Aims and study design.

The parent study was a retrospective pre-post intervention study aimed at scaling and evaluating a dissemination intervention with the public in public libraries in the cities of Québec and Montreal [24]. The parent study’s intervention grounded its design on the Integrated Knowledge Translation framework (IKT) [14,29,30]. This framework recognizes that knowledge is a value-laden social product developed through a dynamic, non-linear, and collaborative process with those who use it [14,29–32]. Following the IKT framework, the parent study’s research team purposively recruited targeted knowledge users as research partners, including a patient partner (i.e., a patient or informal caregiver trained in research practices), public library officials, communication specialists, physicians, and researchers. Together, the research team and the targeted knowledge user representatives jointly co-developed and operationalized an overarching dissemination and knowledge exchange strategy designed for the public defined as "citizen workshop". To do so, they all participated and developed the components of the project, that is, the selection of the research findings to disseminate; the development of the citizen workshop’s content and format, including the patient video testimony; the actualization of the citizen workshop in public libraries; and the citizen workshops’ evaluation. The topic of potentially inappropriate medication was selected because it was determined to concern more people than if the topic had been condition-specific. The thought was that it would attract more people to the workshops.

Study intervention, sample and settings.

Citizen workshops are public interactive workshops aimed at disseminating and exchanging empirical research knowledge to citizens in public settings. Each workshop–entitled "Des medicaments en trop?" (i.e., «Too many medications?")–comprised a computerized 45-minute slide deck presentation that was presented by a physician and facilitated by a communication specialist in French. The slide deck presentation also included a video of the patient partner providing her experience related to the research findings presented during the workshop. This presentation was followed by a 45-minute knowledge exchange session between the physician-speaker, the communication specialist-facilitator and the public. The knowledge disseminated and exchanged in the workshops focused on selected primary care research outcomes addressing the topic of potentially inappropriate medications (PIMs) among the elderly [33]. The research team of the parental study conveniently recruited 18 physicians to present the selected findings and six communication specialists to facilitate the workshops. A total of 362 adult citizens voluntarily participated at the workshops. Overall, 27 citizen workshops were held from April to May 2019, in 26 public libraries that agreed to participate in the research project in Montreal and Quebec City. Each city’s director of libraries played a key role in inviting all the libraries in their respective cities to participate in the project. Selection was based on a convenience sample, with libraries that had the required amenities (ex: space) and the availability to hold the workshop in the Spring of 2019. Although we did not collect information on the specific profile of each library’s patrons, there was a diversity in their location, some serving larger proportion of immigrants and older adults, yet limited to urban settings.

Data collection.

The parent study’s research team audio recorded 22 out of 27 of the workshops’ knowledge exchange discussions, i.e., the session after the slide deck presentation [25]. Five recordings were lost due to technical issues during the workshops. The final 22 recordings were transcribed verbatim using a commercial service and validated by one of the authors (JS). Citizen participants’ sociodemographic characteristics such as age, sex and highest level of education were also collected. The parent study also collected other data from self-administered questionnaires with closed and open-ended questions and direct observers’ notes in predefined data grids on the workshop’s settings and format characteristics.

Ethical considerations.

Participants provided a verbal consent, which was aligned with the ethical approval received. To know the number of participants in each workshop, we used an attendance sheet. We gave a brief oral presentation of the project and distributed an information sheet about the research project and two evaluation questionnaires with predetermined unique numerical codes. We also specified that the workshop was going to be recorded and that any participant who does not wish to be recorded may decide to withdraw or not participate in the discussion. Consenting participants completed the questionnaires anonymously and participated in the discussion.

The study was approved by the research ethics committee of the Centre universitaire intégré de santé et services sociaux (CIUSSS) de la Capitale-Nationale [Project 2017-2018-19]. The committee noted that the project was of minimal risk and that there was no need to present a written consent form to participants.

Data characteristics.

Our secondary analysis used clean, uncoded transcripts from 22 citizen workshops administered and evaluated in the parent study [25]. After reviewing all available data, we determined not to use the data collected from the open-ended questions in the self-administered questionnaires or the direct observers’ notes, as that data did not allow us to answer our research question. We decided to use the transcripts as we were interested in the dialogical nature of the discussions held during the workshops, i.e., the non-hierarchical, symmetrical, and two-way approach to communication. We viewed these discussions as a joint effort among equal partners to seek true understanding and knowledge [46]. Although these group discussions did not follow predetermined questions, the initial information session delivered by the physician-speakers and communication specialist facilitators through the presentation on PIMs guided participants’ discussions while leaving room for emergent opinions and beliefs [47]. In addition, the communication specialist made sure the environment was respectful, and all participants participated comfortably and ensured that people stayed on topic, putting the audience’s questions into perspective, and rewording the doctor’s answers when necessary. Based on the available transcripts collected in the parent study, sixteen physician facilitators, six science communication facilitators, and 322 citizens participated in the study across 22 public library citizen workshops. Of the citizen population, 70 were male, and 198 were female (Table 1). The mean age was 64.7 years of age, and most had completed post-secondary education (Table 1). On average, 14 citizens participated in each workshop. Most physician-speakers and communication specialist-facilitators were female, with only four physician-speakers and two communication specialist-facilitators being male. Due to difficulty in recruiting physicians, the invitation was extended to family medicine residents. There was a total of 16 physicians and 2 residents. They were younger than Quebec’s physician population and were all able to communicate fluently in French.

