GREENHALGH Et Al (2016) Achieving Research Impact Through Co Creation in Community Based Health Services

Original Investigation
Achieving Research Impact Through

Co-creation in Community-Based Health
Services: Literature Review and Case Study
TRISHA GREENHALGH,∗ CLAIRE JACKSON,†
S A R A S H AW , ∗ a n d T I N A J A N A M I A N †
∗
Nuffield Department of Primary Care Health Sciences, University of Oxford;
†
Discipline of General Practice, School of Medicine, University of Queensland
Policy Points:
r Co-creation—collaborative knowledge generation by academics work-
ing alongside other stakeholders—is an increasingly popular approach
to aligning research and service development.
r It has potential for “moving beyond the ivory towers” to deliver signifi-
cant societal impact via dynamic, locally adaptive community-academic
partnerships.
r Principles of successful co-creation include a systems perspective, a
creative approach to research focused on improving human experience,
and careful attention to governance and process.
r If these principles are not followed, co-creation efforts may fail.
Context: Co-creation—collaborative knowledge generation by academics

working alongside other stakeholders—reflects a “Mode 2” relationship (knowl-
edge production rather than knowledge translation) between universities and
society. Co-creation is widely believed to increase research impact.
Methods: We undertook a narrative review of different models of co-creation
relevant to community-based health services. We contrasted their diverse dis-
ciplinary roots and highlighted their common philosophical assumptions,
principles of success, and explanations for failures. We applied these to an
empirical case study of a community-based research-service partnership led by
The Milbank Quarterly, Vol. 94, No. 2, 2016 (pp. 392-429)

c 2016 The Author(s). Milbank Memorial Fund published by Wiley Periodicals, Inc.
This is an open access article under the terms of the Creative Commons Attribution
License, which permits use, distribution and reproduction in any medium, provided the
original work is properly cited.
392
Achieving Research Impact Through Co-creation 393
the Centre of Research Excellence in Quality and Safety in Integrated Primary-

Secondary Care at the University of Queensland, Australia.
Findings: Co-creation emerged independently in several fields, including busi-
ness studies (“value co-creation”), design science (“experience-based co-design”),
computer science (“technology co-design”), and community development (“par-
ticipatory research”). These diverse models share some common features, which
were also evident in the case study. Key success principles included (1) a sys-
tems perspective (assuming emergence, local adaptation, and nonlinearity); (2)
the framing of research as a creative enterprise with human experience at its
core; and (3) an emphasis on process (the framing of the program, the nature
of relationships, and governance and facilitation arrangements, especially the
style of leadership and how conflict is managed). In both the literature re-
view and the case study, co-creation “failures” could often be tracked back to
abandoning (or never adopting) these principles. All co-creation models made
strong claims for significant and sustainable societal impacts as a result of the
adaptive and developmental research process; these were illustrated in the case
study.
Conclusions: Co-creation models have high potential for societal impact but
depend critically on key success principles. To capture the nonlinear chains of
causation in the co-creation pathway, impact metrics must reflect the dynamic
nature and complex interdependencies of health research systems and address
processes as well as outcomes.
Keywords: co-creation, knowledge production, health research systems.
T
his article addresses co-creation, which we define as
the collaborative generation of knowledge by academics work-
ing alongside stakeholders from other sectors. Our particular
interest, and the focus of our case study, is community-based research
collaborations, though we refer in passing to other forms of co-creation.
We consider the extent to which co-creation models linking university
academics with health services in their local community might help
solve the well-described issue of “ivory tower” research that (for what-
ever reason) is not implemented, leading to waste1 and an entrenchment
of the “two cultures” problem—that is, of researchers and research users
failing to understand or engage with one another.2 To put that question
another way, we address the hypothesis that because of its emphasis on
civic engagement, intersectoral collaboration, power sharing, and on-
going conflict resolution, co-created research might have particularly
394 T. Greenhalgh et al.
strong and enduring impact on health and wider outcomes in the local
or regional setting in which universities are located.
The impetus for this article was a wider systematic review of the lit-
erature, funded by the UK Health Technology Assessment Programme,
which asked, What conceptual or methodological approaches to assess-
ing the impact of programs of health research have been developed
and/or applied in empirical studies? That review, whose methodology,
search strategy, and findings are described in detail elsewhere,3 included
a systematic search of 8 electronic databases (including grey literature)
plus hand searching and reference checking. It identified more than 20
different models and frameworks for research impact and 110 studies
describing their empirical applications. A number of these models (de-
scribed variously as “realist,” “participatory,” or “co-production”) shared
an element of collaborative knowledge generation and focused on lo-
cal or regional university-community partnerships. They were described
only briefly in the original systematic review (which focused mainly on
conventional clinical trials and impact through knowledge translation).
In addition, the lead author reviewed collaborative models of impact in
more detail in an unpublished dissertation.4
This article presents the findings of the above work relating to co-
creation between university academics and their local communities and
applies them to an illustrative empirical case study. It is structured
as follows. First, we summarize and critique what is known as the
“Mode 2 hypothesis,” which depicts a relatively recent shift in the
relationship between universities and society from knowledge transla-
tion (or utilization) to knowledge production (or co-creation). Second,
we review 4 contrasting models of co-creation that have relevance to
university-community partnerships—“value co-creation” in the busi-
ness and management literature, “experience-based co-design” in design
science, “technology co-design” in computer science, and “participa-
tory research” in community development. We suggest that, despite
their different origins and ideological allegiances, all share important
philosophical assumptions and operating principles. Third, we review a
somewhat sparse literature on the interorganizational structures devel-
oped to support co-creation between university academics and their local
community partners. Fourth, we consider the question of research im-
pact and the mechanisms by which this may be achieved in co-creation
models. Fifth, we present an empirical example of co-creation in practice
from a major primary care development project in Queensland, Australia.
We conclude by underlining the key elements that appear essential to

maximizing impact in university-community co-creation partnerships.
Mode 2: From “Knowledge Translation”

to “Knowledge Production”
In most medical fields, the dominant assumption about knowledge is
that it exists (or could exist) as more or less generalizable facts about
the world. Research impact is viewed as occurring via translation (or
utilization) of these facts, depicted at 4 levels: individual (eg, via change
in practitioners’ knowledge or attitudes), interpersonal (eg, via peer
influence), collective (eg, via prevailing professional opinion and eth-
ical codes), and organizational (eg, via roles, routines, or institutional
constraints).5
Knowledge translation research (“implementation science”) is a di-
verse intellectual community but tends to focus on a search for trans-
ferable facts about what works at each of these 4 levels.6 It has, for
example, revealed what academics can do to make their research out-
puts more accessible and usable by clinicians and policymakers. Such
strategies include “tailoring,” “targeting,” “framing,” and “narrativiz-
ing” one’s message; mobilizing “boundary spanners,” “brokers,” and
“champions”; providing clear estimates of the strength and quality of
evidence and any residual uncertainties; training service staff to find
and evaluate research evidence; providing incentives and administrative
support for knowledge transfer activities in organizations; and engaging
the media.6-11
All these strategies are important. But they reflect a somewhat deter-
minist, evidence-into-practice logic, with its metaphors of producer-
push and demand-pull.12 This logic has been critiqued by social
scientists as both empirically unfounded13-17 and philosophically and
ideologically flawed.18 In short, the concept of knowledge translation
is predicated on the assumption that research knowledge is created by
university-based scientists and then packaged and processed in a way
that makes it accessible to nonacademics. Yet the (partly medical, partly
social) science of applied health research rarely conforms to this linear
sequence.
In 1994, a book titled The New Production of Knowledge intro-
duced a new taxonomy: “Mode 1 scientific discovery” and “Mode 2
knowledge production.”19 Mode 1 refers to the conventional model of
university-based research that is then “translated.” Gibbons and col-

