Collaboration between community members, researchers, and policy makers drives efforts to solve complex health problems such as obesity, alcohol misuse, and type 2 diabetes. Community participation is essential to ensure the optimal design, implementation and evaluation of resulting initiatives. The terms ‘co-creation’, ‘co-design’ and ‘co-production’ have been used interchangeably to describe the development of initiatives involving multiple stakeholders. While commonalities exist across these concepts, they have essential distinctions for public health, particularly related to the role of stakeholders and the extent and timing of their engagement. We summarise these similarities and differences drawing from the cross-disciplinary literature, including public administration and governance, service management, design, marketing and public health. Co-creation is an overarching guiding principle encompassing co-design and co-production. A clear definition of these terms clarifies aspects of participatory action research for community-based public health initiatives.
Increasing the participation and involvement of key stakeholders (e.g. employers, partners, customers, citizens, policy makers, end-users) can strengthen innovation, implementation and overall success of population health initiatives.1,2 Engaging, respecting and applying these multiple perspectives provides context-specific, practical and relevant knowledge with flow-on impacts on health equity, citizenship and social justice.1,3 The engagement of stakeholders in the development and implementation of initiatives is captured under the broader term ‘Participatory Action Research’ (PAR).3 More recently, co-creation, co-design and co-production have been used to describe specific PAR-type methods.
Each of these terms has emerged from different fields and holds nuance in meaning and application depending on the area in which the concept is applied.4 Apart from the differences, the commonality in emphasis is on the input from consumers or citizens in the design and/or delivery of a product, service, initiative or innovation.5 Limited attempts have been made to establish clear differences and applications between these three terms6, although comparisons have been explored between co-creation and co-design7,8 and between co-creation and co-production.9,10 This paper presents distinguishing characteristics between co-creation, co-design and co-production, and provides a perspective to integrate co-production and co-design into an overarching approach for designing, implementing, and evaluating effective public health initiatives. To our knowledge, this is the first time that co-creation has been presented as an overarching construct that includes co-design and co-production for guiding public health initiatives.
Different aspects help to differentiate co-creation, co-design and co-production. Table 1 summarises key factors that separate these three terms, with distinctions made to highlight the specific attributes observed in the literature when referring to each term.
|Focus||Consumer and experience centric
High level of information processing
|Centred on consumers’ insights to establish new priorities, plans and strategies for improvement||Production- and company-centric|
|Key stakeholders||All relevant stakeholders involved in the process (e.g., consumers, managers, employees, community)||Service users, implementers, and procurers||Managers and employees|
|Stakeholder role||Very active: provide continuous input to service provider throughout the process
|Active: equal and reciprocal relationship between all stakeholders in the improvement process
Useful tool in product and service design
|Passive: rely on the influence of the physical environment provided
Perceived as a resource
Describe acceptability and feasibility of pre-determined strategy
|Stakeholders’ participation||Repeated interactions and transactions across multiple channels
Help to produce knowledge and skills
Collaborative cooperation in all steps of the process from problem definition, design of solutions, and implementation and evaluation of changes.
|Consumers co‐lead the development, design, implementation and evaluation of activities, products and services||Mainly at the end of the value chain|
|Communication||Ongoing dialogue with diverse stakeholders
Bidirectional and transparent communication
|Trusting and open communication||Listening to consumers
|Value creation (e.g. psychological, economic value or a social good)||Creation of unique personalised experiences – ownership and engagement in subsequent action||Intrinsic values of the process.
Lived experiences of all parties involved add value to the final product or service
|Extraction of economic value
Quality products and services
|Resultant initiative||Is created with consumer engagement at all stages of problem definition, boundary-setting etc||Designed with a clear outcome in mind but consumer engagement to firm boundaries and approaches||Designed prior to engagement with consumer|
|Possible outcomes||Creates value of a good or service using the views of diverse stakeholders||Improved design outcomes and enhanced social inclusion||Enhances the value of a good or a service|
Co-creation promotes the creation of value by engaging diverse stakeholders in the process of understanding complex problems, and designing and evaluating contextually relevant solutions (Table 1).15 This value can take multiple forms: for the individual it can be psychological (e.g. feelings of appreciation) or economic (e.g. greater earnings). For organisations, value is most often economic (e.g. lower costs, improved productivity) or a social good.1 Value co-creation can be achieved through the constant feedback from multiple interactions between stakeholders, thereby benefitting the stakeholders involved.
Co-creation refers to the collaborative approach of creative problem solving between diverse stakeholders at all project stages. It emphasises diverse stakeholders at all parts of an initiative process, beginning with determining and defining the problem through to the final stages of a project.12,16 The plan of collaboration is jointly set by co-initiating stakeholders who call for collective action.12,14-16 In public health, these co-initiators could be public agencies (e.g. health departments, community health), stakeholder groups (e.g. patient representatives, maternal and child health nurses) or citizens’ representatives (e.g. breast feeding mothers’ group, active transport lobby) concerned by specific issues such as neighbourhood crime, equal access to healthcare or environmental concerns.14 For example Brimblecombe et al.17 engaged community members, retailers and academics to create a transformative problem-solving solution in remote community stores in Australia. The co-creation process involved identifying the need for a healthier food retail environment, the co-design of a feasible strategy to achieve identified solutions (i.e. restricting merchandising of discretionary foods), and the optimisation of resources to sustain the implementation. The results reported an overall reduction in sales of targeted confectionery and sugary drinks as a result of a co-created initiative that benefited both retailers and public health.
