What does co-creation mean? An attempt at definition informed by the perspectives of school health promoters in France

Background

Community capacity building, which is one of the goals for research and practice in the field of health promotion, has been documented as involving the development of skills, knowledge, leadership, participation and citizens’ and stakeholders’ power (World Health Organization [WHO] Regional Office for Europe, 2002; McLeroy et al., 2003). It is central to improving the outcomes of health promotion programmes (Labonte and Laverack, 2001). In the case of school-based health promotion, which recognises that schools are key settings for health promotion (St Leger et al., 2010; Stewart-Brown, 2006; Marmot, 2010), higher levels of participation are both an aim and an enabling process for health-promoting school strategies (Barnekow et al., 2006). These endeavour to use a whole school approach (Rooney et al., 2015) to engage with pupils in relation to the matters that concern them. The Health Promoting Schools framework (Langford et al., 2015) emphasises the beneficial roles of stakeholder (pupils, parents and school professionals) participation and strengthened relations with the surrounding community. Giving pupils a voice in decision-making processes is both a means and an end as part of democratic school health promotion (Simovska, 2007) and a way to enhance educational outcomes by means of engaging pupils as experts in their own learning (Bovill et al., 2011).

In searching for ways to support high levels of participation, the concept of ‘co-creation’ has been advanced. In recent years, this concept has been used alongside concepts of empowerment, participation, engagement and citizenship to mirror the drive to involve citizens in decision-making processes. The use of co-creation in education builds on the vision that education must pursue and contribute to social justice by reducing inequalities. This starts with concern for power distribution and the re-distribution of power in classrooms (Lubicz-Nawrocka, 2016). But co-creation may also be seen as an end in health promotion or as ‘the process of enabling people to increase control over, and to improve their health’ (Nutbeam, 1998: 1). In 2018, Bjarne Bruun Jensen (2018), the European Vice President of the International Union for Health Promotion and Education, made a compelling case for co-creation, arguing that it would contribute to taking health promotion forward towards its 2.0 version.

However, a major challenge needs to be confronted when aspiring to work with co-creation: namely, what does the term really mean? Definitions of co-creation exist within different professional disciplines; however, these understandings vary across fields. With respect to health promotion, there is no consensus on a definition of co-creation. Bovaird et Loeffler (2012) point out that definitions of co-creation variously embrace the (1) characteristics of the relationship between stakeholders, (2) their joint activities and (3) their joint achievements (Bovaird and Loeffler, 2012). Torfing et al. (2019) highlight how the terms co-creation and ‘co-production’ are sometimes used interchangeably. In the field of education, terms such as collaboration, partnership, student voice, ‘students as partners, co-creation, students as agents and students as producers’ can be found to carry different meanings (Bovill, 2019: 91; Bovill et al., 2011). In the published literature, yet other terms can be found: co-design, co-planning, co-managing, co-delivery, co-construction and co-innovation, among others, which makes co-creation an even more difficult concept to define.

Another approach to understanding co-creation is to characterise it as a learning process. This differs from the definitions presented above in the sense that value is here seen as being created from the mutual implication of stakeholders. Stakeholders share and mutualise their resources and create new resources through a learning process (Leclercq et al., 2016). People who engage in co-creation can be named ‘citizens’, but also end-users or beneficiaries. Different processes and relationships are involved, and it may be useful to draw a distinction between co-creation processes, co-creative activities, creativity and other approaches. In terms of outcomes, co-creation is sometimes the desired outcome itself. In other circumstances, co-creation is a means, a tool and a lever to achieve other goals.

Yet another challenge relates to the methods needed to promote co-creation processes. The health promotion literature identifies some of the difficulties faced in enhancing stakeholder participation, especially in school settings. Inter-sectoral collaboration may prove difficult in schools, and stakeholder participation often involves information and consultation rather than partnership or citizen control (Griebler et al., 2017). This is particularly the case with parents, who are often involved at the later stages of project design and strategic development (Darlington et al., 2018). Among the barriers to higher levels of participation are differences in the perception of the stakes; the different incentives to collaborate; differences in conceptions of the objective of the intervention; and different perceptions of how to define high levels of participation, what they entail and what can be expected from them (Mérini and De Peretti, 2002; Mérini and Ponté, 2009). Other issues relate to professional identity and purpose, beliefs and related complex power dynamics (Bragg, 2007). Being willing to let go of an ‘expert’ position is not always easy for professionals, and claiming to use co-creation is not necessarily a guarantee that power has been re-distributed.