leagues describe this mode as “hegemonic” (that is, relating to dom-
ination) and driven by closed hierarchies of scientists and their
universities, implicitly at the expense of nonacademic stakeholders.
Mode 2 knowledge, in contrast, is “socially distributed, application-
oriented, trans-disciplinary and subject to multiple accountabilities.”20(p179)
Such knowledge is generated within its context of application—a het-
erogeneous transaction space embracing university, state, economy, cul-
ture, and the wider public sphere. In this space, problems are identified,
questions debated, methodologies developed, and outcomes dissemi-
nated. There are many players, many experts (of different kinds), and
an evolving collective view (though rarely a consensus) on what the
questions and challenges are. To be credible with its diverse audiences,
Mode 2 must be seen as socially as well as scientifically robust (hence eth-
ical, environmentally sustainable, socially inclusive, and an appropriate
use of public resources).
In Mode 2, a range of theoretical perspectives and practical
approaches—including but not restricted to specialist scientific
techniques—are mobilized and managed, often for a limited period
only, to address a particular set of problems. Planning, execution, dis-
semination, and implementation of research are not separate and linear
phases but interwoven, and the relationship between scientists and
research users (industry, policymakers, citizens, and so on) is one of co-
production rather than producer-consumer or contractor-commissioner.
In a second book, three of the original authors explained that Mode
2 emerged in parallel with increasing complexity and uncertainty in
both science and society.21 In the past 30 years in particular, science
has become much less certain: “its composition more heterogeneous, its values
more contested, its methods more diverse and its boundaries more ragged.”21(p2)
In the 1970s, an emphasis on control and predictability in both pol-
itics and science, which was depicted as potentially able to fix the
problems of society, gave way to a growing recognition of the non-
linearity and inherent unpredictability of both social and scientific
phenomena.21
Using the philosophical lens of pragmatism, Van de Ven and John-
son argue that Mode 2 is essentially a dialectical process of bringing
competing perspectives (academic and practical) to bear on a problem22
—a process others have called “bricolage.”23 They explain: “By exploit-
ing multiple perspectives, the robust features of reality become salient and can
be distinguished from those features that are merely a function of one particu-
lar view or model.”22(p815) Such an approach is invariably power-charged
and conflict-ridden; the key to its success is making power relations
explicit and encouraging task-oriented conflict (which can be creative
and productive) while managing the potentially destructive influence of
interpersonal conflict.
While the Mode 2 hypothesis is appealing, the original authors offer
only sketchy empirical examples, mostly from outside health care. An
alternative interpretation of the university-society link is that instead of
a progressive shift from Mode 1 (university-based, needing “translation”)
to Mode 2 (collaboratively generated in its field of application), these
modes have coexisted for decades, along with an age-old tension between
scientific rigor and societal relevance.24,25 But whilst there is no doubt
that university academics have long collaborated with both industry
and government on particular projects (reviewers of an earlier draft
of this article, for example, mentioned the development of radar, the
internet, nuclear weapons, and the breaking of the Enigma code in World
War II), there is also strong evidence from the “research on research”
literature that, overall, health research in both the United States and the
United Kingdom involves increasingly complex intersectoral networks
in which university scientists engage with policymakers, civil society,
and industry to a far greater extent than in the past.26
The Mode 1/Mode 2 taxonomy was developed in Europe; a compa-
rable analytic framework (“technocratic” versus “democratic” models of
community engagement by universities) was proposed in the United
States by Jameson, Clayton, and Jaeger.27
Models of Co-creation in Health Care

Whilst the term “Mode 2” is rarely used in the health care literature, it
describes a number of research approaches that are gaining ground and
that are more commonly referred to as “co-creation” or “co-production.”
Table 1 summarizes 4 models of co-creation, which (to our knowledge)
emerged largely independently of one another. The list is not exhaustive.
For example, since the empirical focus of this article is community-based
research, we have omitted human factors in patient safety research (a
largely hospital-based co-creation approach),28 collaborative approaches
to evaluation,29 and various approaches to the collaborative design of
software.
398
Table 1. Different Models of Co-creation

Key Stakeholders
Parent Driving in the Co-creation
Model Discipline Principles Goal Process
1. Value Business and People are naturally creative and Developing long-term Customers, staff, suppliers,
co-creation30,31 management seek to generate value for stakeholder partnerships government, partner
themselves and others. Building “ecosystems of organizations, funders, end
Value is created by providing capabilities” across users, citizens
platforms that allow stakeholders private, public, and
to interact and share their social sectors
experiences. Increasing creativity,
Value is subjective (ie, it depends on productivity, and growth
individuals’ experience of what is Improving the value of
created) and takes many forms. co-created products and
services
2. Experience- Interdisciplinary The patient experience is the Improved patient Patients, staff, facilitators
based co- (phenomenology, starting point for redesigning a experience of health
design32 design science, health service. services
management) Patients and staff can work together
on the redesign process.
Continued
T. Greenhalgh et al.
Table 1. Continued
Key Stakeholders
Parent Driving in the Co-creation
Model Discipline Principles Goal Process
3. Technology Computer science The starting point for technology Technologies that are Technology users and carers,
co-design33,34 design is the intended users’ acceptable, fit for technology designers,
capabilities and what matters to purpose, and which support staff
them. support effective and
efficient work processes
Technologies are never “plug and
play”; helpdesk and service
support must be designed in
parallel with the technology
Achieving Research Impact Through Co-creation
itself.
4. Community- Development Power imbalances between Local learning and change Vulnerable communities,
based studies researchers and community that reduce inequalities advocates, researchers
participatory members must be recognized and Generalizable principles
research35,36 addressed. about effective
Sustainable change depends on partnerships
mutual trust, built over time
through shared endeavor.
399
Some of the models in Table 1 are more explicitly research-oriented

than others, though all have been used in community-based health
research. They have significant differences in perspective and ideology.
Value co-creation (Figure 1 and model 1 in Table 1), which originated
in the business and management field, is focused on creating value (both
economic and otherwise) with and for all stakeholding individuals, with
the goal of developing sustainable long-term partnerships and enhancing
economic and societal benefits: “Co-creation is joint creation and evolution of
value with stakeholding individuals, intensified and enacted through platforms
of engagement, virtualised and emergent from ecosystems of capabilities, and
actualised and embodied in domains of experiences, expanding wealth-welfare-
wellbeing.”37(p14)
Experience-based co-design (model 2 in Table 1) was developed by
Bate and Robert in the health services research field, who drew on
phenomenological philosophy, design science, and management stud-
ies with a view to ensuring that health services and/or care pathways
were designed and continually redesigned around the experiences of pa-
tients and carers. Key features of this model include a grounding in
phenomenology (the perceptions and emotional reactions of the indi-
vidual patient), its strong focus on pragmatic application in frontline
health services,32 and the use of collective sensemaking and negotiation
to “[produce] new understandings, relationships, and engagements.”38(p73) To
that end, its original architects, supported in the United Kingdom by
medical charities, have developed tools, training programs, and manuals
to be used by frontline service managers and facilitators. The approach
is described thus in one online manual:
[Experience-based co-design] involves gathering experiences from patients and
staff through in-depth interviewing, observations and group discussions, iden-
tifying key “touch points” (emotionally significant points) and assigning
positive or negative feelings. A short edited film is created from the patient
interviews. This is shown to staff and patients, conveying in an impactful way
about how patients experience the service. Staff and patients are then brought
together to explore the findings and to work in small groups to identify and
implement activities that will improve the service or the care pathway.39
Experience-based co-design is gaining popularity in the United
Kingdom and has been widely used in hospital-based quality im-
provement efforts (see review by Donetto and colleagues40 ). Its use in
community-based improvement projects has been much more limited
(Table 2). The approach appears to be extremely effective in capturing
Figure 1. Value Co-creationa
a
Adapted from Figures 1–3 in Ramaswamy and Ozcan.37(p29)
401
402
Table 2. Empirical Examples of Co-creation in Community-Based Health Care

Lead Author Brief
(Country) Goal Description Key Outcomes Comment
1. Value co-creation
Jackson45 To support and extend the Development of a “beacon” Within 3 years, new practice was See detailed description
(Australia) capacity of primary health primary health care revenue neutral; complex care in text.
care locally and better practice with shared shifted from hospital to
integrate service delivery governance between community; metrics of process
across the sector university, local health and outcome for chronic
economy, and community disease management improved
2. Experience-based co-design
Larkin46 To use the service user Combined community and Priorities for improvement (eg, Whilst priorities for
(UK) experience to improve hospital service; user and pathways in and out of redesign were readily
mental health services staff interviews; co-design hospital) identified and identified, many were
event focusing on “touch addressed by a series of unimplemented at 9-
points” collaborative redesign and 18-month review.
working groups
Pearce47 To use the experience of Community-based sexual More client-centered ethos, Challenges included
(UK) service users and staff to health clinics in shorter waiting times, logistics and
improve sexual health multiethnic inner London improved physical identifying and
services borough; “mystery environment retaining a
shopper” sexual health “representative” group
patients and staff of service users.
workshops
Continued
Table 2. Continued
Lead Author Brief
3. Technology co-design
Clemensen48,49 To improve the design and User experience workshops Prototype of technological and The design process
(Denmark) delivery of a followed by design service solution for remote appeared successful
technology-supported, workshops with testing of follow-up of diabetic foot and proof of concept
community-based service prototypes in the home problems was demonstrated in a
for diabetic foot and then further field small sample, but
testing with new users follow-through to
service change was not
reported.
Vassilakopoulou50 To improve booking of Combined technology Workable electronic booking The co-design process
(Norway) outpatient appointments co-design and service for health care happened slowly and
in Norwegian health care experience-based providers took much effort: “[I]t
(2 case studies) co-design was gradually realized

what type of relationship
the booking process
entailed, and what is
needed in order to put in
place an electronic service
to support this
relationship” (page
202).
Continued
403
Table 2. Continued
Lead Author Brief
404

