Considerations for Co-production With Children and Young People: A rapid review
An exploration of existing literature and research into into the co-production considerations when working with children and young people in mental health and wellbeing services.
Prepared by: Dr Michaela James Swansea University, Hannah Spacey Public Health Wales, Enfys Preece Public Health Wales, Anna Boggiani-Lloyd Single Parents Wellbeing, Maria Pollard Single Parents Wellbeing.
Funded by The National Lottery Community Fund and in Partnership with Mental Health Foundation, Swansea University and Public Health Wales, the Mental Health Manifesto is led by Single ParentsWellbeing (SPW) CIC, based in Cardiff.
The project aims to engage with children and young people (10-24 years) from single parent households to co-design and deliver what they need to create positive pathways to a mentally healthy future. During the project, beneficiaries are given the opportunity to make new connections, have their voices heard and build positive foundations for their future.
Background
This review was conducted by Public Health Wales, Swansea University and Single Parents Wellbeing and aims to explore existing literature, research and guidance around the co-production of mental health and wellbeing initiatives with CYP. It has been completed to inform Single Parents Wellbeing's approach to the co-production of initiatives with children and young people, focused on mental health and wellbeing. This is in line with project goals of the Mental Health Manifesto led by Single Parents Wellbeing which aims to improve mental health and wellbeing outcomes in CYP (aged 10 - 24 years) from single parent households (SPH). Co-production is at the heart of the project, and because of this, a review of best practice was warranted to inform the design and implementation of the current project. Broadly speaking, the term 'co-production' refers to a process whereby all project members (participants, deliverers, management staff) work together to achieve a shared outcome or goal, through the equal sharing of power and decision making.
Co-production is an important process in the successful design and implementation of health and wellbeing interventions, which has positive outcomes for all involved (1, 2). Because of this, many project funders now incorporate co-production in project requirements, which has led to a surge the number of projects applying co-production principles in their work. Co-production with CYP is especially important, given the complex and ever changing biological, social and emotional landscapes in which they live and their effects on mental health and wellbeing outcomes for CYP.
Poor mental health outcomes in CYP continue to rise across the UK, which has resulted in mental health and wellbeing becoming a key health priority for public health organisations (3). In 2015, Welsh Government introduced the Wellbeing for Future Generations Act (2015), that sets out it's priority areas for improving health and wellbeing of our future generations. The legislation sets out 7 wellbeing goals that ensure a nation that is i) healthier, ii) more resilient, iii) prosperous iv) responsible, v) cohesive, vi) equal, vii) with a vibrant culture and language.
Given the increase in the timeliness of co-production in Wales, a rapid review of the evidence to date was warranted to assess current learning and compile recommendations for use by project stakeholders. Based on the latter, the aim of this rapid review was to provide an overview of the evidence around co-production with CYP to inform the development of community mental health and wellbeing initiatives. The findings of this review will be used to inform the design and implementation of co-production within the Mind Our Futures funded ‘Mental Health Manifesto’ project and will inform future work in this area.
The full methodology of this review can be seen as Appendix A.
1. De Rosis, S, Pennucci, F, Noto, G, Nuti, S., (2020), Healthy Living and Co-Production: Evaluation of Processes and Outcomes of a Health Promotion Initiative Co-Produced with Adolescents, Int. J. Environ. Res. Public Health 2020, 17, 8007; doi:10.3390/ijerph17218007
2. Taylor et al., (2022), Defining research priorities for youth public mental health: reflections on a coproduction approach to transdisciplinary working, Health Research Policy and Systems,20:72, https://doi.org/10.1186/s12961-022-00871-w
3. Grimm F, Alcock B, Butler J, Fernandez Crespo R, Davies A, Peytrignet S, Piroddi R, Thorlby R, Tallack C. Improving children and young people’s mental health services: Local data insights from England, Scotland and Wales. The Health Foundation; 2022 (https://doi.org/10.37829/HF-2022-NDL1).
4. Welsh Government. Well-being of Future Generations (Wales) Act 2015: Essentials Guide. 2015.
This rapid review aims to answer the question:
What are the key co-production considerations when working with children and young people in mental health and wellbeing initiatives?