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Table 1. Citizen participants’ characteristics.

https://doi.org/10.1371/journal.pone.0289153.t001

Data analysis.

One author (FKB), a qualitative researcher, performed the analysis of all transcripts. A second researcher (AG) analyzed 10% of the transcripts. FKB regularly met and discussed the coding process and findings with AG and two researchers (HTVZ and ML) familiar with the overall project. The coded data was then iteratively discussed and interpreted by all the members of the team. We analyzed the text in French and produced analytical results in English. Data were managed and analyzed using Nvivo^®v.12 qualitative analysis software [48]. The analysis followed an inductive and iterative two-staged thematic analytical approach similar to grounded theory: a first open-coding descriptive stage, where FKB and AG stayed very close to the data (i.e., indent-by-indent coding) to describe the data’s characteristics; and a second interpretative focused-coding stage, in which FKB and AG adopted the constant comparison method [49]. FKB systematically drafted analytical memos to enhance analytical sensitivity and refine the initial descriptive codes into abstract categories and themes [36,49]. As the analysis moved forward, the team discussions of the coding process and emergent concepts helped develop new interpretative insights leading to a more refined analysis. As suggested by Thorne, interpretative description began on the grounds of analytical, "informed questioning" [36,39]. Our data analysis was guided by the sensitizing concepts of epistemological values as identified in Tonelli [50] and Parker et al. [51], and the foundational concepts of Kleinman’s multilayered explanatory model [52]. Epistemological values and culturally patterned social and personal views of sickness and health enabled us to identify participants’ preferred sources of knowledge and ways of thinking about knowledge [49–52]. FKB also remained engaged with the data for an extended time and ensured to provide thick descriptions and audit trail of the data [36]. Finally, the researchers analyzing the transcripts practiced reflexivity throughout the analysis process, that is, the practice of continually reflecting on their perspectives in the study [53,54]. Before starting the analysis, FKB and AG wrote a document setting out their previous research experiences and perspectives on their understanding of knowledge to understand their preconceptions and how they might affect their data interpretation. They referred to this document during the analysis process. All researchers had no relationship with citizen participants, and FKB and AG, who conducted the analysis, had no relationship with the physician and communication specialists. Finally, trustworthiness was also established by debriefing with the co-investigators of the parental study throughout the whole research process.

Sociocultural beliefs.

Participants shared several culturally and socially informed beliefs when discussing PIMs with the public during workshops. Participants voiced these beliefs as knowledge on medications, health, sickness, treatments, health professionals’ roles, and encounters in the clinical settings. Sociocultural beliefs were constructed as shared assumptions understood to be true without evidence and derived from localized direct and indirect experiences. Often, beliefs were expressed as anecdotal evidence, i.e., knowledge based on reports of individual cases rather than on systematic research or analysis. Physician-speakers’ anecdotal evidence derived from professional experiences in clinical settings, expert opinions that included medical expert consensus, consultation and clinical experience of other health professionals, and in a few instances from family and friends. Communication specialists-facilitators’ anecdotal evidence stemmed from their own experiences with the health care system and research, from their own professional experiences as scientific journalists and communicators, and the expert opinions of health professionals and scientific media. Citizens drew most of their anecdotal knowledge from health experiences with illnesses, medications and side effects, experiences accessing and navigating the health system and health care professionals, and experiences accessing and interacting with health care information, in some instances, also from personal, professional experiences as health care workers. Finally, citizens valued and often used other sources of knowledge beyond the health system, such as family, friends, traditional and online media. Physician-speakers and communication specialists-facilitators discussed a set of common beliefs shared among health providers and communication specialists-facilitators. They believed in scientific progress and its ability to improve health and health care naturally and organically over time. These participants also asserted beliefs in new clinical practices, such as shared decision-making (SDM) and deprescribing, as this one physician described: “In the past, doctors were more paternalistic and then (…) they are going to give more drugs. But now it’s much more (…) non-pharmacological. Then everything that is the Deprescribe movement, that is a national movement.” (Workshop 15)

However, they also indicated that these beliefs were not shared consistently among doctors. Similarly, physician-speakers and communication specialists-facilitators discussed beliefs as social and cultural trends shaping citizens’ expectations, knowledge, and behaviours.

