In research, the transition from naive practice to a robust co-creation approach is hindered by fragmented knowledge about co-creation. This fragmentation arises from diverse theories, methods and perspectives linked to co-creation, with very little cross-learning between fields and contexts. This complicates the synthesis of existing knowledge and hinders both replication and trustworthiness of the methodology as well as the development of coherent methodologies capable of addressing complex real-world issues and so-called “wicked problems”.
At Health CASCADE, we are part of a wider network of researchers funded to develop robust co-creation methodology and propose co-creation as a promising approach to contemporary societal challenges.
“We are aware of the challenges facing co-creation – from tokenistic engagement to consultation and participation fatigue. Therefore – we believe it is imperative to bring attention to the issues hindering co-creation and work collaboratively towards addressing them systematically”.
“Co-creation” found its first moment in service marketing research during the late 20th century, notably championing the co-creation of value by management theorists like Prahalad and Ramaswamy, advocating for customer involvement in the innovation process – but where does this story take us today?
As informed by Messiha (2023), there was a noticeable surge in the adoption of co-creation, co-design and co-production approaches within public health research since 2012. Agnello and Loisel et al. (2023) visualize this trend, with co-creation becoming a predominate term, outcompeting other related approaches, such as participatory research, in 2018 and onwards. But the question remains, are these co-approaches simply a rebranding of participatory research? To work towards answering this question, Messiha et al. (2023) systematically investigated the theoretical underpinnings of these co-approaches.
Theoretical Underpinnings of Co-creation
In the first systematic review of its kind, Messiha et al. (2023) identified only 10 articles out of a total of 4,874 containing theory and theoretical frameworks used for co-creation, co-design and co-production in public health research, with only six distinct theories and three distinct theoretical frameworks used. This revealed diverse, albeit limited, contemporary theoretical underpinnings of co-approaches. The most dominate theory, Empowerment Theory, was used in two co-creation articles. This finding is promising as Empowerment Theory has the potential to empower stakeholders, for example, to achieve enhanced wellbeing and influence research outcomes. Other identified theories and theoretical frameworks used for co-approaches in public health research range from Social Learning Theory with Narrative Theory to Amartya Sen’s Theoretical Framework of Social Justice. Such theoretical underpinnings have distinct uses and justifications for use, with most of such underpinnings reportedly used to inform analytical methods for co-approaches. Findings like this illuminate critical gaps about the theoretical underpinnings used for co-approaches. This review further offers valuable insights and guidance for future public health research using theories and theoretical frameworks for co-approaches.
Addressing Fragmentation
In Messiha et al.’s (2023) review, explicitness in terminology was key for transparency and preventing the risk of concept stretching of co-approaches. Yet, it was found that the working definitions for the co-approach terms were absent across the included studies. Therefore, Messiha et al. (2023) recommends future researchers to provide clear definitions for creation, co-design and co-production to allow for conceptual clarity as to give more strength to the interpretation of its relevant use of theoretical underpinning(s). To work towards this, we argue that more attention is warranted for consolidating the fragmented knowledge about co-creation.
To do this, Agnello and Loisel et al. (2023) conducted the largest known systematic review to date, by being inclusive of all potential keywords that represent co-creation and including citations from its inception in 1970 to the present day. This resulted in the identification of almost 165,000 citations, creating a need for using hybrid intelligence – entailing the combination of human and artificial intelligence (AI) working together, to screen this vast amount of potentially relevant literature. This AI-assisted systematic review resulted in the creation of a high-quality, curate database of literature about co-creation – proving that indeed, co-creation is likely fragmented. This database is now a resource for people to investigate co-creation and further consolidate the knowledge about how co-creation is designed and implemented globally.