Findings
A full reference list can be seen as Appendix B.
The key themes to emerge from the papers were:
1. Planning
Knowledge and Power
Early engagement
Safe Spaces
2. Implementation
Facilitators and Resources
Supporting Participation
Working Together
Accessible Discussions
Tokenism
Ongoing Evaluation
There were a number of definitions of co-production used in the sources included in the review, with the term 'co-production' being used interchangeably with co-design, co-creation, co-evaluation and PPIE. Despite this, the key themes that were present across all definitions included joint decision making, the importance of voice and the sharing of power.
A list of the definitions used by sources included in this review can be found below.
1. “In simple terms, co-design is a process which involves people in the decisions that will have an impact on them.” – Orygen 2019
2. “The term encapsulates a range of processes linked to co-design, co-creation and co-evaluation, and different strands of debate have led to some murkiness around what actually counts as coproduction.” – Mannell 2023
3. “Meaningful participation ensures that young people have space (opportunity and information) to freely voice their opinions to relevant people (audience) who seriously consider and act upon their views.” (UNICEF 2022)
4. “Co-production is a way of working that utilises the experience, knowledge and skills of a range of stakeholders to design, produce and deliver better services and resources.” (Boing Boing 2017)
5. “Coproduction is “an approach in which researchers, practitioners and the public work together, sharing power and responsibility from the start to the end of the project, including the generation of knowledge”. Coproduction aims to ensure that the knowledge generated is informed by the needs of the target group, is relevant to them, and has greater applicative value in their local setting.” (Fernandes 2023)
Theme 1. Planning for Co-production
Knowledge and Power
Orygen (2019), Mannell (2023), UNICEF (2022)
Projects should prioritise placing equal value on professional and lived experiences and promote the sharing of power between stakeholders, facilitators and CYP through employing processes that lead to equal, long-term participation. If decision making is not equally shared, the work would be classed as consultation and not co-production. The rights of CYP should be
prioritised through the co-production process, which can be achieved by employing a strengths-based approach that acknowledges that CYP will know which methods and strategies work best for them.
Before work begins, stakeholders and facilitators must first acknowledge that there will need to be a shift in beliefs about what constitutes as knowledge and they must be ready to re-assess the assumptions they have about project concepts, next steps and ‘what works’ to make space for CYP’s alternative approaches.
Early Engagement
Thomson (2022), Mannell (2023), Boswell (2021), Boing-Boing (2017), Orygen (2019)
Engaging with CYP early on in the co-production process is key and long-term engagement can be supported by holding regular meetings and workshops across the project lifecycle. It is important to understand where in the project calendar engagement will take place, taking into consideration the key time points for co-production tasks and activities - frameworks such as the Primary Health Network (PHN) Commissioning Framework and Orygen’s Double Diamond Design Process (2019) can help to identify these stages.
While co-production can happen across all project stages, it cannot be done retrospectively so protecting time during the planning stage is very important. Providing CYP with information in advance as to what the co-production is for, why they are being invited to take part and what they are likely to get out of the experience is essential, and should acknowledge their contribution, the time they will dedicate to the work and any subsequent reimbursement for their participation.
Developing a co-production agreement at the start of the project is a great way to include CYP in decision making and setting the rules of the group. The co-production agreement can be revisited during the project and will act as a foundation on which to build your work.
Safe Spaces
Thomson (2022), Mannell (2023)
Creating a safe space for CYP to work with you during the co-production project is important, especially when working with CYP who have lived experience of the issues being discussed. Be mindful that CYP’s knowledge and experience of mental health is very different to that of adults and discussing lived experiences may be upsetting and/or uncomfortable. It is important that co-production serves to benefit the CYP taking part in the project, and CYP should feel protected in project spaces that serve to represent them and not to merely tick boxes.
Previous studies (Mannell, 2023) found it useful to apply a character creation approach to some of
their work, especially when discussing CYP’s experience of mental health. Creating characters takes the spotlight off the individual and allows them to share experiences in a hypothetical way.
This can support CYP to feel more comfortable when engaging in the work and ensures a certain level of anonymity in discussions. Signposting is very important throughout the collaboration, along with appropriate de-briefing at the end of every session.