34
Wherton To inform design of Preliminary ethnographic Input to service improvement Mismatches between
(UK) telehealth/telecare services phase followed by and industry [re]design of current
and technologies for older workshops with users, telecare technologies; general technologies/services
people with assisted-living providers, and industry principles for and user needs were
needs and then one final technology/service co-design evident, but
combined workshop for this user group significant service
change was not
achieved within the
timescale and resources
of the study.
4. Community-based participatory research
Potvin,51 Nield52 To prevent type 2 diabetes in Co-design with community General principles for ethical Despite exemplary
(Canada) a high-risk indigenous members targeting food and democratic processes, changes in
community using outlets and actions, and academic-community hard outcomes (eg,
participatory approaches utilization of exercise partnerships; sustained significant reduction
facilities partnership over 20+ years in diabetes incidence)
with evolving program of were difficult to
community-based resources demonstrate, partly
and facilities due to multiple
confounders.
Findley53,54 To reduce ethnic and Participatory approach High parental satisfaction with Success was attributed to
(USA) socioeconomic differences emphasizing community program; increased community ownership,
in child immunization leadership, integration immunization rates that were integration with
rates through community with existing community significantly higher than existing programs,
participation programs, parental national average, especially for peer educators, intense
empowerment, peer health minority groups parental education and
educators, tracking and empowerment, and
feedback, and links with reminders.

health providers
narratives and thereby identifying key “touch points,” but as the exam-
ples in Table 2 illustrate, some projects have failed to follow through to
significant and sustainable redesign as a result of these.41
Technology co-design (model 3 in Table 1) originated at the cusp of
computer science and management studies in the 1950s and was based
on sociotechnical systems theory. It proposes that technologies and work
practices are best co-designed using participatory methods in the work-
place setting, drawing on such common-sense guiding principles as staff
being able to access and control the resources they need to do their jobs
and insisting that processes should be minimally specified (eg, stipu-
lating ends but not means) to support adaptive local solutions.42 This
early work inspired the emergence of an interdisciplinary field of inquiry
known as computer supported cooperative work (CSCW), a central fo-
cus of which is the workarounds that people develop, individually and
collaboratively, to overcome what has been termed the “brittleness” of
software and other technologies.43 As with experience-based co-design,
most examples of technology co-design in health care are hospital-based.
Emerging community-based examples illustrate an effective design pro-
cess but often also reveal practical or logistical difficulties with following
through to sustainable service change (see Table 2).
Community-based participatory research (CBPR, model 4 in Table 1),
which originated in the development studies literature, defines its goals
in terms of human welfare and emphasizes equity and social justice:
“Community-based participatory research is an orientation to research that em-
phasizes ‘equitable’ engagement of partners throughout the research process, from
problem definition, through data collection and analysis, to dissemination and
use of findings to help effect change.”35(p1615) A closely related approach de-
scribed by Dostilio44 and cited in the higher education literature is titled
“democratically engaged partnerships” and emphasizes power sharing,
reciprocity, and mutual learning between a university research group
and a local community partner. Unsurprisingly, CBPR has been widely
used in community-based public health programs; 2 examples are listed
in Table 2.
Despite their significant differences in perspective and ideology, the
4 co-creation models have a number of common features. First, they all
take a systems perspective, depicting (in different ways) multiple interacting
entities that are emergent, locally adaptive, self-organizing, and path-
dependent, and which generate outcomes that cannot be fully predicted
in advance.
Second, they view research as a creative endeavor, with strong links to

design and the human imagination. Design, especially in relation to
business processes and technologies, can be thought of as part science,
part art—and in both cases, it requires imagination, exploration, field
testing, and reflection on emerging data to move from idea to prototype
to the refined output (product, process, or service). All the models place
individual experience (especially that of the patient, but also of staff) at
the heart of this creative design effort. Indeed, Bate and Robert have
emphasized that it is the experience—and particularly the “emotional
touch points”—that needs to be designed, not the process (an efficient
process may make for a poor patient experience and vice versa).32
Third, all the approaches listed in Table 1 recognize (to a greater or
lesser extent) that the process of co-creation is as important as any par-
ticular products or services generated. This includes how the project or
program is set up and framed, including how different partners view
the co-creation process; the nature of relationships (which require re-
spect and reciprocity); and governance and facilitation arrangements,
especially how conflict is managed and the style of leadership—“leaders
who advance a democratic orientation and who promote structures and facilita-
tion techniques that create space for transparency, deliberation, and inclusion of
diverse stakeholders.”44(p241)
All the co-creation models in Table 1 make strong claims that be-
cause of their developmental and adaptive approach, outputs are more
likely to be fit for purpose, acceptable, valuable, and enduring than the
outputs of a comparable effort organized to conventional, “logic model”
principles.
Co-creation research raises important questions about the relation-
ship between (the generation of) knowledge and (the distribution of)
power. In a Nature editorial, Ziman expressed concern that in multi-
stakeholder partnerships, scientists would be pressured by government,
industry, lobbying groups, and so on to shape their research and inter-
pret their findings in particular ways (thereby distorting the scientific
process).25 Whilst some authors have written positively about the en-
trepreneurial university55 and the “triple helix” of evolving university-
industry-government knowledge production,56 others have warned of
the dangers of “academic capitalism,” which include (but are not
limited to) overt conflicts of interest,57 and proposed adding “Mode
0” (“knowledge production based on relations of power and patronage”) to
Gibbons and colleagues’ original taxonomy.58 The evidence base on this
important controversy, which is beyond the scope of this article, has been
reviewed by others.59
In some community-based models of co-creation, especially
experience-based co-design (with patients and carers) and CBPR (with
vulnerable communities), a central issue is the nonacademic partner’s
lack of power. Power remains an issue (but is generally less salient) in
technology co-design, in which the community partner’s primary role
is that of technology consumer (and, depending on the business model,
perhaps customer), and in value co-creation, in which the main role of
the community stakeholder(s) is “partner(s) in the value chain.” In each
case, there are inherent power differentials, and the end user will need
advocacy support and power-sharing governance arrangements to partic-
ipate meaningfully in the co-creation process. Baranick and colleagues,
writing in the global health literature, offer a model for transitioning
from CBPR (in which the community partner is depicted as lacking the
capacity to assimilate knowledge and handle operational activities on
its own) to co-creation of value (in which the community partner has
matured in absorptive capacity and dynamic capability, and is hence in
a stronger position to negotiate).60
Structures Supporting Co-creation

The growing popularity of co-creation in some circles in recent years
should be seen as part of a wider change in the science-society rela-
tionship. In particular, the simple, one-way, and readily auditable rela-
tionship between a group of scientists that undertakes research and a
funder that commissions and then uses such research (to the extent that
this simple relationship ever existed in the first place) has given way to
complex networks of intersectoral collaborations and interdependencies,
and to an ongoing debate about what should be researched, by whom,
and how.
As Nowotny and colleagues commented: “The research process can no
longer be characterised as an ‘objective’ investigation of the natural (or social)
world, or as a cool and reductionist interrogation of arbitrarily defined ‘others.’
Instead it has become a dialogic process, an intense (and perhaps endless) ‘conver-
sation’ between research actors and research subjects.”20(p187) Today, we might
use the term “research stakeholders” to extend this sentiment to those
(such as policymakers, knowledge intermediaries, fundraisers, or citizen
activists) engaged in different ways in the research process.
The complex forms in which people and organizations negotiate,

undertake, and implement research are sometimes referred to as “health
research systems”—defined as organized networks of researchers and
other stakeholders who provide a context for health sciences research and
its uptake and application26,61 or (to the extent that the partners identify
as an entity and have a formal structure and governance arrangements)
as multi-stakeholder health research collaborations.62
Such collaborations, which often align with one or more co-creation
models listed in Table 1, include:
r Canada’s Community-University Research Alliances, including

universities, community organizations, schools, health and social
care providers, and citizens63 ;
r The Netherlands’ Academic Collaborative Centres for Public
Health, including universities, policymakers, and local public
health organizations64 ;
r Australia’s Centre of Research Excellence in Quality and Safety in
Integrated Primary-Secondary Care (described in the case study
below)65 ; and
r The United Kingdom’s Collaborations for Leadership in Applied
Health Research and Care (CLAHRCs), comprising universi-
ties, local health and social care organizations, and citizens66 ;
and Academic Health Science Networks (AHSNs), comprising
universities, industry and commercial partners, and health care
organizations.67
With the exception of AHSNs, whose main focus is on basic science

research and its translation to bedside tests and treatments (and hence,
on strong industry partnerships and commercialization opportunities),
all these multi-stakeholder research collaborations are primarily com-
munity facing and have strong representation from primary health care
and social services. All are designed to draw researchers and end users
together earlier and more powerfully than in traditional research trans-
lation models. Academics, service users, and service organizations work
together from the outset to frame locally relevant research questions,
create research designs that reflect “real-world” environments, and com-
mit to both implementing the research and utilizing its findings in
the broader health service delivery community. Many (though not all)
prioritize the pursuit of social justice (eg, reduction of inequalities in
access to services) and/or the development of research capacity in health

care organizations and community partners.36,62
Research Impact in Co-creation Models

