Katrina Messiha is a Marie Curie doctoral fellow within the Health CASCADE project. Her research focuses on developing theoretical principles for co-creation in public health.
Rabab Chrifou is a Marie Curie doctoral fellow within the Health CASCADE project. Her research focuses on the ethical aspects of co-creation within public health.
Katrina and Rabab carried out interviews with researchers and facilitators that had published work on and had previous experience with co-creation, respectively, in order to direct their research in evidence-based co-creation principles and ethics. A topic that they both picked up on in their conversations was the notion of a ‘true’ and ‘false’ form of co-creation.
A key consideration in exploring theory and ethics relating to co-creation is its ‘true’ versus ‘false’ form – in other words, whether there is a ‘deep’ co-creation that is distinguished against the notion of tokenistic co-creation. Interviews with researchers and facilitators with expertise regarding co-creation revealed their thinking around this.
When participants were asked to define co-creation, examples of insights given included: ‘collaboration between different groups of stakeholders to develop a mutually-beneficial outcome’, ‘a process where, we have people representing organisations, they come together and they try to create something’, ‘co-creation is about participants being involved in the whole process, from initiation to commenting on the final policy’, and ‘co-creation is an umbrella and includes different ways of participation, including participatory health research’.
The underlying definitions, extracted from our interviews, suggests that co-creation (directed at health improvement) consists of ‘participants’ who engage in the process of creating something with a goal (for instance, of obtaining a beneficial health outcome). Furthermore, our interviewees mentioned that ‘true’ co-creation can be characterized by intense time investment, collective value creation, combining different types of knowledge, more obligations with regards to inclusiveness, focus on reciprocity and the presence of a preliminary process to arrive at a shared question.
In terms of what does not include co-creation, the participants identified that it is ‘something that doesn’t benefit all groups of stakeholders’, ‘tokenism: having your own ideas but you involve others to strengthen your own ideas’, and ‘doing it on your own’. But there were some different views on this topic. For instance, one participant felt that consultation is very useful for co-creation, whereas another participant said that it is not ‘true’ co-creation, thus perhaps more tokenistic. That said, some participants argued that the distinctive features of ‘true’ co-creation should be preserved, and that one has to be careful not to overstate it to avoid devaluing the concept of it over time.
Besides these two extremes of ‘true’ and ‘false’ co-creation, some participants referred to the nature of co-creation. As one of the participants stated: ‘So there’s deep co-creation and then there’s surface co-creation and that deep co-creation, it means we are on equal terms with those that we co-create with.’ Also, co-creation, as is understood by the participants, may not be the ultimate solution for the concerned public health issue. Other, less intense forms of participation, may be equally valuable for the envisioned purpose: ‘Within participatory work, co-creation is at the top of the tree, co-creation describes a process of a certain type which is right in certain circumstances, and other approaches are equally right in that circumstance.’
Overall, the interviews showed that co-creation cannot be categorised as easily as Arnstein’s Ladder (1969) portrays participation to be, since participation itself is nuanced and not straightforward. Whilst the interviews served to stimulate thinking around what potentially counts as true co-creation, our first impression is that the fluidity around the concept and approach of co-creation leaves room for us to further scrutinise both the theoretical and ethical implications of it within public health. This will be achieved through thorough systematic work and a novel angle, additionally applying it to several real-life co-creation-based projects, which can enrich the process and strengthen evidence-based research.