparent during data analysis was that these are not blanket strengths and limitations of creative PPI as a whole. The umbrella term ‘creative PPI’ is broad and encapsulates a wide range of activities, ranging from music and poems to prototype development and persona-scenarios, to more simplistic things like the use of sticky notes and ordering cards. Many different activities can be deemed ‘creative’ and the strengths and limitations of one does not necessarily apply to another. For example, cultural animation takes greater effort to prepare than the use of sticky notes and sorting cards, and the use of Facebook is cheaper and wider reaching than persona development. Researchers should use their discretion and weigh up the benefits and drawbacks of each method to decide on a technique which suits the project. What might be a limitation to creative PPI in one project may not be in another. In some cases, creative PPI may not be suitable at all.

Furthermore, the choice of creative PPI method also depends on the needs and characteristics of the PPI group. Children, adults and people living with dementia or language difficulties all have different engagement needs and capabilities. This indicates that creative PPI is not one size fits all and that the most appropriate method will change depending on the composition of the group. The choice of method will also be determined by the constraints of the research project, namely time, money and the research aim. For example, if there are time constraints, then a method which yields a lot of data and requires a lot of preparation may not be appropriate. If generalisation is important, then an online method is more suitable. Together this indicates that the choice of creative PPI method is highly individualised and dependent on multiple factors.

Although the limitations discussed in this review apply to creative PPI, they are not exclusive to creative PPI. Ethical issues are a consideration within general PPI research, especially when working with more vulnerable populations, such as children or adults living with a disability. It can also be the case that traditional PPI methods lack generalisability, as people who volunteer to be part of such a group are more likely be older, middle class and retired [ 24 ]. Most research is vulnerable to this type of bias, however, it is worth noting that generalisation is not always a goal and research remains valid and meaningful in its absence. Although online methods may somewhat combat issues related to generalisability, these methods still exclude people who do not have access to the internet/technology or who choose not to use it, implying that online PPI methods may not be wholly representative of the general population. Saying this, however, the accessibility of creative PPI techniques differs from person to person, and for some, online mediums may be more accessible (for example for those with a physical disability), and for others, this might be face-to-face. To combat this, a range of methods should be implemented. Planning multiple focus group and interviews for traditional PPI is also time and resource intensive, however the extra resources required to make this creative may be even greater. Although, the rich data provided may be worth the preparation and analysis time, which is also likely to depend on the number of participants and workshop sessions required. PPI, not just creative PPI, often requires the provision of a financial incentive, refreshments, parking and accommodation, which increase costs. These, however, are imperative and non-negotiable, as they increase the accessibility of research, especially to minority and lower-income groups less likely to participate. Adequate funding is also important for co-design studies where repeated engagement is required. One barrier to implementation, which appears to be exclusive to creative methods, however, is that creative methods are not mainstream. This cannot be said for traditional PPI as this is often a mandatory part of research applications.

Regarding the strengths of creative PPI, it could be argued that most appear to be exclusive to creative methodologies. These are inclusive by nature as multiple approaches can be taken to evoke ideas from different populations - approaches that do not necessarily rely on verbal or written communication like interviews and focus groups do. Given the anonymity provided by some creative methods, such as personas, people may be more likely to discuss their personal experiences under the guise of a general end-user, which might be more difficult to maintain when an interviewer is asking an individual questions directly. Additionally, creative methods are by nature more engaging and interactive than traditional methods, although this is a blanket statement and there may be people who find the question-and-answer/group discussion format more engaging. Creative methods have also been cited to eliminate power imbalances which exist in traditional research [ 12 , 13 , 17 , 19 , 23 ]. These imbalances exist between researchers and policy makers and adolescents, adults and the community. Lastly, although this may occur to a greater extent in creative methods like prototype development, it could be suggested that PPI in general – regardless of whether it is creative - is more time and cost efficient in the long-term than not using any PPI to guide or refine the research process. It must be noted that these are observations based on the literature. To be certain these differences exist between creative and traditional methods of PPI, direct empirical evaluation of both should be conducted.