In many countries, notably the United Kingdom where the 2014
Research Excellence Framework sought evidence of “impact” in all aca-
demic disciplines,68 intersectoral outreach along with targets for deliver-
ables beyond academia (such as improved health and well-being, patents
and profits for commercial partners, financial savings for patients or
the public purse, greater public understanding of science, cultural arti-
facts, and so on) is becoming a dominant component of universities’ core
business.69,70
A key driver for research impact is researchers’ relationships with
different stakeholder groups—including industry, policymakers, health
care providers, service users, the media, and citizens. It has long been
known (though not always acted upon) that proactive linkage and ex-
change introduces researchers and the intended users of research to one
another’s worlds, builds two-way bridges between them, and devel-
ops the mutual trust on which collaboration depends.71,72 This finding
resonates with Weiss’s taxonomy of mechanisms by which research evi-
dence influences policy—more often through a steady process of mutual
enlightenment born of long-standing exposure to each other’s ideas
than through the direct and instrumental use of published research
evidence.73
“Mode 1” research impact frameworks take a more or less linear view of
impact (dollars in, grants awarded, papers published, findings translated,
impact achieved) and generally focus on a limited range of predefined
impact metrics such as deaths avoided or improved health status.3,74
Such “logic models” have their place, but they are particularly unfit for
purpose for assessing the interactions, negotiations, and activities of an
unstable and organically evolving research system in which the chain
of causation for any particular outcome is diffuse and contested.75,76 It
follows that as the complexity of health research systems increases, there
is limited mileage in attempting to measure downstream impacts of
co-created research. Conversely, much could be learned about impact in
such complex systems by shifting the focus of study to the processes by
which knowledge is collaboratively generated.
An emerging science of “societal impact assessment” seeks to cat-

egorize and measure both the various interactions between university
academics and other stakeholders and the outputs and outcomes emerg-
ing from them.77,78 The European Seventh Framework Programme, for
example, sought to assess synergies with science education, engagement
with civil society and policymakers, dissemination to the general pub-
lic in multiple languages, and the employment consequences of the
research.79 But measures of societal impact have had limited success in
practice, partly because stakeholders rarely agree on what should be mea-
sured or how80 and partly because (some have argued) this conventional
framing of research impact is predicated on a technocratic, “intellectual
property” view of knowledge and overlooks more critical perspectives
on the relation between knowledge generation and the distribution of
power among stakeholders.44,57,59,81,82
Boaz and colleagues describe examples of co-created research from the
international development literature, which has traditionally favored
“qualitative, participatory evaluations with a focus on learning and service
improvement.”83(p260) Naturalistic methods such as ethnography and sto-
rytelling have been used to capture multiple voices in what are typically
presented as “positive utilization narratives” that describe the processes
of engagement as well as key outputs and outcomes. But as pressure
to demonstrate accountability grows, sponsors increasingly question
the veracity of such narratives and seek external evaluations that priv-
ilege logic models, quantitative methods, and predefined performance
indicators.
Perhaps partly in response to such expectations, Cacari-Stone and col-
leagues (Table 1, model 4) have offered what might be referred to as a
highly permeable logic model to link the co-creation process (specifi-
cally, CBPR) to the policymaking cycle while also acknowledging the
importance of the power-knowledge axis (Figure 2).35 These authors pro-
pose that impact depends on aligning the contexts of the collaboration
(political-societal and specific collaborative histories) and partnership
processes (eg, the extent to which decision making is equitable and the
nature of leadership) with intermediate research and system or capac-
ity outcomes, and more distally with health outcomes. They depict the
policy process as iterative, nonlinear, and characterized by windows of
opportunity. If we apply Weiss’s terminology,73 co-creation may influ-
ence this both instrumentally (by generating evidence) and interactively
(through civic engagement).
Figure 2. Cacari-Stone and Colleagues’ Model of Impacts From Community-Based Participatory Researcha
a
Reproduced from Figure 1 in Cacari-Stone and colleagues.35(p1616)
411
Figure 3. Realist Model of Impact in a Multi-stakeholder Research

Collaboration, Based on a National Evaluation of UK CLAHRCsa
+ve = positive, -ve = negative.

a
Reproduced under terms of UK noncommercial government license
from Rycroft-Malone and colleagues.66
Other authors have chosen realism as a theoretical lens to help meet an

expectation for “facts” in an inherently unpredictable system. Realist re-
search seeks to produce more or less generalizable statements about what
works for whom in what circumstances.84 Realist methods, based mostly
on stakeholder interviews conducted over time, were used in a major na-
tional evaluation in the United Kingdom of the impacts of CLAHRCs,
whose approach included elements of value co-creation, experience-based
co-design, and technology co-design.66 Evaluators sought to tease out ac-
tors’ theories of change and explore how context shaped and constrained
their efforts to achieve particular goals. The resulting impact model
(Figure 3) encompasses all the key principles identified in previous
work reviewed above: impact will be stronger and more enduring if
the collaboration takes a systems perspective; frames research as a cre-
ative enterprise with human experience (particularly that of patients and
staff) at its core; ensures an appropriate style of leadership; and empha-
sizes processes (especially relationships, interactions, sensemaking, and
dialogue) as well as outcomes.
Jagosh and colleagues used a realist lens to study processes and out-
comes of co-creation in a systematic review of participatory research
programs (Table 1, model 4).62,85 This review confirmed the impor-
tance of relationship building, facilitation, and democratic program
governance. More specifically, it centered on the notion of partnership
synergy, defined as combining people’s perspectives, resources, and skills
to “create something new and valuable together—a whole that is greater than
the sum of its individual parts.”86(p318) Multi-stakeholder partnerships are
often characterized, at least initially, by conflict, but synergy may in-
crease as co-governing partners work together, leading to convergence
of perspectives by progressive alignment of purpose, values, and goals
and growth of mutual understanding and trust through what has been
termed a “ripple effect.”85
In their review, Jagosh and colleagues suggest that it is this process of
emerging partnership synergy, not the structures of governance per se,
that is the key to success in CBPR.36 This construct may have wider
applicability. Indeed, there may be parallels with what Janamian and
colleagues have called the “interlocking” of academic and nonacademic
stakeholders to generate impacts in the co-created value chain.65 This
process is described further in the case study that follows.
Case Study: Co-creation in a Primary

Care “Beacon” Practice
We describe an example of the application of the value co-creation model
in a community-based initiative in Queensland, Australia, which part-
nered research, service delivery, and professional communities. Following
the “n of 1” case study approach of Stake,87 we deliberately present this
case in narrative form. Further empirical details, including quantitative
outcomes metrics and the perspectives of community stakeholders, are
available in the additional articles referenced in this section.
In 2005, the University of Queensland and the local health board,
Queensland Health, faced a problem—their mutually run general prac-
tice teaching facility was losing $800,000 annually and was destined
for closure. Health care delivery to a vulnerable and underprivileged
community was under threat. For the university this also meant the
potential loss of a significant and long-standing teaching facility; the
health board faced a possible reputational and political risk. A small
team of academics and executives from clinical backgrounds was tasked

with finding a solution.
The initial team was attracted to the value co-creation approach
(model 1 in Table 1) because it appeared to allow a collaborative en-
gagement with a focus on service transformation to create value for all
end users.30,88 The approach resonated with a shift in health care away
from “quality improvement” (increasingly seen as aspirational and of
questionable generalizable efficiency) and toward “value-based health
care,” in which the ideal of quality was explicitly aligned with the busi-
ness case for achieving it and with quantifiable estimates of benefits, both
human and financial.89,90 The architects of the value co-creation model
emphasize that co-creation is not about “build it and they will come”
but rather “build it with them, and they are already there.”37 Faced with
a stark economic picture and a network of health care providers who all
sought to improve health outcomes but were not yet delivering these
efficiently, the team found the idea of developing what Ramaswamy and
Ozcan37 have called a “nexus of engagement platforms” oriented to de-
livering business success (“enterprise”) in a way that placed the patient
(and staff) experience at the core of the endeavor and generated tangible
value for all stakeholders (Figure 1) relevant and appealing.
The first step was to invite individual stakeholders (in this case, ser-
vice users, primary and secondary care providers, funders, policymakers,
and health bureaucrats) to be involved in co-creating the value proposi-
tion and the network and processes through engagement and dialogue.
A small design and planning group, comprising relevant organizational
leaders known for their innovation and flexibility, was formed to review
potential approaches and prepare a proposal for funders. They recom-
mended a new practice model—a “beacon” practice—be established.
The vision was for a community-focused practice, premised on an ethos
to support and extend the capacity of all primary care in the area and to
better integrate service delivery locally between general practice, special-
ist services, and other state-funded care. The beacon practice would be
separated from individual funders and governed as its own not-for-profit
company, with a board whose membership reflected the community it
served and with a goal of restoring financial balance within a 3-year time
frame.
The 7-person board comprised 2 nominees each from Queensland
Health and the University of Queensland, a community member (the
local member of parliament and recipient of complaints regarding health
and social care delivery in the area), a representative with formal financial
skills, and an independent chair with skills in strategic leadership and