Advertisement and food industries played an important role in shaping expectations among citizens, feeding off what physician-speakers and communication specialists-facilitators defined as a medicalized society, that is, a society organized around a common trust in medications’ beneficial effects. Physician-speakers discussed media’s influence in promoting misleading notions about medications, about specific types of health practices, such as diets, homeopathy, and consultation practices, e.g., turning to "Dr. Google" rather than to doctors to learn about their health status and treatment options. Whereas physician-speakers and communication specialists-facilitators focused on beliefs of scientific development and clinical practice innovation, citizens held differing beliefs. Citizens often voiced anti-medication views. Anti-medication beliefs often meant avoiding medications and preferring natural products or lifestyle behaviours. These beliefs also shaped citizens’ views and knowledge of health care professionals and the health care system. Some citizens believed doctors had all the answers to their questions and could fix all their health problems. Others believed physicians prescribed too many medications, or that physicians in academic clinical institutions were less qualified, or that pharmaceutical companies influenced physicians’ clinical and prescribing behaviours:

1. “I think that very often doctors are prescribing drugs [for] people 65 and older, but doctors are prescribing a lot and too much.” (Workshop 23)

Value-based knowledge.

At the most abstract level, participants discussed ways of thinking based on values. Values are preferences, wishes, needs, positive and/or negative evaluations and judgments. Values represented what was important to individuals. All participants referred to both patients’ and physicians’ values.

Physician-speakers and communication specialists-facilitators explicitly and implicitly expressed that values influenced and shaped their thinking. They used value-based reasoning during the knowledge exchange sessions when discussing patients’ freedom of choice. Choice was framed as respecting patients’ autonomy, ensuring fair and transparent access to knowledge and fair decision-making in health care. Physician-speakers and communication specialists-facilitators discussed patients’ autonomy as respecting and empowering patients to gain a greater role and become active participants in health care, as this physician described: “It is always the patient who decides first.” (Workshop 21)

Concurrently, they framed patients’ freedom of choice as patients’ fair access to knowledge together with health care providers’ support, ensuring patients received clear and transparent knowledge for informed decision-making. Similarly, citizens shared the same understanding of freedom of choice as respecting patient autonomy, ensuring patient empowerment and partnership through education and fair participation in decision-making. Yet, citizens expressed these values by describing the lack of opportunities for patient empowerment and the lack of participation in health care decision-making. In other instances, some citizens expressed appreciation collaborating with physicians, and others stressed their active role in controlling their health, as this citizen emphasized:

1. “I think that we are the orchestra directors at the moment. Because in my case, that’s what I’m doing, I’m the one who goes from one to the other and asks to look at this or that thing.” (Workshop 7)

Citizens expressed the value of trustworthy sources of knowledge, both in and beyond the health system. Citizens discussed trustworthiness in terms of transparency and the legal and ethical conduct of health professionals. Some citizens voiced their trust and desire to trust their health professionals. Others expressed concerns regarding the integrity of health professionals’ recommendations, behaviours, roles. For example, citizens questioned pharmaceutical companies and physicians’ relationships and questioned pharmacists’ roles as both vendors and chemists interested in selling drugs rather than, or only, providing independent, trustworthy information. Citizens expressed worry and mistrust related to health care providers’ recommendations, as illustrated by this citizen: “At what moment, when a general practitioner gives us medication do we think whoa… because then I relied on my doctor and then… you know, I, I took some medication. Is there, uh, any place we can go to for information? I mean, how do I know that this, this, this doctor knows everything.” (Workshop 19b)

Citizens identified the need for transparent communication with their health providers as a condition for trust. Citizens valued clear instructions on the ways to navigate the health system–e.g., differences in accessing different clinical settings, such as family physicians versus hospitals, as well as clear and detailed explanations of their treatment alternatives:

1. “Speaking of options, I’ve never seen a doctor who said, uh, you have three options, and I’ll [give you the list here]. They say: Ok, you’re going to take this, you’re going to take this and you… I have… Do doctors now have to give us options?” (Workshop 19a)

Physician-speakers and communication specialists-facilitators also discussed trustworthiness as a value central to their way of thinking yet framing it in terms of credibility and accountability. First, they described scientific evidence as a source of accountability, often presented as opposed to online, non-health or non-research-related sources of knowledge. Second, they expressed these values as providing regular check-ups and medication audits as well as ensuring health providers’ and patients’ collaboration. Physician-speakers and communication specialist-facilitators also included values related to ethical principles inherent in clinical practice and professionalism. These participants described ethical principles of clinical decision-making, such as avoiding harms and delivering benefits, professional deontological code and medical training as essential forms of knowledge shaping their views and behaviours.