To the best of our knowledge, this is the first review to identify the strengths and limitations to creative PPI, however, similar literature has identified barriers and facilitators to PPI in general. In the context of clinical trials, recruitment difficulties were cited as a barrier, as well as finding public contributors who were free during work/school hours. Trial managers reported finding group dynamics difficult to manage and the academic environment also made some public contributors feel nervous and lacking confidence to speak. Facilitators, however, included the shared ownership of the research – something that has been identified in the current review too. In addition, planning and the provision of knowledge, information and communication were also identified as facilitators [ 25 ]. Other research on the barriers to meaningful PPI in trial oversight committees included trialist confusion or scepticism over the PPI role and the difficulties in finding PPI members who had a basic understanding of research [ 26 ]. However, it could be argued that this is not representative of the average patient or public member. The formality of oversight meetings and the technical language used also acted as a barrier, which may imply that the informal nature of creative methods and its lack of dependency on literacy skills could overcome this. Further, a review of 42 reviews on PPI in health and social care identified financial compensation, resources, training and general support as necessary to conduct PPI, much like in the current review where the resource intensiveness of creative PPI was identified as a limitation. However, others were identified too, such as recruitment and representativeness of public contributors [ 27 ]. Like in the current review, power imbalances were also noted, however this was included as both a barrier and facilitator. Collaboration seemed to diminish hierarchies but not always, as sometimes these imbalances remained between public contributors and healthcare staff, described as a ‘them and us’ culture [ 27 ]. Although these studies compliment the findings of the current review, a direct comparison cannot be made as they do not concern creative methods. However, it does suggest that some strengths and weaknesses are shared between creative and traditional methods of PPI.

Strengths and limitations of this review

Although a general definition of creative PPI exists, it was up to our discretion to decide exactly which activities were deemed as such for this review. For example, we included sorting cards, the use of interactive whiteboards and sticky notes. Other researchers may have a more or less stringent criteria. However, two reviewers were involved in this decision which aids the reliability of the included articles. Further, it may be that some of the strengths and limitations cannot fully be attributed to the creative nature of the PPI process, but rather their co-created nature, however this is hard to disentangle as the included papers involved both these aspects.

During screening, it was difficult to decide whether the article was utilising creative qualitative methodology or creative PPI , as it was often not explicitly labelled as such. Regardless, both approaches involved the public/patients refining a healthcare product/service. This implies that if this review were to be replicated, others may do it differently. This may call for greater standardisation in the reporting of the public’s involvement in research. For example, the NIHR outlines different approaches to PPI, namely “consultation”, “collaboration”, “co-production” and “user-controlled”, which each signify an increased level of public power and influence [ 28 ]. Papers with elements of PPI could use these labels to clarify the extent of public involvement, or even explicitly state that there was no PPI. Further, given our decision to include only scholarly peer-reviewed literature, it is possible that data were missed within the grey literature. Similarly, the literature search will not have identified all papers relating to different types of accessible inclusion. However, the intent of the review was to focus solely on those within the definition of creative.

This review fills a gap in the literature and helps circulate and promote the concept of creative PPI. Each stage of this review, namely screening and quality appraisal, was conducted by two independent reviewers. However, four full texts could not be accessed during the full text reading stage, meaning there are missing data that could have altered or contributed to the findings of this review.

Research recommendations

Given that creative PPI can require effort to prepare, perform and analyse, sufficient time and funding should be allocated in the research protocol to enable meaningful and continuous PPI. This is worthwhile as PPI can significantly change the research output so that it aligns closely with the needs of the group it is to benefit. Researchers should also consider prototype development as a creative PPI activity as this might reduce future time/resource constraints. Shifting from a top-down approach within research to a bottom-up can be advantageous to all stakeholders and can help move creative PPI towards the mainstream. This, however, is the collective responsibility of funding bodies, universities and researchers, as well as committees who approve research bids.

A few of the included studies used creative techniques alongside traditional methods, such as interviews, which could also be used as a hybrid method of PPI, perhaps by researchers who are unfamiliar with creative techniques or to those who wish to reap the benefits of both. Often the characteristics of the PPI group were not included, including age, gender and ethnicity. It would be useful to include such information to assess how representative the PPI group is of the population of interest.