primary care reform. All board members were champions of care integra-
tion, community development, and service partnership. The board es-
tablished a clinical advisory committee, with broader input from clinical
care deliverers locally, and a research committee to inform and evaluate
the new approach to care. Decision making was shared equally across
the co-creators, with consensus always the sought end result. Actions
did not proceed until all co-creator organizations were signed up.
As well as the need for good primary care access (already recognized
as a priority), working groups identified other key health issues: long
waits for outpatient assessment for patients with complex chronic disease
and significant transport and health access difficulties for the commu-
nity. Hospital clinicians were concerned about high (up to 40%) nonat-
tendance rates for outpatient appointments in the area and expressed
commitment to working with primary care clinicians on innovative so-
lutions with shared resources. All groups engaged in robust debate as
they sought to find agreement on the optimal path to community access,
affordability, and service excellence.
Individuals invited to join these working groups were selected for
having a personal commitment to a philosophy valuing innovation,
multisector diversity, and patient-centeredness. They became champi-
ons of the new approach within their own organizations and identified
opportunities for improved care and funding efficiency to assist their in-
dividual executive and clinician communities in supporting the change.
A significant feature of this collaboration was that stakeholders’ di-
verse organizational, fiscal, and governance challenges, opportunities,
and requirements were discussed frankly and openly in all meetings
and activities. All partners committed to an outcome where the service
model was valued by all, even if not directly delivered by each.
Meetings and interactions were supported by real-time data (such as
aggregated patient clinical and access statistics, service costings, previous
minutes and commitments, and staff and patient feedback). A subgroup
was established to develop unique best practice clinical guidelines sup-
porting chronic disease management across the care continuum (this
required capacity building among primary care staff). More generally,
the shared commitment to basing decisions on robust evidence inspired
a series of systematic literature reviews addressing the evidence base for
optimal practice organization,91 challenges to implementation of new
service models in primary care,92 and governance models for primary-
secondary care integration.93 The program also required and supported
a stream of empirical research, undertaken in parallel with the change

effort, on the organizational challenges and patient and staff experience
of the new model. Research activities included a development and pilot
study of a primary care improvement tool,94 a qualitative evaluation of
a clinical microsystems model in diabetes care,95 a quantitative study of
the evidence-practice gap in gestational diabetes follow-up,96 and the
development and evaluation of a community-based diabetes surveillance
and management program.97-100
The many partner organizations brought different capabilities and
connections and drew on these collaboratively to create the new prac-
tice, devolving some hospital functions to the community (eg, diabetes
self-management education and insulin stabilization) with the increased
primary care capacity made possible via the beacon. Within 3 years,
the beacon practice was revenue neutral and was partnering with local
clinicians to care for complex care patients from the area with better out-
comes and high satisfaction at significantly reduced cost. For example,
diabetes control in patients served by the beacon practice improved over
time; compared to neighboring sites, preventable diabetes-related hospi-
talizations halved and metrics of patient satisfaction and empowerment
increased.98-100
The partners continued to grow “ecosystems of capabilities” (see
Figure 1) together. As the partnership has grown, trust has increased
and relationships have strengthened (“partnership synergy”), allowing
the collaboration to share robust data on both processes and outcomes
and to make medium-term strategic decisions (such as the continua-
tion of applied research programs). The initiative created excitement
within the broader health environment; it received various awards and
attracted public interest, which generated further impetus through a
“ripple effect.”85 A notable success was the receipt of both substantial
Department of Health funding to extend the beacon model to other
parts of the state and major research grant funding (from the Australian
National Health and Medical Research Council) to develop a center of
excellence in integrated care. Beacon practices are now being established
in refugee health, chronic kidney disease, and maternity care.
The story of Queensland’s primary care beacon practice included a
number of established success features of the value co-creation approach:
creating a common vision oriented to delivering value for each partner
member; flexible, outcome-focused leadership; recognizing and respect-
ing the very different cultures and perspectives of organizational stake-
holders; committing to ongoing collaborative relationships rather than
one-off projects; and collectively celebrating wins and problem-solving

challenges. The research stream resonated with a key success principle
gleaned from our literature review: a creative approach to research with
a strong collaborative and ongoing partner involvement in design—and
human experience at its core. Whilst the approach taken was explicitly
aligned with model 1 in our taxonomy (see Table 1), it thus also had
features of model 2 (experience-based co-design).
The program described in this case study was by no means smooth
sailing. Both at the outset and periodically as it unfolded, stakeholders
clashed at both clinical governance and executive meetings regarding the
best way forward. Members were often very focused on their traditional
ways of doing things, tending to default to historical roles, funding
streams, and divisions of labor. Group leaders managed these conflicts
proactively, using the guiding co-creation engagement principles and
a strong governance structure that aided power sharing and conflict
management. A few initiatives took several meetings to reach consen-
sus; though since the agreed priority was innovative care delivery that
created value for all, partners were respectful of the need for this. They
learned to define “value” more flexibly (the term might, for example,
mean improved access or less tangible benefits, rather than direct care
delivery).
Meeting chairs were selected for their leadership qualities, ability to
identify and rise above “groupthink” (bland consensus was explicitly
discouraged), and commitment to ensuring that potential challenges
to new ideas were identified and vigorously discussed. They set an
important ethos of constructive criticism and creative innovation, with
the patient experience as the central focus.31 They recognized that if
properly handled, conflict was not merely healthy and constructive,
but an essential process in achieving successful change in a complex
adaptive system.85 As partners worked together, trust was built through
a growing understanding and valuing of one another’s different positions
and organizational requirements. Co-creation champions looked for ways
to neutralize territorial anxieties by identifying opportunities to deliver
better local services together.
Discussion
This article has described, via both a literature review and a support-
ing case study, the key principles required for effective co-creation in
community-based research. These include (1) a systems perspective (as-

suming emergence, local adaptation, and nonlinearity); (2) the framing
of research as a creative enterprise oriented to design and with human
experience at its core; and (3) an emphasis on process, including the
framing of the program, the quality of relationships, and governance
and facilitation arrangements, especially power-sharing measures and
the harnessing of conflict as a positive and engaging force.
Being mindful of the above principles in designing and implementing
co-creation projects is likely to help maximize their success. Because co-
creation requires a systems perspective, a “logic model” mind-set with
inflexible goals will be less effective than an approach that acknowledges
nonlinearity and encourages local adaptation as the program unfolds. Co-
creation models are not suited to all kinds of research. Rather, they appear
to lend themselves to a particular kind of research—the systematic study
of creative efforts oriented to improving human experience (a focus that
has the potential to align stakeholders within a complex system). Both
our own case example and others in the literature illustrate that “im-
pact” efforts need to face internally as well as externally; they depend
critically on the quality of relationships within the collaborative and
the effectiveness of stakeholders’ ongoing negotiation of, and reflection
on, the program’s changing goals. Robust governance, skilled facili-
tation, relationship-building efforts, and conflict management are all
necessary (though as argued below, they may not be sufficient) to assure
success.
Despite (and perhaps partly because of) the evident tensions and ongo-
ing negotiations among the project’s various stakeholders, the Queens-
land beacon practice appears to have been more successful than many
other similar multi-stakeholder co-creation initiatives. In a recent em-
pirical study of governance in a UK CLAHRC, for example, Fitzgerald
and Harvey found that governance structures never “gelled” and that as
the program unfolded, partners began to withdraw their commitment
and funding.101 One reason for this was that once established, the net-
work became divided into silos, each of which became very externally
facing and focused on “knowledge translation” to audiences beyond the
CLAHRC. There was marked duplication of effort and weak internal
communication, to the extent that different teams within the CLAHRC
had little idea what other local teams were doing. The authors concluded
that externally facing knowledge translation measures are insufficient to
ensure local uptake and impact of research findings; there also needs to
be attention to the internal mobilization and negotiated utilization of

knowledge within the network of participating stakeholders—a process
they describe as a “balanced power” form of collaboration.101
Multi-stakeholder research-service collaborations are characterized by
structural complexity and multiple competing interests and by pressure
from various quarters to measure their activities and impacts and to
demonstrate accountability. Power and conflict are prominent themes in
published evaluations of these complex forms, which talk of “colliding in-
stitutional logics,”102 “ambiguous loyalties . . . different interests . . . competing
goals,”103 and “multiple accountabilities.”64 Perhaps especially where com-
mercial partners or government are involved, competing interests may
loom large. Hinchcliff and colleagues distinguish between the sanitized
written accounts of multi-stakeholder interactions (“draped in the formal
collaborative language and procedures prescribed by funding agency protocols”)
and the reality in which “participants . . . view each other pragmatically as
consultants, clients or even competitors, rather than partners.”62(p126)
Arguably, the structures of co-creation are inherently unstable and
may have unclear and/or shifting goals. Bennet and colleagues have used
the metaphor of collaborative entanglement104 (explored further by Phipps
and colleagues105 ) to depict the conflict-ridden, messy, unpredictable,
and evolving interactions possible among stakeholders pursuing
Mode 2 activity where structures and governance are suboptimal. As
Van de Ven and Johnson’s pragmatic theory predicts, the structures
of co-creation depend on skilled leadership, ongoing negotiation, and
dedicated resources (time, expertise, money) to focus the salient features
of reality and avoid descent into stalemate, ensuring that organizations
deliver on agreed commitments.62,64,67
The relatively recent emergence of complex forms for co-created re-
search has, arguably, outstripped the pace of research into the optimum
structures and types of governance that might support them. The value
co-creation literature views robust governance structures and co-creative
management systems as the key mechanisms for guiding the co-creation
process both within the enterprise and with external stakeholders.37
Such governance includes setting ground rules for co-creative applica-
tions, defining early on who is responsible for what and to whom, and
ensuring evenly distributed power constellations. This model depicts
the co-creation of value as dependent on high-quality stakeholder inter-
actions and the integration of resources among them—and this in turn
depends on the formal and equitable distribution of power, for which
active involvement of stakeholders is a requirement (since participants

