Co-producing health research: Saying what we mean, meaning what we say, and learning as we go
Dr. Bev Holmes, Interim President & CEO of MSFHR, draws on her research experience in health communications and knowledge translation to discuss the concept of ‘co-production’ in health research, what it means, how to facilitate it, and how to advance both co-production science and practice.
Co-producing health research: The importance of saying what we mean, meaning what we say, and learning as we go
Co-producing research is not a new concept, but it is gaining increased attention in health research under the terms ‘co-production’ and ‘co-creation’.
More than a decade ago, MSFHR launched two programs to help researchers and research users work together: the Health Services and Policy Research Support Network and the BC Nursing Research Initiative. At the time, these efforts were seen as leading edge for agencies like ours.
Through these two programs and other activities, MSFHR learned that bridging the worlds of researchers and research users is tough. Providing collaborative granting opportunities is only one piece of a complex puzzle that the research community is still working to solve.
In 2017, MSFHR and funding agency colleagues worldwide are still pushing boundaries, committed to maximizing research impact. The concept of co-production or co-creation of research continues to be discussed in materials I read and events I attend. For example:
- I recently presented on knowledge translation (KT) at two Australian partnership centres, collaborations funded by Australia’s National Health and Medical Research Council, industry partners and other agencies. These centres, The Australian Prevention Partnership Centre and the Cognitive Decline Partnership Centre, both operate under a co-production model that includes policy-makers, researchers, industry and consumers.
- At the Global Implementation Conference (GIC), colleagues Annette Boaz (Kingston University, St. George’s University of London), Allison Metz (National Implementation Research Network, University of North Carolina) and I were invited to give a workshop on co-creation.
- On behalf of MSFHR, I’m involved in a Canadian Institutes of Health Research project led by Ian Graham (University of Ottawa) on integrated knowledge translation (iKT), another term for co-production.
- Gabriele Bammer’s Integration and Implementation Insights blog, which I read regularly, is abuzz with related articles.
These and other examples suggest a groundswell similar to patient engagement, where a practice active for years in some circles spreads to new sectors and suddenly becomes “the way we do things”. The potential benefits are significant. But to recall the earlier lessons learned by MSFHR, are we – those of us involved in co-production – doing enough to understand what it means?
In their work on public involvement, Antoine Boivin and colleagues note there is such widespread support for the rhetoric that we may dismiss (I would add not even acknowledge) the tensions that arise when professionals and lay people work together. I think co-production in health research is similar, and suggest we need to work harder to say what we mean, mean what we say, and learn as we go.
Say what we mean
Co-production is easy enough to say, but what does it actually mean? I don’t often hear it defined, perhaps because it sounds obvious. When pushed, people may describe it as partnership or collaboration.
At the GIC workshop, we defined co-production as collaboration in governance, priority setting, conducting research and/or KT. In turn, we defined collaboration according to the International Association of Public Participation’s (IAP2) public participation spectrum: to partner in each aspect of decision-making. We noted that co-production involves researchers and others with a stake in the project: citizens, patients, health care providers, and/or health care decision-/policy-makers.
Co-creation sometimes goes by other names, with slightly nuanced definitions:
- IKT is a model of collaborative research where researchers work with knowledge users who identify a problem and have the authority to implement the research recommendations.
- Engaged scholarship, described by Van De Ven and Johnson in the management literature, is a collaborative form of inquiry where academics and practitioners leverage their different perspectives and competencies to co-produce knowledge.
- Community-based research, which includes participatory- and other action-based approaches, is collaborative, concerned with equity, involves community and university scholars as equal partners, and combines knowledge with action to achieve social change.
The important piece in all of the above, per the IAP2 spectrum, is shared decision-making. But operationalizing the ‘co’ in co-production – a prefix implying joint, mutual, in common – is not an easy task. Is co-production the appropriate model for the project at hand? It’s not always: the other elements on the spectrum (informing, consulting, involving, empowering) are as valid, depending on the situation. But they mean different things. The message here is that definitions – or lack thereof – have significant implications for action, discussed next.