Creative PPI is a relatively novel approach of engaging the public and patients in research and it has both advantages and disadvantages compared to more traditional methods. There are many approaches to implementing creative PPI and the choice of technique will be unique to each piece of research and is reliant on several factors. These include the age and ability of the PPI group as well as the resource limitations of the project. Each method has benefits and drawbacks, which should be considered at the protocol-writing stage. However, given adequate funding, time and planning, creative PPI is a worthwhile and engaging method of generating ideas with end-users of research – ideas which may not be otherwise generated using traditional methods.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Critical Appraisal Skills Programme

The Joanna Briggs Institute

National Institute of Health and Care Research

Public Advisory Group

Public and Patient Involvement

Web of Science

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National Institute for Health and Care Research. A Researcher’s Guide to Patient and Public Involvement. https://oxfordbrc.nihr.ac.uk/wp-content/uploads/2017/03/A-Researchers-Guide-to-PPI.pdf Accessed 01 Nov 2023.

Selman L, Clement C, Douglas M, Douglas K, Taylor J, Metcalfe C, Lane J, Horwood J. Patient and public involvement in randomised clinical trials: a mixed-methods study of a clinical trials unit to identify good practice, barriers and facilitators. Trials. 2021 https://doi.org/10.1186/s13063-021-05701-y

Coulman K, Nicholson A, Shaw A, Daykin A, Selman L, Macefield R, Shorter G, Cramer H, Sydes M, Gamble C, Pick M, Taylor G, Lane J. Understanding and optimising patient and public involvement in trial oversight: an ethnographic study of eight clinical trials. Trials. 2020. https://doi.org/10.1186/s13063-020-04495-9

Ocloo J, Garfield S, Franklin B, Dawson S. Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: a systematic review of reviews. Health Res Policy Sys. 2021. https://doi.org/10.1186/s12961-020-00644-3

National Institute for Health and Care Research. Briefing notes for researchers - public involvement in NHS, health and social care research. https://www.nihr.ac.uk/documents/briefing-notes-for-researchers-public-involvement-in-nhs-health-and-social-care-research/27371 Accessed 01 Nov 2023.

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Acknowledgements

With thanks to the PHIRST-LIGHT public advisory group and consortium for their thoughts and contributions to the design of this work.

The research team is supported by a National Institute for Health and Care Research grant (PHIRST-LIGHT Reference NIHR 135190).

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Olivia R. Phillips and Cerian Harries share joint first authorship.

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Nottingham Centre for Public Health and Epidemiology, Lifespan and Population Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK

Olivia R. Phillips, Jo Leonardi-Bee, Holly Knight & Joanne R. Morling

National Institute for Health and Care Research (NIHR) PHIRST-LIGHT, Nottingham, UK

Olivia R. Phillips, Cerian Harries, Jo Leonardi-Bee, Holly Knight, Lauren B. Sherar, Veronica Varela-Mato & Joanne R. Morling

School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, Leicestershire, LE11 3TU, UK

Cerian Harries, Lauren B. Sherar & Veronica Varela-Mato

Nottingham Centre for Evidence Based Healthcare, School of Medicine, University of Nottingham, Nottingham, UK

Jo Leonardi-Bee

NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, NG7 2UH, UK

Joanne R. Morling

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Author contributions: study design: ORP, CH, JRM, JLB, HK, LBS, VVM, literature searching and screening: ORP, CH, JRM, data curation: ORP, CH, analysis: ORP, CH, JRM, manuscript draft: ORP, CH, JRM, Plain English Summary: ORP, manuscript critical review and editing: ORP, CH, JRM, JLB, HK, LBS, VVM.

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Phillips, O.R., Harries, C., Leonardi-Bee, J. et al. What are the strengths and limitations to utilising creative methods in public and patient involvement in health and social care research? A qualitative systematic review. Res Involv Engagem 10 , 48 (2024). https://doi.org/10.1186/s40900-024-00580-4

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Perspective

When pto stands for 'pretend time off': doctors struggle to take real breaks.

Mara Gordon

A survey shows that doctors have trouble taking full vacations from their high-stress jobs. Even when they do, they often still do work on their time off. Wolfgang Kaehler/LightRocket via Getty Images hide caption

A survey shows that doctors have trouble taking full vacations from their high-stress jobs. Even when they do, they often still do work on their time off.

