The pitfalls of co-creation: reflections from Health CASCADE facilitators on critical events, consequences and preventive and mitigating strategies

Objectives: Co-creation is increasingly applied in public health research, particularly to develop solutions. Due to the unpredictable and ‘messy’ nature of co-creation, co-creation processes often do not go as planned. To inform facilitators of co-creation research, we aimed to identify critical events in planning, conducting, evaluating and reporting of co-creation and to provide strategies to prevent or mitigate them, by reflecting on co-creation projects within the Health CASCADE project. Study design: Qualitative study design. Methods: Online or in-person reflection sessions were held with facilitators of six co-creation projects, across various sectors, in different populations, and addressing diverse topics. Facilitators were asked to reflect on critical events in their project that could have negatively impacted the co-creators, the co-creation process, or the co-created solution, and to identify preventive and mitigating measures. Two researchers analysed meeting summaries using inductive thematic analysis. Results: We identified 16 overarching themes, representing critical events from planning to reporting, including not recruiting the 'right' participants, low engagement, lack of motivation for implementation, and biased evaluations. These can result in insufficient inclusion of diverse opinions and reduced co-creation time, which in turn can lead to less effective solutions and lack of trust in co-creation. We identified various preventive (e.g., scheduling reflection meetings beforehand) and mitigating (e.g., having a co-facilitator in case of difficulties) strategies. Conclusions: The results highlight the crucial role of facilitators in making co-creation an effective approach in public health. Allocating ample time for facilitator training beforehand and ongoing reflection during the co-creation project is essential.