Against this backdrop, it is important to better understand what co-creation is and what it represents for school health promotion professionals. The aim of this study, therefore, was to explore how to promote co-creation processes in the field of school-based health promotion. The research questions were as follows: how do school health promotion professionals perceive and define co-creation; and what specificities/commonalities can be identified in their definitions of co-creation?

Methods

This research was carried out as an offshoot of the ERASMUS Plus Co-creating Welfare (CCW) ¹ project, which aimed to design a training programme for professionals to develop competences to promote co-creation in their daily practices (Anastacio et al., 2019). The study was not included in the project, but some of the methods developed by the CCW project were used as data collection tools. As part of the Erasmus project, three workshops were organised in 2018–2019, which brought together three groups (labelled groups 1, 2 and 3) of French health promotion professionals who currently had, or had recently had, an interest in school settings (school nurses, teachers, teaching assistants, social workers, community workers, researchers and project managers). Overall, 46 professionals from the health, education and social sectors participated in the study on a voluntary basis.

The 3-hour workshops were originally organised as part of the larger project, but the research team saw an opportunity to collect data for research on co-creation. All the participants indicated being familiar with higher levels of participation as they worked in the field of health promotion which advocates empowerment, higher levels of stakeholder participation and decision-making power. Some participants had experienced co-creation, as they understood it, beforehand; others were not sure whether they had or not, as they did not know of a definition of co-creation. Therefore, participants were asked to think about the highest level of stakeholder participation they had experienced and imagine how they could engage with even higher participation modes. The research team did not wish to provide a definition of co-creation as this was the specific aim of the workshop. The purpose, methods and intended use of the research were, however, shared with all groups. Participants gave their informed consent for the use of the data collected, no names were recorded and anonymity was ensured during data collection, data handling and data analysis. No risk was identified from participating in the study.

Data collection

A set of qualitative data were collected by the two researchers involved in the data analysis. Previous experiences of co-creation were collected before the workshop, using an open-ended questionnaire in one group. In total, 14 questionnaires were collected. This method was chosen for convenience and advance preparation purposes. Forty-two blank cards on which participants wrote their own personal definition of co-creation in health promotion were also collected during an icebreaker activity, as well as via word clouds written by participants on a white board about their impressions/feelings towards co-creation. Then followed a plenary brainstorming session in each group to identify commonalities/differences between individual definitions, explain/discuss the reasons for such differences, categorise the different aspects of co-creation and provide a collective and more in-depth definition of co-creation. The main points from this discussion were synthesised collectively and written up on a white board, which was then photographed. Then, seven CUbes ² (Magee et al., 2015; Moody et al., 2020) were collected. The CUbe is a creative thinking tool which aims to generate ideas in a group through iterations for a set time of 30 minutes, building knowledge in layers as any new idea is added to what has been previously written and expressed. The moderator (researcher in this case–E.D.) asked, ‘What are the incentives and benefits of using co-creation in your practice?’ Every participant had an opportunity to write, draw and sketch on the CUbe while they explained what they wished to add to the conversation. A follow-up plenary brainstorming discussion enabled the whole group to collectively deepen its understanding of co-creation in health promotion, what it entailed, its benefits and its specificities, adding new or refined categories and specifying each component, giving it more detail and perspective based on their own experiences. Different colours were used at different stages of the discussion. Pictures were taken throughout the workshop to keep a record of discussion and collect data. ³

Data analysis

The same researcher (E.D.) carried out all the workshops with all the groups, and collected and transcribed the data from the cards, CUbes, questionnaires, board word clouds and brainstorming activities. They also analysed the whole dataset. The second researcher (J.M.) attended to a whole day of workshops with one of the groups. He conducted a reliability check on the analysis at a final stage. Content analysis was used to identify and develop themes from within the data (Hsieh and Shannon, 2005). The methods used to analyse the dataset extracted from the questionnaires, CUbes and brainstorming activities involved a three-stage iterative process. See online supplemental material Appendix 1 for a more detailed description of the screening process.

Validity criteria

With respect to internal validity, construct validity and authenticity were enhanced by using participants’ words and categorisations during analysis. The same two researchers conducted all the workshops as ‘participant researchers’ who themselves contributed to the data analysis and categorisation during the brainstorming sessions. Links between ideas were made explicit, either verbally or using arrows and colours on the CUbes.