A few weeks ago, I took a vacation with my family. We went hiking in the national parks of southern Utah, and I was blissfully disconnected from work.

I'm a family physician, so taking a break from my job meant not seeing patients. It also meant not responding to patients' messages or checking my work email. For a full week, I was free.

Taking a real break — with no sneaky computer time to bang out a few prescription refill requests — left me feeling reenergized and ready to take care of my patients when I returned.

But apparently, being a doctor who doesn't work on vacation puts me squarely in the minority of U.S. physicians.

Research published in JAMA Network Open this year set out to quantify exactly how doctors use their vacation time — and what the implications might be for a health care workforce plagued by burnout, dissatisfaction and doctors who are thinking about leaving medicine.

"There is a strong business case for supporting taking real vacation," says Dr. Christine Sinsky , the lead author of the paper. "Burnout is incredibly expensive for organizations."

Shots - Health News

Health workers know what good care is. pandemic burnout is getting in the way.

Researchers surveyed 3,024 doctors, part of an American Medical Association cohort designed to represent the American physician workforce. They found that 59.6% of American physicians took 15 days of vacation or less per year. That's a little more than the average American: Most workers who have been at a job for a year or more get between 10 and 14 days of paid vacation time , according to the U.S. Bureau of Labor Statistics.

However, most doctors don't take real vacation. Over 70% of doctors surveyed said they worked on a typical vacation day.

"I have heard physicians refer to PTO as 'pretend time off,'" Sinsky says, referring to the acronym for "paid time off."

Sinsky and co-authors found that physicians who took more than three weeks of vacation a year had lower rates of burnout than those who took less, since vacation time is linked to well-being and job satisfaction .

And all those doctors toiling away on vacation, sitting poolside with their laptops? Sinsky argues it has serious consequences for health care.

Physician burnout is linked to high job turnover and excess health care costs , among other problems.

Still, it can be hard to change the culture of workaholism in medicine. Even the study authors confessed that they, too, worked on vacation.

"I remember when one of our first well-being papers was published," says Dr. Colin West , a co-author of the new study and a health care workforce researcher at the Mayo Clinic. "I responded to the revisions up at the family cabin in northern Minnesota on vacation."

Sinsky agreed. "I do not take all my vacation, which I recognize as a delicious irony of the whole thing," she says.

She's the American Medical Association's vice president of professional satisfaction. If she can't take a real vacation, is there any hope for the rest of us?

I interviewed a half dozen fellow physicians and chatted off the record with many friends and colleagues to get a sense of why it feels so hard to give ourselves a break. Here, I offer a few theories about why doctors are so terrible at taking time off.

We don't want to make more work for our colleagues

The authors of the study in JAMA Network Open didn't explore exactly what type of work doctors did on vacation, but the physicians I spoke to had some ideas.

"If I am not doing anything, I will triage my email a little bit," says Jocelyn Fitzgerald , a urogynecologist at the University of Pittsburgh who was not involved in the study. "I also find that certain high-priority virtual meetings sometimes find their way into my vacations."

Even if doctors aren't scheduled to see patients, there's almost always plenty of work to be done: dealing with emergencies, medication refills, paperwork. For many of us, the electronic medical record (EMR) is an unrelenting taskmaster , delivering a near-constant flow of bureaucratic to-dos.

When I go on vacation, my fellow primary care doctors handle that work for me, and I do the same for them.

But it can sometimes feel like a lot to ask, especially when colleagues are doing that work on top of their normal workload.

"You end up putting people in kind of a sticky situation, asking for favors, and they [feel they] need to pay it back," says Jay-Sheree Allen , a family physician and fellow in preventive medicine at the Mayo Clinic.

She says her practice has a "doctor of the day" who covers all urgent calls and messages, which helps reduce some of the guilt she feels about taking time off.

Still, non-urgent tasks are left for her to complete when she gets back. She says she usually logs in to the EMR when she's on vacation so the tasks don't pile up upon her return. If she doesn't, Allen estimates there will be about eight hours of paperwork awaiting her after a week or so of vacation.