must carry the responsibility for the implementation and consequences
of shared decisions).106
An alternative argument is that governance structures alone cannot
assure the appropriate power-sharing processes for the complex forms
that now characterize community-based research. Brown has argued
from a Foucauldian perspective that the interaction between researchers
and nonacademic stakeholders is complex and necessarily political; the
structures of democratic interaction (representation, independent chair-
ing, transparency, public debate, and so on) may or may not overcome
the subtle and insidious use of power by vested interests (for example,
in defining what kind of knowledge “counts” in key decisions).82 In-
deed, Schmachtel has coined the term “rationalized myths” to depict
the illusion of order and democracy that is inevitably created when
a local collaboration is formalized; the shared narrative and supporting
structures serve both to “ . . . [legitimize] the partnership’s setup, yet [conceal]
its complex, contradictory and antagonistic reality.”107(p1)
These two contrasting framings—the one focusing on the formal dis-
tribution of power and the management of overt conflicts of interest,
the other seeking to expose and question more covert influences—raise
a key empirical question (but one that has no easy answer): to what
extent was the success of the Queensland case study attributable to
good governance processes (including the selection of leaders for partic-
ular personal qualities)? More generally, to what extent can such good
governance processes alone assure the success of co-creation partnerships
in community settings?
To date, the literature on co-creation, both within and beyond the
health care field, has tended to be aligned with particular projects and
programs. Less attention has been paid (at both a theoretical and an
empirical level) to the co-creation of policy and guidance—especially
the processes for guiding and overseeing health research systems—to
inform and shape how we define and judge research. In other words, the
models set out in Table 1 and reviewed above are helpful in thinking
through the co-creation process in particular programs of research but
have so far contributed little to the science of research—for example, the
study of how research is (co-)developed, funded, assessed, and evaluated.
Given that the literature on “research on research” remains dominated
by a “Mode 1” ethos and values, the applied science of co-creation may
yet take some time to establish a stronger and more coherent paradigm.
Conclusion
This article has reviewed the literature on co-creation in community-
based health care with a particular emphasis on societal impact and
offered a worked example of one model in practice. Whilst we are not
suggesting that our single example is statistically generalizable, both
the literature review and the case study support the conclusion that it is
not collaborative structures per se that add value in the research-impact
relationship. Rather, those who wish to reap the benefits of a co-creation
model should carefully note, and seek to apply, the key success principles
advocated by this article, so as to avoid failure in the complex, important,
and (sometimes) rapidly evolving partnerships that now exist between
researchers and health service end users.
In conclusion, co-creation models offer one approach to moving re-
search out of the ivory towers and closer to the real world. As such,
they have high potential for research impact, though such impact is
by no means guaranteed. Among the key success principles for achiev-
ing societal impact from co-creation models are embracing an adaptive
“complex system” model of change and attending carefully to processes,
relationships, and conflict management (though the extent to which
these efforts will produce success is likely to depend on local contin-
gencies). It surely follows that in order to capture the nonlinear chains
of causation in the co-creation pathway, impact metrics should evolve
to reflect the dynamic nature and complex interdependencies of health
research systems and address processes as well as outcomes.
References
1. Glasziou P, Altman DG, Bossuyt P, et al. Reducing waste from

incomplete or unusable reports of biomedical research. Lancet.
2014;383(9913):267-276.
2. George AL. The two cultures of academia and policy-making:
bridging the gap. Political Psychology. 1994;15(1):143-172.
3. Raftery J, Hanney S, Greenhalgh T, Glover M, Young A. Models
and applications for measuring the impact of health research: up-
date of a systematic review for the Health Technology Assessment
Programme. Health Technol Assess. 2015.
4. Greenhalgh T. Research Impact in the Community Based Health Sci-
ences: What Would Good Look Like? [MBA dissertation]. London,
United Kingdom: UCL Institute of Education; 2015.
5. Grol R, Grimshaw J. From best evidence to best practice:

effective implementation of change in patients’ care. Lancet.
2003;362(9391):1225-1230.
6. Eccles MP, Armstrong D, Baker R, et al. An implementation
research agenda. Implement Sci. 2009;4(1):18.
7. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thom-
son MA. Closing the gap between research and practice: an
overview of systematic reviews of interventions to promote the
implementation of research findings. BMJ. 1998;317(7156):465-
468.
8. Graham ID, Logan J, Harrison MB, et al. Lost in knowledge trans-
lation: time for a map? J Contin Educ Health Prof. 2006;26(1):13-
24.
9. McCormack L, Sheridan S, Lewis M, et al. Communication and Dis-
semination Strategies to Facilitate the Use of Health-Related Evidence.
Evidence Report/Technology Assessment No. 213. Rockville,
MD: Agency for Healthcare Research and Quality; 2013.
10. Oliver K, Innvar S, Lorenc T, Woodman J, Thomas J. A system-
atic review of barriers to and facilitators of the use of evidence by
policymakers. BMC Health Serv Res. 2014;14:2.
11. Long JC, Cunningham FC, Braithwaite J. Bridges, brokers and
boundary spanners in collaborative networks: a systematic review.
BMC Health Serv Res. 2013;13(1):158.
12. Brown C. The “policy-preferences model”: a new perspective on
how researchers can facilitate the take-up of evidence by educa-
tional policy makers. Evidence & Policy. 2012;8(4):455-472.
13. Meagher L, Lyall C, Nutley S. Flows of knowledge, expertise and
influence: a method for assessing policy and practice impacts from
social science research. Research Evaluation. 2008;17(3):163-173.
14. Ferlie E, Crilly T, Jashapara A, Peckham A. Knowledge mobili-
sation in healthcare: a critical review of health sector and generic
management literature. Soc Sci Med. 2012;74(8):1297-1304.
15. Dopson S, Fitzgerald L. Knowledge to Action? Evidence-Based Health
Care in Context. New York, NY: Oxford University Press; 2005.
16. Davies H, Nutley S, Walter I. Why ‘knowledge transfer’ is mis-
conceived for applied social research. J Health Serv Res Policy.
2008;13(3):188-190.
17. Nicolini D, Powell J, Conville P, Martinez-Solano L. Man-
aging knowledge in the healthcare sector. A review. IJMR.
2008;10(3):245-263.
18. Ellis KS. Knowledge Translation and the Governance of Health Research
in Canada: A Critical Discourse Analysis [dissertation]. London,
Canada: University of Western Ontario; 2014.
19. Gibbons M, Limoges C, Nowotny H, Schwartzman S, Scott P,

Trow M. The New Production of Knowledge: The Dynamics of Science
and Research in Contemporary Societies. London, United Kingdom:
Sage; 1994.
20. Nowotny H, Scott P, Gibbons M. Mode 2 revisited: the new
production of knowledge. Minerva. 2003;41(3):179-194.
21. Nowotny H, Scott P, Gibbons M. Re-thinking Science: Knowledge
and the Public in an Age of Uncertainty. Cambridge, United King-
dom: Polity Press; 2001.
22. Van de Ven AH, Johnson PE. Knowledge for theory and practice.
Acad Manage Rev. 2006;31(4):802-821.
23. Kincheloe JL. Describing the bricolage: conceptualizing a new
rigor in qualitative research. QI. 2001;7(6):679-692.
24. Hessels LK, Van Lente H. Re-thinking new knowledge pro-
duction: a literature review and a research agenda. RP.
2008;37(4):740-760.
25. Ziman J. Is science losing its objectivity? Nature. 1996;
382(6594):751-754.
26. Hanney S, Kuruvilla S, Soper B, Mays N. Who needs what from
a national health research system: lessons from reforms to the
English Department of Health’s R&D system. Health Res Policy
Syst. 2010;8:11.
27. Jameson JK, Clayton PH, Jaeger AJ. Community-engaged schol-
arship through mutually transformative partnerships. In: Harter
LM, Hamel-Lambert J, Millesen J, eds. Participatory Partnerships
for Social Action and Research. Dubuque, IA: Kendall Hunt Pub-
lishing; 2010:259-277.
28. Carayon P. Human factors of complex sociotechnical systems.
Appl Ergon. 2006;37(4):525-535.
29. Patton MQ. Utilization-Focused Evaluation. London, United King-
dom: Sage; 2008.
30. Ramaswamy V, Gouillart F. Building the co-creative enterprise.
HBR. 2010;88(10):100-109.
31. Hardyman W, Daunt KL, Kitchener M. Value co-creation
through patient engagement in health care: a micro-level
approach and research agenda. Public Management Review.
2015;17(1):90-107.
32. Bate P, Robert G. Bringing User Experience to Healthcare Improve-
ment: The Concepts, Methods and Practices of Experience-Based Design.
Abingdon, United Kingdon: Radcliffe Publishing; 2007.
33. Procter R, Greenhalgh T, Wherton J, Sugarhood P, Rouncefield
M, Hinder S. The day-to-day co-production of ageing in place.
CSCW. 2014;23(3):245-267.
34. Wherton J, Sugarhood P, Procter R, Hinder S, Greenhalgh T.