Mean what we say
Committing to co-creation – and all it implies with regard to shared decision-making – means acknowledging that co-production is challenging: it requires role clarity, attention to power imbalances, difficult discussions about research rigour versus research relevance, and constant monitoring. It also means putting in place the mechanisms to support it.
Boivin and colleagues note three areas for attention (although working in public involvement, their advice applies regardless of stakeholder group):
- Credibility: Participants need to learn each other’s language and be seen as valued and relevant sources of knowledge for each other.
- Legitimacy: Participants need to be clear on whose behalf they speak (e.g., people in the same profession, users of a particular service, patients with the same condition, employees in a specific organization) and be supported to do so.
- Power: All participants must be able to influence decisions.
Practical steps can be taken in all these areas. For example credibility comes from participants’ experience and expertise, but can be built through access to additional information or skill-building. For legitimacy, Boivin and colleagues point out the difference between statistical representativeness of a group (correspondence between the descriptive characteristics of a sample and those of the population from which they are drawn) and representation. The former is difficult and expensive; the latter, where individuals speak for a wider constituency, is feasible through appropriate connections, for example access to community groups or related data. To achieve a balance of power, facilitation can be critical, helping with seemingly simple strategies like seating plans and titles, as well as ground rules and agenda setting.
Learn as we go
In the field of KT, the science and practice are out of step. The same can be said of patient engagement, where there is lots of doing, but (in my opinion) not enough studying, at least not in areas that truly align to the practice.
It feels similar in co-production: I’m involved in more and more conversations about it, but when I ask about theories, models, frameworks and methods for co-production, I don’t get a lot of answers.
We need to study co-production as a topic, over and above the focus of the research in which it is used. Ideally, those involved in co-productive research will a) draw on the plentiful and useful, but largely dispersed, literature that can provide evidence for what works, where; b) use an existing framework and model; and c) commit to the study of their initiative – for example testing the adopted framework – for the benefit of the field. Rather than more lists of barriers and facilitators, we need studies of co-production in action.
Conclusion: The bigger picture
Of course, co-produced research will ultimately only be as successful as the broader system enables it to be. In this post I’ve focused primarily on those parties directly involved or potentially involved. But there are many other players, indirectly involved but with considerable influence on the initiative.
With regard to funders, many community-based granting agencies have long supported co-production. It’s quite new – and challenging – for funders who have traditionally supported research in the distinct pillars of biomedical, clinical, health services, and population health, and through formal peer review with a focus on excellence as opposed to relevance. But increasingly, agencies like MSFHR are embracing new ways to support research and all the related questions, including who is a valid applicant, how are applications reviewed, what are eligible expenses and how is success best measured.
Health care and academic organizations have a role to play as well. Many health care leaders are already active in this space, having adopted co-production by embedding researchers in their organizations alongside practitioners. Academic leaders are exploring how formal education of researchers and practitioners can build co-productive capacity. And although early, many people are having discussions about mismatched incentives – including the ‘publish or perish’ imperative for researchers – and the need to adapt to the changing landscape of research that has given rise to promising concepts like co-production.
In the spirit of learning as we go, I look forward to more open and in-depth conversations around the science and practice of co-production, particularly how we address the important issues of authority and power.
- Kothari A, McCutcheon C, Graham ID. Defining integrated knowledge translation and moving forward: A response to recent commentaries. Int J Health Policy Manag. 2017; 6(5): 299–300.
- Boivin A, Lehoux P, Burgers J, Grol R. What are the key ingredients for effective public involvement in health care improvement and policy decisions? A randomized trial process evaluation. Milbank Q. 2014; 92(2): 319–350.
- Van De Ven AH, Johnson PE. Knowledge for theory and practice. Acad Manage Rev. 2006; 31(4): 802-821.
- Holmes B, Best A, Davies H, Hunter D, Kelly M, Marshall M, Rycroft-Malone J. Mobilising knowledge in complex health systems: A call to action. Evid Policy. 2016; 12(3).