"My strategy, I absolutely do not recommend," Allen says. But "I would prefer that than coming back to the total storm."

We have too little flexibility about when we take vacation

Lawren Wooten , a resident physician in pediatrics at the University of California San Francisco, says she takes 100% of her vacation time. But there are a lot of stipulations about exactly how she uses it.

She has to take it in two-week blocks — "that's a long time at once," she says — and it's hard to change the schedule once her chief residents assign her dates.

"Sometimes I wish I had vacation in the middle of two really emotionally challenging rotations like an ICU rotation and an oncology rotation," she says, referring to the intensive care unit. "We don't really get to control our schedules at this point in our careers."

Once Wooten finishes residency and becomes an attending physician, it's likely she'll have more autonomy over her vacation time — but not necessarily all that much more.

"We generally have to know when our vacations are far in advance because patients schedule with us far in advance," says Fitzgerald, the gynecologist.

Taking vacation means giving up potential pay

Many physicians are paid based on the number of patients they see or procedures they complete. If they take time off work, they make less money.

"Vacation is money off your table," says West, the physician well-being researcher. "People have a hard time stepping off of the treadmill."

A 2022 research brief from the American Medical Association estimated that over 55% of U.S. physicians were paid at least in part based on "productivity," as opposed to earning a flat amount regardless of patient volume. That means the more patients doctors cram into their schedules, the more money they make. Going on vacation could decrease their take-home pay.

But West says it's important to weigh the financial benefits of skipping vacation against the risk of burnout from working too much.

Physician burnout is linked not only to excess health care costs but also to higher rates of medical errors. In one large survey of American surgeons , for example, surgeons experiencing burnout were more likely to report being involved in a major medical error. (It's unclear to what extent the burnout caused the errors or the errors caused the burnout, however.)

Doctors think they're the only one who can do their jobs

When I go on vacation, my colleagues see my patients for me. I work in a small office, so I know the other doctors well and I trust that my patients are in good hands when I'm away.

Doctors have their own diagnosis: 'Moral distress' from an inhumane health system

But ceding that control to colleagues might be difficult for some doctors, especially when it comes to challenging patients or big research projects.

"I think we need to learn to be better at trusting our colleagues," says Adi Shah , an infectious disease doctor at the Mayo Clinic. "You don't have to micromanage every slide on the PowerPoint — it's OK."

West, the well-being researcher, says health care is moving toward a team-based model and away from a culture where an individual doctor is responsible for everything. Still, he adds, it can be hard for some doctors to accept help.

"You can be a neurosurgeon, you're supposed to go on vacation tomorrow and you operate on a patient. And there are complications or risk of complications, and you're the one who has the relationship with that family," West says. "It is really, really hard for us to say ... 'You're in great hands with the rest of my team.'"

What doctors need, says West, is "a little bit less of the God complex."

We don't have any interests other than medicine

Shah, the infectious disease doctor, frequently posts tongue-in-cheek memes on X (formerly known as Twitter) about the culture of medicine. Unplugging during vacation is one of his favorite topics, despite his struggles to follow his own advice.

His recommendation to doctors is to get a hobby, so we can find something better to do than work all the time.

"Stop taking yourself too seriously," he says. Shah argues that medical training is so busy that many physicians neglect to develop any interests other than medicine. When fully trained doctors are finally finished with their education, he says, they're at a loss for what to do with their newfound freedom.

Since completing his training a few years ago, Shah has committed himself to new hobbies, such as salsa dancing. He has plans to go to a kite festival next year.

Shah has also prioritized making the long trip from Minnesota to see his family in India at least twice a year — a journey that requires significant time off work. He has a trip there planned this month.

"This is the first time in 11 years I'm making it to India in summer so that I can have a mango in May," the peak season for the fruit, Shah says.

Wooten, the pediatrician, agrees. She works hard to develop a full life outside her career.

"Throughout our secondary and medical education, I believe we've really been indoctrinated into putting institutions above ourselves," Wooten adds. "It takes work to overcome that."

Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR. She's on X as @MaraGordonMD .