Co-design describes active collaboration between stakeholders in designing solutions to a prespecified problem. It promotes citizen participation to formulate or improve specific concerns (i.e. service or product improvement, better prevention activities, more resources, better trained health promotion staff and, evidence informed initiatives).7 Co-design is not always formally documented and can take the form of group problem solving, critically after the problem has been determined.18 Bogomolova et al.19 describe co-design as a seven-step systematic method that was used to develop a program that promoted health and wellbeing in a supermarket in collaboration with consumers, supermarket staff and academics. The process involved a series of co-design workshops to generate creative solutions for a storewide implementation program. Due to the high volume of ideas and strategies, these were reviewed by retailers and academics in collaboration, to prioritise and implement the most attainable strategies and create a route for next iterations of the program. Results showed that the chosen strategies helped to increase consumers’ knowledge about healthier food choices. This study shows the importance of collaborating with stakeholders from the early stages of the co-creation process through co-design, which can enable successful implementation and positive results.
Co-production engages stakeholders in the implementation of a previously agreed solution (strategy) to a previously agreed problem and focuses on how to allocate resources and assets within these constraints, to achieve better outcomes.7,12,20 Etgar20 suggests that co-production occurs after the initiative was designed and takes place at the point of implementing the initiative. Sharpe et at.6, describes the development of services for children and young people living with diabetes in East London through a process of co-production. The process involved consulting young people to better understand barriers and options they encountered after receiving a diabetes diagnosis and in using National Health Service services and the type of changes they would like to see. Their input led to a series of planning sessions between health practitioners to transform the local health diabetes services. Through this co-production process, young people were identified as essential agents for the delivery of these improved services. This example differs from co-design, as the goal was to improve an already available service that could be optimised. In this sense, the delivery of the health service could not be successfully co-produced without the input of the consumers.
Co-creation engages stakeholders before the problem is defined and considers that stakeholders (e.g. suppliers and consumers or citizens) are not necessarily on opposite sides but can collaborate to find new shared values and opportunities for mutual benefit in defining the problem and subsequent solutions.21 The extent and timing of stakeholder engagement are critical distinctions between co-creation, co-design and co-production (Table 1). Since co-design serves as a tool for co-creation, and co-creation involves different stakeholders in the co-production of a service, co-design and co-production can be positioned under the umbrella of co-creation. The principles of open innovation and participatory design have helped to integrate and disseminate co-creation as a reference to participation in complex problems.18
Co-creation approaches are difficult to compare due to the variety of context where they are applied.18 Yet the principles of participation, involvement, and engagement from participatory action research can serve as a guide to frame and contextualise interactions of co-creation in practice1,22, as these conditions are essential for co-creation.15 Greenhalgh, et al.1 identified four significantly diverse health initiatives that – at a co-creation level – have a common emphasis on power-sharing, reciprocity and mutual learning between stakeholders.
Co-creation aligns with participatory research23, engaging stakeholders in co-design or co-production approaches15 and enables those stakeholders to construct a shared agenda that facilitates a collective action, creating useful solutions.18,24 de Koning et al.25, analysed and clustered12 models of co-creation into a six-step continual research cycle. We used this framework to prototype the use of co-creation as an overarching concept that involves co-design and co-production (Figure 1). Figure 1 represents co-creation as a linear process, yet it entails continual improvement of outputs or outcomes as an incremental change and transformative innovation.12
Figure 1. Model for co-creation of public health initiatives (click on figure to enlarge)
The six steps shown in Figure 1 are described below:
Co-design prioritises the expertise and knowledge as essential resources in the design process7 and emphasises equal and reciprocal relationships among all stakeholders (Figure 1).13 We consider that the nature and methods of co-design can ensure the meaningful involvement of stakeholders during the first four steps (identify, analyse, define and design).27 Stakeholder involvement that goes beyond occasional participation or consultation is essential for the relevant design of solutions that suit the context of the involved parties.4,12,14,15 Active involvement requires power-sharing between stakeholders and a joint action that recognises trust and mutual dependence.12,13,28 Following the design stage, co-production will aid an effective realisation of the project. The perspectives and skills of stakeholders are central for the co-production of knowledge in the evaluation stage, which will inform the identification stage and relationship continuation, thereby promoting a continual cycle.16,29 Research co-design and co-production have established a set of principles that help create an environment that promotes equal partnership and values the knowledge and expertise of those involved in the process.13,28 The key principles for research co-production28 and co-design13 can guide the co-creation process so that the design, realisation and evaluation of an initiative ensure equity, citizenship and social justice.
Our understanding of co-creation is framed and contextualised within PAR. It provides basic steps and considerations to identify the specific issues to be addressed to inform the design of an initiative. The key principles suggested by co-design of strategies and co-production literature are required for enhanced social inclusion and empowerment. Co-creation is considered an overarching construct which is defined as the active involvement of stakeholders, from the exploration and articulation of problems or needs to the creation, implementation and evaluation of solutions or initiatives.15,16 In this vision, co-design relates to the design of an initiative that positions participants’ needs, expertise and knowledge at its centre. Co-production assists in the collaborative delivery and production of knowledge.
CV and JW are supported by the National Health and Medical Research Council (NHMRC) funded Centre of Research Excellence in Food Retail Environments for Health (RE-FRESH) (APP1152968). The opinions, analysis, and conclusions in this paper are those of the authors and should not be attributed to the NHMRC.
Externally peer reviewed, invited.
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