With respect to external validity, a ‘thick’ and detailed analysis was developed to identify typicality in the main components of co-creation as expressed by participants. We believe that sufficient data are provided for the reader to assess the potential of our findings to be generalised (Lincoln & Guba, 1985: 316, in Cohen et al., 2018).

Triangulation between data collection instruments (as described above), investigator triangulation (as two researchers were involved successively) and triangulation of data were also used to strengthen interpretive validity (Cohen et al., 2018).

Results

When asked how they felt about co-creation, even though they had participated in the workshop with considerable motivation and positivity, professionals expressed feelings of excitement, motivation, interest and curiosity, but also indicated that they were somewhat destabilised by co-creation. They referred to co-creation as ‘conflictual’ in the sense of potentially creating conflict and emphasised that co-creation was difficult to define and operationalise, and that it could trigger doubt and worry. They were also perplexed, co-creation being a vague concept that triggered questions. Their overall perception of co-creation was therefore not as positive as might have been expected.

With regards to defining co-creation, professionals gave varied definitions of co-creation as a first step (see online supplemental material Appendix 2). When discussing the definitions given, one professional from group 2 emphasised how ‘For me, co-creation is the ability to work together with different stakeholders, for the benefit of the people for whom the project is created’. The end-user or beneficiary was seen as having a crucial role in the creation of a project which addresses their need. Another participant in the same group wrote, ‘Co-creation is the construction of a project or something else, together with all the stakeholders, taking into account the different contexts, the needs and expectations of each of the participants’.

Drawing together all stakeholders’ knowledge and expertise, the aim of co-creation was ‘to create together, or with the people, to open up possibilities, and enrich creation; it is collective intelligence. Thinking together, getting tuned, and producing together’. The competences of a whole group of people are used for the benefit of the whole group and to serve a common purpose in the form of a ‘joint project, which is implemented by a group of individuals. The project objectives involve each of the participants’ competences’ (school nurse from group 1), in which ‘the different stakeholders have a common goal and start creating together from the first steps’ (school nurse from group 1).

Co-creation was seen as clearly related to projects and teamwork, from which ‘something’ is created, or at least ‘something’ is shared by all group members, whether it be a goal, a definition, or even a setting. Another participant from group 2 pointed out in the definition card that co-creation is ‘a philosophy, a state of mind, a working methodology’, which it is about openness and togetherness. ‘Co-creation is about a problem: listening, sharing, openness, diversity of viewpoints for a common goal’, a means of creativity: ‘Co-creation is a permanent brainstorming’ (definition card from group 2 participant).

Commonalities

In the brainstorming session, participants identified commonalities in their definition, which led to identifying the core elements of co-creation as detailed below.

The specific people involved and how to name them

The first issue that emerged from the data was how to name the people involved in co-creative processes (see Figure 1). Some participants referred to them as stakeholders and others to end-users, partners, actors, community, participants or beneficiaries. Co-creation was seen as involving a variety of participants from different backgrounds, which was thought to be especially relevant, but which also raises a few issues in terms of who they should be, the way they should be engaged in the process, and how they should be selected. According to participants, the people involved in co-creative processes should complement each other. They should work as a group to combine their ideas, drawing upon their differences, in a friendly atmosphere. Also raised were questions about each participant’s place and how to include everyone in the process.

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Figure 1.

Mind mapping of data relating to people involved in co-creative processes.

Co-creation as involving collaboration, cooperation and collective work

Co-creation consists of creating a project together in the form of a concrete action which is useful for the group. In many instances, the initial objective may be different from what is achieved. The project created emerges from a shared problem and addresses existing needs and expectations. It is constructed in steps, on a voluntary basis, and in mutual trust between participants. Collaboration can take many forms such as cooperation and partnership work. In participants’ own words, co-creation is ‘to create, to build something in collaboration with several people from different backgrounds ⁴ ’ (definition card from group 3 participant), ‘sharing ideas’ (definition card from group 3 participant), ‘experiences, to create, invent, together’ (definition card from group 3 participant), based on ‘different points of view’ and ‘multidisciplinarity’. This collaborative process involves ‘meetings’ (CUbe from group 2), ‘exchange and communication’ (CUbe from group 1), to ‘create a team dynamic’ (CUbe from group 2) and ‘facilitate the implementation of actions and projects’ (CUbe from group 3). For co-creation to work, group cohesion needs to be fostered. Finally, one of the benefits of co-creative collaboration is to ‘meet atypical profiles’ (CUbe from group 2) and ‘people from other universes’ (CUbe from group 2) in order to ‘build a network’ and ‘no longer be isolated’ (CUbe from group 2). Potential difficulties relating to such collaboration include ‘power issues’, the ‘different visions’ put forward by each participant, ‘which is also an asset’, their differing ‘positions and attitudes’ towards an issue and the differences in contexts (questionnaire from group 3).