Theme 2. Implementation of Co-production
Facilitators and Resources
Mannell (2023), Boswell (2021), Fernandes (2023)
Facilitators have an important role in the development and maintenance of non-judgemental spaces that CYP feel comfortable in and facilitators can use a range of formal and informal methods to achieve this. Facilitators should work hard to ensure a mutually respectful environment is developed and maintained, with trust at the forefront of all relations.
While the role of facilitator is very important, it is also helpful to have an external mediator on board to ensure the project stays on track. While there is great benefit in conducting co-production projects, they require extra time for facilitation, administrative tasks and evaluation, which needs to be considered when allocating resources and setting goals. Successful co-production requires facilitators that are skilled and have experience in co-production with CYP, which may mean extra resources and funding is required to upskill project staff.
Supporting Participation
Pavarini (2019), Boswell (2021), Mind, Thomson (2022), Fernandes (2023), UNICEF (2022)
Before co-production begins, project stakeholders should consider whether CYP can meaningfully contribute throughout the stages of the project and should reflect on the amount of decision-making power that they will have during co-production activities and overall outcomes (e.g. system change). Is there joint responsibility between stakeholders and CYP for these outcomes?
When working with a group of CYP with a large age gap, projects should be mindful to consider cognitive abilities between the younger and older participants, and ensure that all resources, activities, and materials are tailored to suit all involved. During sessions, facilitators should ensure that CYP have the opportunity for equal participation, and have frequent opportunities to contribute to session discussions, project planning and decision making.
CYP and stakeholders will often have differing interpretations of information due to social, emotional and, cognitive backgrounds and may have varying understanding of concepts, so using CYP’s own words during workshops/meetings is useful to discuss topics.
Project leaders should be mindful that working with CYP will mean that the scheduling of workshops, meetings and other co-production activities is likely to fall outside of school/college hours so a certain level of flexibility is needed to accommodate the CYP’s timetables.
Depending on project parameters, offering online co-production sessions could open the project to a greater number of CYP and make participation more accessible. Frameworks such as the Ladder of Participation help frame participation and provide a visual guide as to how much or how little is actively being done.
Working Together
Thomson (2022), Fernandes (2023), Boswell (2021), Orygen (2019), UNICEF (2022)
It’s useful to hold regular group meetings during the co-production process to build rapport and provide opportunities for CYP to build peer relationships. Meetings and workshops should include ice-breaker activities and casual check in’s to allow CYP to settle in and build confidence when talking to peers and facilitators.
For CYP who are long-standing members of the project, there should be pathways built in where they are able to act as peer mentors to newer members. Incorporating youth-only co-production spaces into the project calendar provides an opportunity for peer-to-peer conversations about how work is going without stakeholders being in the room. Be sure to consider the amount of time and resource that this will require from project staff and ensure to allow ample time for all project activities such as; periods of reflection, regular whole group meetings, peer-to-peer sessions, training and other workshops.
To ensure the safety of all CYP taking part in the co-production work, safeguarding training should be provided to project staff and participants. UNICEF provides a Stepping Stone protocol comprising of 5 (+1)core components to safeguard and protect wellbeing during the coproduction process.
Accessible Discussions
Mannell (2023), Boswell (2021), Thomson (2022), Fernandes (2023)
It’s very important to select methods that support open, accessible conversations during co-production work with CYP, especially when working with those who have lived experience of the topic of interest. Ensuring that CYP have a baseline knowledge of terminology and concepts is important and it should never be assumed that CYP will come with prior knowledge.
The facilitators should offer a range of methods and activities to ensure CYP remain engaged throughout the co-production lifecycle and are able to contribute through a variety of mediums e.g. focus groups, workshops, drawing, journaling and creative methods. Examples of good practice in this area can be seen in UNICEF (2022) with activities such as; expression boxes and body mapping.
Tailoring co-production outputs and resources to the needs of CYP involved in the project is important to ensure the equitable engagement of all involved and supports feelings of cohesion and shared concepts. This should be something that is led by CYP themselves, with CYP steering the development of resources and communications both in and outside of the project. It is important to ensure that all those involved in the project have ownership of the data and its outputs.