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What's in this year's federal budget? Here are all of the announcements we already know about

Treasurer Jim Chalmers will hand down his third budget on Tuesday night, but has been tempering expectations for weeks in the lead-up, warning Australians not to expect a "cash splash".

Inflation remains a key challenge for the government, and we already have a pretty good idea of how Mr Chalmers plans to use his budget to provide cost-of-living relief while also trying to jump-start a slowing economy and navigate growing uncertainty overseas.

Here are the measures we already know about before the treasurer reveals all at 7:30pm AEST.

Short on time?

There's been no shortage of announcements in the lead-up to the budget. If you're interested in a specific topic, tap on the links below to take you there:

Cost-of-living relief

Education, training and hecs changes, tax changes, future made in australia, health and aged care, paid parental leave, domestic violence, defence and foreign affairs, environment, infrastructure, additional announcements.

Is your area of interest not covered?

• Tell us what other cost-of-living measures you're hoping to see included in this year's budget .

The bottom line

Will the budget be in surplus or deficit?

• The budget will deliver a surplus of $9.3 billion for the 2023-24 financial year, making it the second consecutive budget surplus in almost two decades
• That said, the following three financial years are all forecasted to have larger deficits than previously expected in December, but the size of each deficit is not yet known
• Overall, the treasurer says Australia's total debt has been reduced by $152 billion in the 2023-24 financial year, and the budget will benefit by a $25 billion boost in revenue upgrades

What does the budget mean for inflation and interest rates?

• The treasurer has repeatedly said he's kept inflation in mind when crafting this year's budget, and is confident that the measures won't contribute to it
• In fact, Treasury predicts inflation will fall to 2.75 per cent by December — well before the Reserve Bank's most recent forecast for the end of 2025 — due to yet-to-be-announced budget measures taking pressure off inflation
• For what it's worth, RBA governor Michele Bullock wasn't too concerned about the upcoming budget last Tuesday, saying she  would wait to see its impact first , but she said the treasurer reassured her that he was focused on curbing inflation  

The reworked stage 3 tax cuts form the centrepiece of the government's budget. They were announced in January, legislated in February and come into effect on July 1.

The changes to tax cuts originally legislated by the Morrison government mean that all Australian taxpayers who earn more than $18,200 (that is, more than the tax-free threshold) will get a tax cut.

Before Labor's changes, the original stage 3 tax cuts were skewed more heavily to higher-income earners .

A person with a taxable income between $45,000 and $120,000 will receive a tax cut of $804 more come July 1  under the revised stage 3 changes compared to the Morrison government's tax plan.

However, the government has hinted at other cost-of-living measures, with the treasurer calling the tax cuts the "foundation stone" of broader assistance.

Among those measures appears to be energy bill relief (in addition to what some states have already announced), with the treasurer pointing out that last year's measure curbed living costs and eased inflation.

Adjustments to rent assistance also seem likely, as do increases to JobSeeker and the aged pension.

Back to top

The biggest announcement in this area is the wiping out of $3 billion worth of HECS debts  triggered by last year's indexation of 7.1 per cent.

It means student debts will be lowered for more than 3 million Australians, with the average student receiving an indexation credit of about $1,200 for the past two years.

The debt relief will also apply for apprentices who owe money through the VET Student Loan program or the Australian Apprenticeship Support Loan.

Speaking of university, the government is aiming to tackle "placement poverty" by providing financial support to students to help make ends meet while they complete practical hands-on training as part of their course.

Under the scheme, those studying nursing, teaching or social work will receive a Commonwealth Prac Payment of up to $319.50 a week, but they will be subjected to means testing.

Similarly, apprentices willing to learn clean energy skills as part of their trade will be eligible to receive up to $10,000 in payments . The scheme already exists, but the government has broadened the eligibility to include apprentices in the automotive, electrical, housing and construction sectors based on industry feedback.

Universities will also be required to stop a surge in the number of international students, as part of the government's broader plans to cut annual migration levels back to 260,000 a year — much to the concern of peak education bodies .

Another  $90 million will be put towards 15,000 fee-free TAFE and VET places to get more workers into the housing construction sector , with an extra 5,000 pre-apprenticeship places provided from 2025.