Credibility and accountability, together with medical education, law, professional and governmental authorities, such as the College of Physicians, were also discussed as established means to ensure protecting the public’s safety by regulating the practice of medicine through licensing policies, as this communication specialists-facilitator described: “You are dealing with a doctor, you are dealing with someone who is a member of a professional order. (…) we know all about the training he received, the courses, the uh… No, but all that when you deal with a naturopath, he has no professional order, and has no mandatory naturopathic training. You go there, uh, it’s a Russian roulette, eh? But no guarantee.” (Workshop 13)

Citizens shared physician-speakers and communication specialists-facilitators views on accountability as a relevant value and voicing the desire for care continuation and coordination, including audit and monitoring of their medication list and use of medications. Additionally, citizens described accountability also as defined roles and responsibilities. In the context of the conference topic—i.e., PIMs—this meant defining which physicians, specialists or family physicians, were responsible for prescribing and reviewing patients’ medications. Citizens discussed the government’s role and responsibilities, the market, pharmaceutical companies and insurance companies, addressing issues of accountability for selling over-the-counter drugs, ensuring that medications are regularly reviewed, and the government’s control over insurance companies.

Institutional knowledge.

When discussing PIM, participants, especially citizens, expressed knowledge as understandings about the interplay of relationships among institutional actors and material resources embedded in practices, routines, and procedures. Participants spent time discussing institutional knowledge as the understanding of regulating and organizational frameworks that define the distribution, access, and use of health care resources. In particular, participants addressed knowledge as practical knowledge on accessing and navigating health care services. Citizens identified both barriers and facilitators in accessing and navigating the health care system. These participants described the shortage of family physicians and limited consultation time with providers as primary obstacles to care: “When you say: talk to your doctor. They don’t listen to us that much, and then they can’t wait for us to get out of the office. Uh, well, if he’s standing, he turns his back on us, and then we go, we’re going to have his back on us, no communication. I’m telling you, it’s a terrible thing to live through.” (Workshop 19a)

Yet, citizens also described being aware of alternative points of access to health care and knowledge, mostly indicating pharmacists as a common alternative to physicians: “But in fact, pharmacists are extremely open; they have, they are not in the rush of the appointment.” (Workshop 19a)

Citizens relied on family physicians and traditional sources of knowledge, including family, friends, and media, to learn to navigate the health system and access care. Physician-speakers and communication specialists-facilitators identified family physicians and pharmacists as primary sources of knowledge. They also discussed trustworthy sources of knowledge from traditional and online outlets, such as conferences, Doctissimo, Extenso, Passeport Santé, and tools, such as Carnet Santé Quebec and Choosing Wisely. However, citizens identified the lack of coordinated care and lack of knowledge and skills to navigate the health system as another barrier to health care and knowledge. They often described disagreement among different healthcare professionals as a cause of disorientation and uncertainty regarding which health recommendation to follow: “My question was how do you deal with a doctor, the one, the neurologist who wants to prescribe an Alzheimer’s drug, and the cardiologist who says: No, no, no, it makes tachycardia, he already has a low pulse.” (Workshop 7) Physician-speakers and communication specialists-facilitators discussed different health professionals’ roles and duties instead, describing the family doctor as the gatekeeper of care and the pharmacist as the medications’ expert. Concurrently, these participants indicated how health professionals collaborate and work in institutionalized frameworks aimed at coordinating teamwork: “Doctors these days, we work in FMGs, in family medicine groups, and when your doctor works there, sometimes you have access to a pharmacist (…) and geriatricians, who are specialists in geriatric problems. (…) Often your family doctor has access to many specialists, including a nurse including a pharmacist. Ask your doctor: do you have a pharmacist in the building? He might say no, he might say yes. Tell him you want to meet them. It’s not expensive for the doctor. The doctor writes a prescription and then says: perfect, follow up in the pharmacy.” (Workshop 18b)

When discussing the role of institutions, physician-speakers and communication specialists-facilitators talked about systemic barriers to care delivery. These participants viewed scarce resources and an overburdened health system limiting the availability of human healthcare resources, doctors’ time with patients and coverage of alternative medicine services. Citizens, on the other hand, did not consider systemic barriers. Instead, financial and medical insurance barriers related to health care and medication costs represented a matter of concern for them, as these matters affected their health and health care.