Another important point raised during discussion was that differences between co-creators could become the roots of new ideas, ‘diversity, divergences and pluralities’ (group 1 CUbe and discussion), which was seen as pursuing the ‘same objective’ however facing ‘different challenges’, and called for ‘openness, exchange, listening, compromise, and concessions’ (group 1 CUbe and discussion).

Expected results of co-creation

With respect to the expected results of co-creation, or what is produced by the process, participants expressed a range of ideas which were sub-categorised as follows: the products of co-creation, which is a project, an action; innovation, which comes from the combination of ideas, and supports new leads and new ways; the results of co-creation for the group, which include personal development, a time and resources saver/gain and networking; and the results of co-creation for the community, which will be all the more beneficial as co-creation enables the development of tailored solutions which meet the needs of community participants.

Purpose of co-creation, its aim or goal

Participants indicated that one of the aims of co-creation is to create something new, to explore, invent using creativity tools, connecting ideas and using group dynamics to move beyond usual practices. One of the objectives of this endeavour is to build knowledge and experience, and develop new competences while learning from each other. Another aspect that was suggested without further specification concerned the value of transgressing existing frameworks and established ways of working. The underlying purpose here is to focus on addressing and meeting people’s needs. Among the strategies that may be used to create a useful project, participants mentioned promoting empowerment, facilitating processes, creating a shared culture based on mutual discovery, acknowledging people’s knowledge and talents, and developing a civic culture, enabling voices to be heard.

Specific difficulties in relation to the use of co-creation

Participants also identified that specific difficulties and issues would have to be addressed and overcome when using co-creation. They mentioned three types of constraint: space, time and what they named ‘institutional constraints’, which referred to organisational issues. Participants also mentioned issues relating to collaboration, which required ‘concessions, compromise’, sometimes even ‘arguing, confronting ideas, thinking’, which could lead to ‘resistance’, ‘satisfaction, or dissatisfaction’. Co-creation involves getting ‘out of [one’s] comfort zone, [one’s] usual frame of thought’, ‘outside the walls’.

Participants highlighted the need to avoid repetition in the process and highlighted how co-creation ‘allows [for] questioning’ from a reflective perspective. However, ‘there is a fine line between persuasion and manipulation’, and some people mentioned that co-creation had become fashionable ‘because it is in tune with the times, cool’ and disruptive. However, at the end of the day, there should be ‘no obligation to co-create’.

Funding to support co-creation was also mentioned as a difficulty, as well as the importance of ‘not being mistaken’ by what can be achieved with co-creation. It is about getting ‘the group to say what you can’t say individually’, ‘confronting with other professionals especially when working alone/freelance’ and ‘reinvest[ing] training concretely’ while letting ‘everyone find a place’, with a sense of freedom in the process: ‘Go towards creation, feel more free in the process’.

A few questions that professionals would need to address if working with co-creation were raised during the workshops. They included the following: How to create the starting impulse? Who does co-creation benefit? Why do we use co-creation? What is it useful for? What common interest(s) do we have? How to give up sometimes? Is co-creation about ‘how’ or ‘what’? How much personal commitment is needed? Is a leader required? Finally, the key question of how best to evaluate co-creation emerged.

Set of values

A set of values were advanced as underpinning co-creative processes. Participants pointed to the importance of respecting others, others’ knowledge and others’ opinions. Trust and freedom were seen as two pillars of co-creation. Co-creation should involve everyone and support the sharing of responsibility. Power should be balanced, and processes should be based on equality and fairness and rooted in democracy. Such values derive from a bottom-up approach to community health in which communication is key, ‘anyone can express themselves’ and ‘everyone’s voice has the same value’. Different levels of influence need to be understood and influence should be shared. Group dynamics and hierarchy have to be balanced against risks and benefits. Each person has their own ‘values’. Values relate both to the subject of the project and to the project itself. Choices require to be ‘informed’ and based on ethical principles. One of the phrases used was to ‘avoid the excesses of – I know better than you what is good/bad for you’. The preceding values as pre-requisites to co-creative processes differentiated co-creation from other forms of collaboration.