Previous studies discussed the difficulty CYP had in identifying solutions to the problems that CYP were facing. Because of this, stakeholders should be mindful that some of the discussions around identifying solutions may need to be re-visited on multiple occasions using a variety of techniques while the CYP reflect on the issues and the possible ways to tackle them.
Tokenism
Thomson (2022), Fernandes (2023), Pavarini (2019), Orygen (2019), Boing-Boing (2017)
A number of papers discussed the importance of ensuring co-production work with CYP did not become tokenistic or just a ‘tick box’ activity. Incorporating evaluation and a regular feedback loop is a good way of ensuring work does not become tokenistic and holds all involved accountable for the work. Ongoing M&E is also helpful to ensure effective collaboration and should be built in to project timelines.
CYP feel valued when their ideas are listened to and recommendations are put into practice, so feeding back to CYP about co-production outcomes is an important part of the process. It is worthwhile setting out or identifying core values of working together to ensure all participants are on the same page. For existing principles include Orygen (2019) and Boing Boing (2017).
While co-production is a growing area of interest for project funders, stakeholders should assess whether co-production compliments the project being delivered and if it adds tangible value. If not, there is a risk of the co-production work becoming tokenistic. Remember- co-production should be empowering, not patronising for CYP participating in the project. Who is it serving – the adults or the CYP?
Ongoing Evaluation
Pavarini (2019), Boswell (2021)
It’s important to undertake ongoing evaluation to ensure the co-production is running to plan, is mutually beneficial to all involved, and to assess the impact of the co-production for participants and overall project outcomes. Co-production work needs to be sustainable and able to develop over a period of time, so keeping a record of all steps taken is important to keep track of the project and avoids a lack of clarity of process at the end of the work.
Pavarini (2019) provide some suggestions as to how undertake ongoing evaluation of co-production with CYP. Periodic, anonymous project/activity feedback from participants can help to consider priority areas for development going forward, while capturing participant reflections of personal skill development can aid in assessing project impact. Continuous assessment and reflection from project leads, deliverers and stakeholders is an important step in the evaluation process and helps to promote partnership working throughout the co-production work. The benefits of evaluating co-production with CYP goes beyond impacting the immediate project, as evaluation findings also contribute key insights to the small body of literature surrounding co-production with CYP.
Recommendations
1. Promote Equal Power and Knowledge Sharing:
Emphasize equal value on both the professional and lived experiences in co-production projects, ensuring that power is shared among EVERYONE involved in the project.
Adopt an approach that recognises CYP's expertise in knowing what methods and strategies work best for them.
Prioritize the rights of CYP throughout the co-production process, steering away from consultation towards true co-production where decision-making is equally shared.
2. Early Engagement and Establishing Safe Spaces:
Engage with CYP early on the co-production process and plan for long-term engagement by scheduling regular meetings and workshops throughout the project’s life cycle.
Develop an agreement at the start of the project, that clearly outlines the purpose, expectations, and rules of the co-production project, and revisit it during the project's progression.
Create safe spaces for CYP by considering their experiences, utilising approaches like character creation to discuss sensitive topics, and providing appropriate signposting and debriefing after sessions.
3. Facilitators, Resources, and Accessible Discussions:
Invest in facilitators with experience in working with CYP, and consider the need for external mediators to ensure project effectiveness.
Allocate resources and funding for facilitation, administrative tasks, and evaluation in co-production projects, recognising the extra time required.
Support meaningful participation by considering the cognitive abilities of CYP, offering flexible scheduling, providing online sessions, and incorporating youth-only spaces.
Ensure accessible discussions by selecting methods that support open conversations, avoiding assumptions about prior knowledge, and tailoring outputs to meet the diverse needs of CYP involved.
These recommendations aim to guide practitioners in implementing effective co-production processes with children and young people, emphasizing equality, early engagement, safety, skilled facilitation, and ongoing evaluation.
Appendix A- Methodology
The review was completed by an external senior evaluation officer from Public Health Wales (HS), a research officer from Swansea University (MJ), a research officer from Public Health Wales (EP), a placement student from Single Parents Wellbeing (AB-L) and, a member of the Single Parents Wellbeing team (MP).