While we can expect to hear more about the stage 3 tax cuts, it seems likely that the government will unveil other changes to tax in the budget to encourage business investment.

One such change will be the extension of the government's instant asset write-off scheme for small businesses for another year, allowing businesses with a turnover of less than $10 million to claim $20,000 from eligible assets.

However, the same measure from last year's budget is still yet to pass parliament — and businesses are urgently calling on them to pass the measure before it expires on June 30 .

In addition to spending more to attract skilled workers in the housing and construction sectors, the government is also tipping billions of dollars into building new homes across the country .

It's estimated the government will be putting roughly $11.3 billion towards housing, as the government works to deliver its promised 1.2 million new homes by 2030.

$1 billion will be spent on crisis and transitional accommodation for women and children fleeing family violence and youth through the National Housing Infrastructure Facility, which is re-allocated funding.

The government has also committed to providing $9.3 billion to states and territories under a new five-year agreement to combat homelessness, assist in crisis support, and to build and repair social housing — including $400 million of federal homelessness funding each year, matched by the states and territories.

Another $1 billion will be given to states and territories to build other community infrastructure to speed up the home-building process, including roads, sewerage, energy and water supplies.

The government has also committed to consulting with universities to construct more purpose-built student accommodation.

Overall, the funding announcements for housing build on the $25 billion already committed to new housing investments, with $10 billion of that in the Housing Australia Future Fund, which is designed to help build 30,000 social and affordable rental homes.

The government says the housing funding measures will also help take the pressure off the private rental market, which is experiencing record-low vacancy rates and surging growth in weekly rent prices.

Aside from the revised stage 3 tax cuts, the revival of local manufacturing is the other centrepiece of the government's budget this year.

The Future Made in Australia Act (which is often referred to without the "act" on the end) is bringing together a range of new and existing manufacturing and renewable energy programs under one umbrella, totalling in excess of $15 billion.

In other words, the government is putting serious taxpayer money towards supporting local industry and innovation, especially in the renewable energy space.

A number of measures have already been announced (or re-announced), including:

• $1 billion for the Solar SunShot program to increase the number of Australian-made solar panels
• $2 billion for its Hydrogen Headstart scheme to accelerate the green hydrogen industry
• $470 million to build the world's first "fault-tolerant" quantum computer in Brisbane , matching the Queensland government's contribution
• $840 million for the Gina Rinehart-backed mining company Arafura to develop its combined rare earths mine and refinery in Central Australia
• $230 million for WA lithium hopeful Liontown Resources , which is also partly owned by Gina Rinehart
• $566 million over 10 years for Geoscience Australia to create detailed maps of critical minerals under Australia's soil and seabed
• $400 million to create Australia's first high-purity alumina processing facility in Gladstone
• $185 million to fast-track Renascor Resources' Siviour Graphite Project in South Australia
• A $1 billion export deal to supply Germany with 100 infantry fighting vehicles , manufactured at Rheinmetall's facility in Ipswich

All up, the government is spending an extra $8.5 billion on health and Medicare in this year's federal budget, with $227 million of that put towards creating another 29 urgent care clinics.

Millions of dollars are also being poured into medical research, including $20 million for childhood brain cancer research , and a $50 million grant for Australian scientists developing the world's first long-term artificial heart .

Another $49.1 million is being invested to support people who have endometriosis and other complex gynaecological conditions such as chronic pelvic pain and polycystic ovarian syndrome. The funding will allow for extended consultation times and increased rebates to be added to the Medicare Benefits Schedule.

As for aged care, the government hasn't announced anything specific for the sector, nor has it outlined its response to the Aged Care Taskforce report that was delivered in March.

Parents accessing the government-funded paid parental leave scheme will be paid superannuation in addition to their payments from next July .

Under the current program, a couple with a newborn or newly adopted child can access up to 20 weeks of paid parental leave at the national minimum wage — however that figure will continue to rise until it reaches 26 weeks in July 2026 .

The plan, which Labor will take to the next election, would see superannuation paid at 12 per cent of the paid parental leave rate, which is based on the national minimum wage of $882.75 per week.