Co-creation is initiated and implemented in a specific context

Sometimes initiation may stem from the need or will to upgrade one’s own skills; on other occasions, professionals have no choice. Co-creation occurs within specific legislative and ethical frameworks which have to be taken into account by professionals and which also orient the way co-creation is implemented.

Co-creation is a process, which occurs in stages and steps

Co-creation is a process that is about creating a space or a moment; it is singular and specific, and it involves creativity. Professionals need to appropriate the process, and different levels of decision-making need to be identified during the course of this process.

In summary

Based on our findings, co-creation in health promotion is a process that would seem to involve a team of people formed on a voluntary basis recognising they have something in common. Such people might be called ‘co-creators’. Co-creators come from diverse backgrounds, each of which is recognised as a legitimate place within the group. To be co-creative, the group must recognise everyone’s place and competence.

Co-creators have a common interest to create something together for the benefit of the larger whole. Interactions between co-creators should be based on cohesion and collaboration should be based on mutual trust, openness, autonomy, freedom, respect, democratic processes and shared responsibility. Co-creators should share ideas equally and freely to mutualise knowledge and promote innovation. Differences between co-creators, whether in terms of background, culture or professional identity, are embraced and transformed into opportunities for creativity, novelty and connection.

Co-creation is a process which includes communication, compromise, collective reflexion, horizontal decision-making and the creation of a shared culture. Equal value is given to the knowledge, competence, action and decision power of each member in the group. A shared culture between co-creators is a pre-requisite and a result.

Co-creation results in a joint creation, a new project or action, a joint decision, or the improvement in existing projects and practices, all of which are useful and tailored to existing needs and will contribute to promoting health and well-being. Co-creation benefits members of the group by enabling them to gain new experiences, competences and skills, and strengthen networks and social relations between them. Co-creation also benefits the community as it promotes the effectiveness of health-promoting actions and projects, and enriches networks and successful living together.

Specific competences are needed to promote co-creation such as active listening, mediation, stepping out of one’s comfort zone, reflexivity and thinking outside the box. An overall definition of co-creation is provided in Figure 2.

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Figure 2.

A definition of co-creation in health promotion based on an analysis of the data.

Discussion

In this article, we have tried to provide a definition of co-creation which is as close as possible to a set of health promotion professionals’ experiences and vision of how to work in their line of practice, that is, within a school setting. Our methods were intended to capture the complex meanings conveyed by professionals during the workshops that took place. Giving stakeholders a voice can be a challenge to researchers in terms of the appropriate methods to choose to undertake participatory research. In addition, it is important to question the ethical and epistemological perspectives that underlie research designs which endeavour to give stakeholders a voice (Fielding, 2007).

To our knowledge, no consensual definition of co-creation yet exists in the field of health promotion. Definitions can be found in other fields of research and for different purposes and end results. In health promotion, the overall aim is to promote decision-making and action-based power and to enable individuals to take/increase their power to make their own decisions about their health, which in turn will enable them to improve their own health in their living environments. Processes of co-creation hold potential to build capacity, which can be the desired outcome. Our intention in this study was to contribute to facilitating the future implementation of co-creative processes by identifying the different components of co-creation within health promotion practice.

A key feature of the benefit of co-creation as described by health promotion professionals concerns the multiple roles that any professional is required to play. Health promotion professionals are also citizens, parents and community-members, and they can be promoters of co-creation as well as the beneficiaries of this process. This is not the case in the business or marketing field, which more clearly distinguishes between the provider and the user. This distinction highlights the asymmetrical relationship between the provider and the user – the provider being the person who gives, who proposes, who even has the idea for a product; the user being the beneficiary, the taker. The user is engaged to make the product, which has been designed by the provider, as appealing as possible so that is sells better. In health promotion, professionals highlighted that all stakeholders are engaged in the process of co-creation from the start, and the eventual outcome or output of this process is not necessarily known in advance. This means, for example, that in school-based work, co-creation used for learning may not necessarily lead to the design of a curriculum, but may instead result in a different kind of health-promoting solution.