Co-production in practice: how people with assisted living needs
can help design and evolve technologies and services. Implement
Sci. 2015;10(1):75.
35. Cacari-Stone L, Wallerstein N, Garcia AP, Minkler M. The
promise of community-based participatory research for health
equity: a conceptual model for bridging evidence with policy.
Am J Public Health. 2014:e1-e9.
36. Jagosh J, Macaulay AC, Pluye P, et al. Uncovering the benefits of
participatory research: implications of a realist review for health
research and practice. Milbank Q. 2012;90(2):311-346.
37. Ramaswamy V, Ozcan K. The Co-creation Paradigm. Redwood
City, CA: Stanford University Press; 2014.
38. Iedema R, Merrick E, Piper D, et al. Codesigning as a discur-
sive practice in emergency health services: the architecture of
deliberation. J Appl Behav Sci. 2010;46(1):73-91.
39. King’s Fund. Experience-Based Co-design Toolkit. London,
United Kingdom: King’s Fund; 2013. http://www.kingsfund.
org.uk/projects/ebcd/experience-based-co-design-description.
Accessed March 12, 2016.
40. Donetto S, Tsianakas V, Robert G. Using Experience-Based Co-
design (EBCD) to Improve the Quality of Healthcare: Mapping Where
We Are Now and Establishing Future Directions. London, United
Kingdom: King’s College London; 2014.
41. Coulter A, Locock L, Ziebland S, Calabrese J. Collecting data on
patient experience is not enough: they must be used to improve
care. BMJ. 2014;348.
42. Cherns A. Principles of sociotechnical design revisted. Human
Relations. 1987;40(3):153-161.
43. Symon G, Long K, Ellis J. The coordination of work activities:
cooperation and conflict in a hospital context. CSCW. 1996;5:1-
31.
44. Dostilio LD. Democratically engaged community-university
partnerships: reciprocal determinants of democratically ori-
ented roles and processes. J High Educ Outreach Engagem.
2014;18(5):235-244.
45. Jackson C, Askew D. Is there a polyclinic alternative acceptable
to general practice? The “beacon” practice model. Br J Gen Pract.
2008;58(555):733.
46. Larkin M, Boden ZV, Newton E. On the brink of genuinely
collaborative care: experience-based co-design in mental health.
Qual Health Res. 2015;25(11):1463-1476.
47. Pearce V, Baraitser P, Smith G, Greenhalgh T. Experience-based

co-design. In: Greenhalgh T, Humphrey C, Woodard F, eds. User
Involvement in Health Care. Hoboken, NJ: BMJ Books; 2010:28-
51.
48. Clemensen J, Larsen SB, Kyng M, Kirkevold M. Participatory
design in health sciences: using cooperative experimental meth-
ods in developing health services and computer technology. Qual
Health Res. 2007;17(1):122-130.
49. Clemensen J, Larsen SB, Kirkevold M, Ejskjaer N. Treatment of
diabetic foot ulcers in the home: video consultations as an alterna-
tive to outpatient hospital care. Int J Telemed Appl. 2008:132890.
doi:10.1155/2008/132890.
50. Vassilakopoulou P, Grisot M, Aanestad M. Co-creation of patient-
oriented services: design of electronic booking for Norwegian
healthcare. In: Oinas-Kukkonen H, Iivari N, Kuutti K, Öörni
A, Rajanen M, eds. Nordic Contributions in IS Research. Vol. 223.
Switzerland: Springer International Publishing; 2015:193-207.
51. Potvin L, Cargo M, McComber AM, Delormier T, Macaulay AC.
Implementing participatory intervention and research in commu-
nities: lessons from the Kahnawake Schools Diabetes Prevention
Project in Canada. Soc Sci Med. 2003;56(6):1295-1305.
52. Nield A, Quarrell S, Myers S. Community based early inter-
vention for the prevention of type 2 diabetes: a case report of
the Kahnawake Schools Diabetes Prevention Project. J Diabetes
Metab. 2013;4(277):2.
53. Findley S, Irigoyen M, Sanchez M, et al. Community empower-
ment to reduce childhood immunization disparities in New York
City. Ethn Dis. 2004;14(3 Suppl 1):S134-141.
54. Findley SE, Irigoyen M, Sanchez M, et al. Effectiveness of a
community coalition for improving child vaccination rates in
New York City. Am J Public Health. 2008;98(11):1959.
55. Thorp H, Goldstein B. Engines of Innovation: The Entrepreneurial
University in the Twenty-First Century. Chapel Hill, NC: UNC
Press Books; 2010.
56. Etzkowitz H, Leydesdorff L. The dynamics of innovation: from
National Systems and “Mode 2” to a Triple Helix of university-
industry-government relations. RP. 2000;29(2):109-123.
57. Rhoades G, Slaughter S. Academic capitalism in the new econ-
omy: challenges and choices. American Academic. 2004;1(1):37-
59.
58. Bresnen M, Burrell G. Journals à la mode? Twenty years of liv-
ing alongside Mode 2 and the new production of knowledge.
Organization. 2013;20(1):25-37.
59. Larsen MT. The implications of academic enterprise for public

science: an overview of the empirical evidence. RP. 2011;40(1):6-
19.
60. Baranick E, Baird A, Vinze A. An economic framework for transi-
tioning to capacity building. Glob Public Health. 2015;10(1):15-
27.
61. Hanney S, Gonzalez-Block MA, Buxton MJ, Kogan M. The util-
isation of health research in policy-making: concepts, examples
and methods of assessment. Health Res Policy Syst. 2003;1(1):2.
62. Hinchcliff R, Greenfield D, Braithwaite J. Is it worth engaging
in multi-stakeholder health services research collaborations? Re-
flections on key benefits, challenges and enabling mechanisms.
Int J Qual Health Care. 2014;26(2):124-128.
63. King G, Servais M, Forchuk C, et al. Features and impacts of five
multidisciplinary community-university research partnerships.
Health Soc Care Community. 2010;18(1):59-69.
64. Wehrens R, Bekker M, Bal R. Hybrid management configura-
tions in joint research. STHV. 2014;39(1):6-41.
65. Janamian T, Jackson C, Dunbar J. Co-creating value in research:
stakeholders’ perspectives. Med J Aust. 2014;201(3 Suppl):S44-
S46.
66. Rycroft-Malone J, Burton C, Wilkinson J, et al. Collective action
for knowledge mobilisation: a realist evaluation of the Collabora-
tions for Leadership in Applied Health Research and Care. Health
Serv Deliv Res. 2015;3(44).
67. McGough R, Rubenstein S. Academia. Shaping the new science
networks. Health Serv J. 2013;123(6340):32-33.
68. Higher Education Funding Council for England. Research
Excellence Framework 2014: Overview Report by Main Panel A and
Sub-panels 1 to 6. London, United Kingdom: HEFCE; 2015.
http://www.ref.ac.uk/media/ref/content/expanel/member/Main
Panel A overview report.pdf. Accessed February 1, 2015.
69. Frank C, Nason E. Health research: measuring the social, health
and economic benefits. CMAJ. 2009;180(5):528-534.
70. Bouter LM. Knowledge as a common good: the societal relevance
of scientific research. Higher Education Management and Policy.
2010;22(1):119-132.
71. Lomas J. Using “linkage and exchange” to move research
into policy at a Canadian foundation. Health Aff (Millwood).
2000;19(3):236-240.
72. Lomas J. The in-between world of knowledge brokering. BMJ.
2007;334(7585):129-132.
73. Weiss CH. The many meanings of research utilization. Public