The lack of consolidated knowledge about co-creation also raises questions about where implementation and evaluation science fits. To address this, Longworth et al.’s (2024) scoping review explores existing implementation and evaluation frameworks – and their relevance to co-creation. In the review, several frameworks were highlighted, including the CFIR Consolidated Framework for Implementation Research, the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, which may be used to guide implementation in co-creation, according to the specific purpose, while also considering the recommendations included in the study
Longworth et al. (2024) suggests some key lessons for co-creation, namely, the integration of implementation considerations from an early stage of the project and proposes embracing a system thinking approach to explore various levels of influence, contextual factors and systems factors. Emphasising the significance of partnering with stakeholders, the review recommends planning for an iterative and cyclical evaluation design, including an evaluation of the experience of those involved as co-creators. Furthermore, the use of iterative evaluation is recommended, including evaluation of the experience of those participating in the co-creation process. This is important given a constant need for adaptation and re-design during this emergent process – constituting a well-informed way if the process is being evaluated. This is a move away from the traditional approach to evaluation, which includes an evaluation at the end of a project.
We cannot do this alone
The first attempts to consolidate the knowledge about co-creation – from identification and consolidation of theoretical underpinnings of co-approaches, relevant and supportive literature (such as through the curated database) and frameworks as well as recommendations for implementing and evaluating co-creation – comprise great first steps in addressing knowledge fragmentation. Beyond this, the Health CASCADE network is working to further investigate co-creation, including its methodological basis, supportive technologies and the multi-sectorial applications of this basis – to underpin best practices for co-creation. Yet, this is the beginning of a long and much needed process of bridging the gap from a naive praxis to robust co-creation for designing and implementing solutions to complex and wicked public health challenges. Join us in investigating this valuable approach before it becomes too stretched and too fragmented to be trustworthy or effective.
References:
Messiha, K., Chinapaw, M.J., Ket, H.C., An, Q., Anand-Kumar, V., Longworth, G.R., Chastin, S. and Altenburg, T.M., 2023. Systematic review of contemporary theories used for co-creation, co-design and co-production in public health. Journal of Public Health, 45(3), pp.723-737.
Agnello DM.*, Loisel QEA.*, An Q., Balaskas G., Chrifou R., Dall P., de Boer J., Delfmann LR., Giné-Garriga M., Goh K., Longworth GR., Messiha K., McCaffrey L., Smith N., Steiner A., Vogelsang M., Chastin S., 2023. Establishing a Health CASCADE–Curated Open-Access database to consolidate knowledge about Co-creation: Novel Artificial intelligence–assisted methodology based on systematic reviews. Journal of medical Internet research, 25, p.e45059.
Longworth, G.R., Goh, K., Agnello, D.M., Messiha, K., Beeckman, M., Zapata-Restrepo, J.R., Cardon, G., Chastin, S. and Giné-Garriga, M., 2024. A review of implementation and evaluation frameworks for public health interventions to inform co-creation: a Health CASCADE study. Health Research Policy and Systems, 22(1), pp.1-12.
Image Sources: AI Generated on Canva Premium “Magic Media”.
About the authors:
Katrina Messiha, a Marie Skłodowska–Curie PhD fellow at the VU University Medical Centre in Amsterdam, is part of the EU Health CASCADE project funded by Horizon 2020. Her research focuses on theory-based principles for co-creation in public health.
Danielle Agnello, a Marie Skłodowska–Curie PhD fellow at Glasgow Caledonian University in Scotland, is part of the EU Health CASCADE project funded by Horizon 2020. Her research focuses on methods in evidence-based co-creation.
Giuliana Longworth, a Marie Skłodowska–Curie PhD fellow at Blanquerna University in Barcelona, is part of the EU Health CASCADE project funded by Horizon 2020. Her research focuses on building evidence-based co-creation: implementation and evaluation.
Quentin Loisel, a Marie Skłodowska–Curie PhD fellow at Glasgow Caledonian University in Scotland, is part of the EU Health CASCADE project funded by Horizon 2020. His research focuses on bridging the gap between humans and technology in the collective intelligence process of co-creation.