Importantly, co-planning, co-design, co-managing and co-production (Bovaird and Loeffler, 2012) are not interchangeable with ‘co-creation’. In healthcare research, co-production can be used to characterise the type of communication that sometimes takes place between a clinician and patient, which aims to empower staff and engage service users in choosing the best service options for them (Realpe et al., 2015). From our findings, we can identify a difference from this process, since co-creation, as described by participants, does not engage citizens in deciding what services are best, but whether services are relevant and whether the problem is well-defined. Co-creation could in fact (and often does) result in a totally new solution, not in the tailoring of existing products or services. Co-creation may therefore be an overarching concept which requires its different stages to be co-defined and co-implemented, starting with the co-definition of the initial issue/problem, as co-creation is intended to address an existing need. Dollinger and Lodge’s (2020) evidence-informed model presents student–staff co-creation as involving a combination of processes requiring individual and environmental inputs and which results in benefits to the student mainly. Our definition of co-creation is slightly different in the sense that the outcome of co-creation can imply changes in power relations and relationship building, which, as mentioned previously, are among the principal aims of health promotion. Outcomes also differ as they would likely include the promotion of health and well-being of all members of the community.

Citizen participation is a key feature of community approaches to health promotion (Labonte et al., 2002). In Arnstein’s (1969) model of citizen participation, the highest level of citizen participation occurs when citizens exercise total control and decision power on any subject that concerns them. We argue that participation and co-creation are related; however, clearer links between the two concepts are needed from a conceptual point of view. Is participation a means to an end in co-creation? Is co-creation a means to an end in participation? Citizen control is usually defined in terms of decision power. In contrast, the proposed definition of co-creation identified multiple dimensions to a complex process of collaboration, which cannot be defined in terms of decision-making power only. Nor can it be defined only in terms of how participants collaborate/cooperate together (Barthe and Queinnec, 1999) and/or negotiate common goals as defined in Merini’s definition of partnership (Mérini and De Peretti, 2002).

In the WHO’s Health Promotion Glossary (Nutbeam, 1998), principles of ‘enabling’ to empower groups of stakeholders to promote health also relate to the processes described by professionals as co-creation. Co-creation as described by health promoters is in this respect similar to the ‘student voice’ approach as presented by Bovill et al. (2011), in that the citizens/beneficiaries of co-created health promotion projects are considered experts, and their expertise is legitimised by and from the process. The shared responsibility and democratic aspects of what may be described in co-created learning are similar to what our results underline as the type of collaboration described as co-creation by health promotion professionals. Barthe and Queinnec distinguish between different modes of collaboration based on whether or not goals, aims and tasks are shared among partners at different steps in the process of collaboration (Barthe and Queinnec, 1999). From what professionals expressed during this study, co-creation requires a common goal and collaboration throughout the whole process of achievement. In addition, co-creation in health promotion does not necessarily occur within a fixed framework, as does much of school-based learning. Initiation modes also differ, as health promotion practices involve schools and also other settings and the whole community.

Co-creation as described in this study also differs from the concept of ‘alliance’ as put forward in the WHO Health Promotion Glossary – ‘an alliance for health promotion is a partnership between two or more parties that pursue a set of agreed upon goals in health promotion’ (Nutbeam, 1998: 5) – in the sense that co-creation is a complex construct that includes a specific mix of people, a specific process and specific outcomes, outputs and results which are created collectively. Co-creation can therefore be a process leading to community action for health (Nutbeam, 1998: 5), which in turn may enhance community empowerment. In this study, health promotion professionals described the group of stakeholders involved in co-creation in a way that clearly relates to a ‘community’ ⁵ as defined in the WHO Health Promotion Glossary, which could be explained by the fact that health promotion professionals often work with community health and bottom-up approaches.

Conclusion

To conclude, co-creation is a complex concept that requires more work to understand its use within the field of health promotion. Co-creation is a current trend and key feature of health promotion practice: central to the promotion of success, but also key to some of the common difficulties experienced in practice. Both the negative and the positive aspects of co-creation need to be taken into account when engaging in the process.

One of the most important features of co-creation as expressed by professionals in this study was its roots in humanistic values, which recall the founding principles of health promotion. The specific competences needed to promote co-creation, as well as the methods needed to evaluate its achievements and the added value of co-creation, need to be explored further.

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