Administration Review. 1979; 39(5):426-431.
74. Penfield T, Baker MJ, Scoble R, Wykes MC. Assessment, eval-
uations, and definitions of research impact: a review. Research
Evaluation. 2013:rvt021.
75. Hawe P. Lessons from complex interventions to improve health.
Annu Rev Public Health. 2015;36:307-323.
76. De Savigny D, Adam T. Systems Thinking for Health Systems
Strengthening. Geneva, Switzerland: World Health Organization;
2009.
77. Niederkrotenthaler T, Dorner TE, Maier M. Development of
a practical tool to measure the impact of publications on the
society based on focus group discussions with scientists. BMC
Public Health. 2011;11(1):588.
78. Mostert SP, Ellenbroek S, Meijer I, van Ark G, Klasen EC. So-
cietal output and use of research performed by health research
groups. Health Res Policy Syst. 2010;8(1):30.
79. Hansen J, Muscat N, Keskimaki L. Measuring and improving the
societal impact of health care research. Eurohealth. 2013;19(3):32-
35.
80. Martin BR. The Research Excellence Framework and the “im-
pact agenda”: are we creating a Frankenstein monster? Research
Evaluation. 2011;20(3):247-254.
81. Nowotny H. Engaging with the political imaginaries of science:
near misses and future targets. Public Underst Sci. 2014;23(1):16-
20.
82. Brown C. The policy agora: how the epistemological and ide-
ological preferences of policy-makers affect the development of
government policy. Human Welfare. 2012;1(1):57-70.
83. Boaz A, Fitzpatrick S, Shaw B. Assessing the impact of re-
search on policy: a literature review. Science and Public Policy.
2009;36(4):255-270.
84. Pawson R. The Science of Evaluation: A Realist Manifesto. London,
United Kingdom: Sage; 2013.
85. Jagosh J, Bush PL, Salsberg J, et al. A realist evaluation of
community-based participatory research: partnership synergy,
trust building and related ripple effects. BMC Public Health.
2015;15:725.
86. Lasker RD, Weiss ES, Miller R. Partnership synergy: a practi-
cal framework for studying and strengthening the collaborative
advantage. Milbank Q. 2001;79(2):179-205.
87. Stake RE. The Art of Case Study Research. Thousand Oaks, CA:
Sage; 1995.
88. Lusch RF, Vargo SL, O’Brien M. Competing through ser-

vice: insights from service-dominant logic. Journal of Retailing.
2007;83(1):5-18.
89. Brook RH. The end of the quality improvement movement: long
live improving value. JAMA. 2010;304(16):1831-1832.
90. Gray M, El Turabi A. Optimising the value of interventions for
populations. BMJ. 2012;345:e6192.
91. Crossland L, Janamian T, Jackson CL. Key elements of high-
quality practice organisation in primary health care: a systematic
review. Med J Aust. 2014;201(3 Suppl):S47-S51.
92. Janamian T, Jackson CL, Glasson N, Nicholson C. A systematic
review of the challenges to implementation of the patient-centred
medical home: lessons for Australia. Med J Aust. 2014;201(3
Suppl):S69-S73.
93. Nicholson C, Jackson C, Marley J. A governance model for in-
tegrated primary/secondary care for the health-reforming first
world—results of a systematic review. BMC Health Serv Res.
2013;13(1):528.
94. Crossland L, Janamian T, Sheehan M, Siskind V, Hepworth J,
Jackson CL. Development and pilot study of the Primary Care
Practice Improvement Tool (PC-PIT): an innovative approach.
Med J Aust. 2014;201(3 Suppl):S52-S55.
95. Janamian T, Crossland LJ, Jackson C, Morcom J. Triggering
change in diabetes care delivery in general practice: a qualitative
evaluation approach using the clinical microsystem framework.
BMC Fam Pract. 2014;15(1):32.
96. Wilkinson SA, Brodribb WE, Upham S, Janamian T, Nicholson
C, Jackson CL. Primary care of women after gestational dia-
betes mellitus: mapping the evidence-practice gap. Med J Aust.
2014;201(3 Suppl):S74-S77.
97. Askew DA, Jackson CL, Ware RS, Russell A. Protocol and base-
line data from The Inala Chronic Disease Management Service
evaluation study: a health services intervention study for diabetes
care. BMC Health Serv Res. 2010;10(1):134.
98. Zhang J, Donald M, Baxter KA, et al. Impact of an integrated
model of care on potentially preventable hospitalizations for peo-
ple with type 2 diabetes mellitus. Diabet Med. 2015;32(7):872-
880.
99. Burridge LH, Foster MM, Donald M, Zhang J, Russell AW,
Jackson CL. Making sense of change: patients’ views of diabetes
and GP-led integrated diabetes care. Health Expect. 2015;Jan:
1-13.
100. Russell A, Baxter K, Askew D, Tsai J, Ware R, Jackson C. Model

of care for the management of complex type 2 diabetes managed
in the community by primary care physicians with specialist
support: an open controlled trial. Diabet Med. 2013;30(9):1112-
1121.
101. Fitzgerald L, Harvey G. Translational networks in healthcare?
Evidence on the design and initiation of organizational networks
for knowledge mobilization. Soc Sci Med. 2015;138:192-200.
102. Swan J, Bresnen M, Robertson M, Newell S, Dopson S. When pol-
icy meets practice: colliding logics and the challenges of “Mode 2”
initiatives in the translation of academic knowledge. Organization
Studies. 2010;31(9-10):1311-1340.
103. Orr K, Bennett M. Public administration scholarship and the
politics of coproducing academic-practitioner research. PAR.
2012;72(4):487-495.
104. Bennet A, Bennet D, Fafard K, et al. Knowledge Mobilization in the
Social Sciences and Humanities. Frost, WV: MQI Press; 2007.
105. Phipps DJ, Jensen KE, Myers JG. Applying social sciences re-
search for public benefit using knowledge mobilization and social
media. In: Lopez-Varela A, ed. Theoretical and Methodological Ap-
proaches to Social Sciences and Knowledge Management. Rijeka, Croa-
tia: InTech; 2012:179-208.
106. Prahalad CK, Ramaswamy V. Co-creation experiences: the next
practice in value creation. J Interactive Mark. 2004;18(3):5-14.
107. Schmachtel S. Local partnerships as “rationalized myths”: a criti-
cal examination of the micro-discourse in educational partnership
working. Critical Policy Studies. 2015:1-20.
Funding/Support: Trisha Greenhalgh and Sara Shaw were supported by a Se-

nior Investigator Award in Society and Ethics to Trisha Greenhalgh from the
Wellcome Trust (104830MA).
Conflict of Interest Disclosures: All authors have completed and submitted the
ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs. Jackson and
Janamian were stakeholders in the Australian case study described in the article.
No other potential conflicts were reported.
Acknowledgment: We are grateful to the editor, 3 reviewers, and a technical editor
for helpful comments on previous drafts.
Address correspondence to: Trisha Greenhalgh, Radcliffe Primary Care Building,

Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United
Kingdom (email: [email protected]).

GREENHALGH Et Al (2016) Achieving Research Impact Through Co Creation in Community Based Health Services

Uploaded by

Copyright:

Available Formats

GREENHALGH Et Al (2016) Achieving Research Impact Through Co Creation in Community Based Health Services

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

GREENHALGH Et Al (2016) Achieving Research Impact Through Co Creation in Community Based Health Services

Uploaded by

Copyright:

Available Formats

Original Investigation

Achieving Research Impact Through

Context: Co-creation—collaborative knowledge generation by academics

The Milbank Quarterly, Vol. 94, No. 2, 2016 (pp. 392-429)

the Centre of Research Excellence in Quality and Safety in Integrated Primary-

We conclude by underlining the key elements that appear essential to

Mode 2: From “Knowledge Translation”

university-based research that is then “translated.” Gibbons and col-

Models of Co-creation in Health Care

Table 1. Different Models of Co-creation

Some of the models in Table 1 are more explicitly research-oriented

Table 2. Empirical Examples of Co-creation in Community-Based Health Care

(2 case studies) co-design was gradually realized

(Country) Goal Description Key Outcomes Comment

feedback, and links with reminders.

Second, they view research as a creative endeavor, with strong links to

Structures Supporting Co-creation

The complex forms in which people and organizations negotiate,

r Canada’s Community-University Research Alliances, including

With the exception of AHSNs, whose main focus is on basic science

access to services) and/or the development of research capacity in health

Research Impact in Co-creation Models

An emerging science of “societal impact assessment” seeks to cat-

Figure 3. Realist Model of Impact in a Multi-stakeholder Research

+ve = positive, -ve = negative.

Other authors have chosen realism as a theoretical lens to help meet an

Case Study: Co-creation in a Primary

team of academics and executives from clinical backgrounds was tasked

skills, and an independent chair with skills in strategic leadership and

a stream of empirical research, undertaken in parallel with the change

one-off projects; and collectively celebrating wins and problem-solving

community-based research. These include (1) a systems perspective (as-

be attention to the internal mobilization and negotiated utilization of

active involvement of stakeholders is a requirement (since participants

1. Glasziou P, Altman DG, Bossuyt P, et al. Reducing waste from

5. Grol R, Grimshaw J. From best evidence to best practice:

19. Gibbons M, Limoges C, Nowotny H, Schwartzman S, Scott P,

34. Wherton J, Sugarhood P, Procter R, Hinder S, Greenhalgh T.

47. Pearce V, Baraitser P, Smith G, Greenhalgh T. Experience-based

59. Larsen MT. The implications of academic enterprise for public

73. Weiss CH. The many meanings of research utilization. Public

88. Lusch RF, Vargo SL, O’Brien M. Competing through ser-

100. Russell A, Baxter K, Askew D, Tsai J, Ware R, Jackson C. Model

Funding/Support: Trisha Greenhalgh and Sara Shaw were supported by a Se-

Address correspondence to: Trisha Greenhalgh, Radcliffe Primary Care Building,

You might also like