The cost to the budget is not yet known, however a review commissioned by the former government estimated that paying super on top of paid parental leave would cost about $200 million annually.

About 180,000 families access the government paid parental leave payments each year.

The federal government has pledged almost $1 billion to combat violence against women , including permanent funding to help victim-survivors leave violent relationships, and a suite of online measures to combat online misogyny and prevent children from viewing pornography.

The $925.2 million will go towards permanently establishing the Leaving Violence Program over five years, after it was established as a pilot program in October 2021 known as the Escaping Violence Program.

The program will provide eligible victim-survivors with an individualised support package of up to $1,500 in cash and up to $3,500 in goods and services, plus safety planning, risk assessment and referrals to other essential services for up to 12 weeks.

While the funding has been broadly welcomed, survivors and advocates want to see more investment .

The package also includes funding to create a pilot of age verification technology to protect children from harmful content, including the "easy access to pornography" online, which the government says will tackle extreme online misogyny that is "fuelling harmful attitudes towards women".

The federal government is planning to spend an extra $50 billion on defence over the next decade , meaning Australia's total defence spend will be equivalent to 2.4 per cent of its gross domestic product (GDP) within 10 years.

All up, the government is planning to invest a total of $330 billion through to 2033-34, which includes the initial cost for the AUKUS initiative to purchase nuclear-powered submarines.

Part of that $50 billion will be spent on upgrading defence bases across northern Australia, with $750 million to be allocated in the budget for the "hardening" of its bases in the coming financial year.

More than $1 billion of that funding will also be spent on an immediate boost on long-range missiles and targeting systems.

In the Pacific, Australia has committed $110 million to fund development initiatives in Tuvalu , including an undersea telecommunications cable and direct budget support.

The government has also pledged $492 million to the Asian Development Bank to provide grants to vulnerable countries in the Asia-Pacific.

The only dedicated announcement for the environment so far is the scrapping of the waste export levy , also known as a "recycling tax".

The proposed $4 per tonne levy was first legislated by the Morrison government in 2020 in a bid to reduce and regulate waste exports, after China announced it would no longer handle Australian rubbish.

Waste industry players had been concerned that once the levy was introduced in July, it would have caused more waste to be sent to landfill instead of being recycled.

The scrapping of the waste export levy is part of Australia's broader move to manage its own waste.

A slew of funding commitments have been made around the country, including a $1.9 billion funding commitment for upgrades in Western Sydney, ranging from road improvements to planning projects and train line extensions.

The government is also putting $3.25 billion towards Victoria's North East Link, which is being built between the Eastern Freeway and M80 Ring Road in Melbourne.

Ahead of the Brisbane Olympics in 2032, the government is also chipping in $2.75 billion to fund a Brisbane to Sunshine Coast rail link , matching the amount promised by Queensland Premier Steven Miles. (That said, $1.6 billion had been previously announced by the federal government.)

Also in Queensland, the Bruce Highway will receive $467 million for upgrades, while Canberra will receive $50 million to extend its light rail.

A proposed high-speed train line between Sydney and Newcastle will also receive $78.8 million to deliver a business case for the project.

The government will also put $21 million towards the creation of a national road safety data hub.

There are several other funding commitments the government has made in the lead-up to the budget that don't fit neatly into the categories above.

The government will spend $161.3 million on creating a national firearms register , which will give police and other law-enforcement agencies near real-time information on firearms and who owns them across the states and territories.

The money will be spent over four years to establish the register, and comes after state and territory leaders agreed to set up the register in December last year. The government has described the register as the biggest change to Australia's firearm management systems in almost 30 years.

Another $166.4 million will be spent on expanding anti-money-laundering reporting obligations , requiring real estate agents, lawyers and accountants to report dodgy transactions in a move that will bring Australia in line with the rest of the developed world.

And ahead of the 2032 Brisbane Olympic Games, the government has given the Australian Institute of Sport (AIS) a $249.7 million funding boost to upgrade its facilities to support local athletes.

The government has also committed to a $107 million support package for farmers, after announcing it will end Australia's live sheep export trade by 2028 .

Farmers and regional communities will also benefit from a $519.1 million funding boost to the government's Future Drought Fund.

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