The search strategy (see below) were run through a number of databases and a few key journals for the topic area including: CINAHL, JSTOR, PubMed, Science Direct, Web of Science, Web of Science, Wiley Online Library, BMJ, Journal of Adolescent Health, Journal of Environmental Research and Public Health and, Charity/Public and Private Sector grey literature.
Search strategy:
“young people” OR “children” OR “adolescence” OR “teenagers” OR “child” OR “young person” OR “young people”
AND
“mental health” OR “mental wellbeing” OR “emotional wellbeing” OR “emotional health”
AND
““co-production” OR “co-design” OR “co-delivery” OR co-analysis” OR “partnership working” OR “involvement” OR “participation” OR “co-creation” OR “co-innovation” OR “co-evaluation” OR “participatory” OR “decision-making”
AND
“community-based” OR “community-led” OR “community”
Exclusion criteria included: studies/reports focusing on young children (0-9 years), adults (26 years and over), dissertations, presentations.
A full protocol of the review can be accessed by e-mailing Public Health Wales (phw.research@wales.nhs.uk) or Dr Michaela James (m.l.james@swansea.ac.uk).
Critical appraisal was undertaken to assess the quality and relevance of the studies included in the review. Once the studies are identified, the researchers assessed their quality and relevance via abstract and full text screening using Rayyan. The appraisal assessed aspects such as study design, sample population, data collection methods, data analysis, and potential biases. For example, papers with wrong populations were removed if they fell into the exclusion criteria - e.g. wrong age, wrong publish date, or wrong outcome, such as focus on PPIE instead of co-production, where PPIE (Patient and Public Involvement/Engagement) was defined as instances where populations were only engaged with at one stage of the project or used for consultation.
For studies where there are major quality concerns that significantly undermine their validity and reliability, they will be excluded from the synthesis. This decision will be made based on consideration of the specific concerns and their potential impact on the research question and overall findings. Excluding such studies helps maintain the integrity and credibility of the review.
Appendix B- Included Literature
1.Orygen (2019). Co-designing with young people – The fundamentals. Retrieved from https://www.orygen.org.au/Training/Resources/Service-knowledge-and-development/Guidelines/Co-designing-with-young-people-The-fundamentals
2.Mannell J, Washington L, Khaula S, et al. (2023). Challenges and opportunities in coproduction: reflections on working with young people to develop an intervention to prevent violence in informal settlements in South Africa. BMJ Global Health; 8:e011463. DOI:10.1136/bmjgh-2022-011463
3.UNICEF (2022) Young People’s Participation and Mental Health: A Protocol for Practitioners. Retrieved from https://www.unicef.org/reports/young-peoples-participation-and-mental-health
4.Boing Boing (2017). Engaging Children And Young People In The Solutions (Co-Production). Retrieved from https://www.boingboing.org.uk/wp-content/uploads/2018/04/YoungMentalHealth.section4.pdf
5.Fernandes B, Neelakantan L, Shah H, et al. (2023). Evidencing the Impact of Web-Based Coproduction With Youth on Mental Health Research: Qualitative Findings From the MindKind Study. JMIR Public health and surveillance; 9:e42963. DOI: 10.2196/42963
6.Thomson A, Peasgood E, Robertson S (2022). The Youth Patient and Public Involvement Café – A youth-led model for meaningful involvement with children and young people. Health Expectations; 25:2893-2901. DOI: 10.1111/hex.13597
7.Boswell N, Douglas-Osbourne E, Halkyard T, Woods K (2021). Listening to children and young people: an Educational Psychology Service co-production journey. Educational Psychology in Practice; 37:4, 396-412, DOI: 10.1080/02667363.2021.1975097
8.Pavarini G, Lorimer J, Manzini A, Goundrey-Smith E, Singh I (2019). Co-producing research with youth: The NeurOx young people’s advisory group model. Health Expectations; 22:743-751. DOI: 10.1111/hex.12911
9.Mind (2023). Carrying out influence and participation activities: Co-production. Retrieved from https://www.mind.org.uk/media-a/4639/co-production-web-pdf-061017.pdf
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