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The Participatory Zeitgeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement
  1. Victoria Jane Palmer1,
  2. Wayne Weavell1,
  3. Rosemary Callander1,
  4. Donella Piper2,
  5. Lauralie Richard1,3,
  6. Lynne Maher4,5,
  7. Hilary Boyd6,
  8. Helen Herrman7,
  9. John Furler1,
  10. Jane Gunn1,
  11. Rick Iedema8,
  12. Glenn Robert9
  1. 1 The Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
  2. 2 Business School, University of New England, Armidale, New South Wales, Australia
  3. 3 Department of General Practice and Rural Health, Dunedin School of Medicine, The University of Otago, Dunedin, New Zealand
  4. 4 Ko Awatea, Health System Innovation and Improvement, Counties Manukau Health, Auckland, New Zealand
  5. 5 School of Medicine, University of Auckland, Auckland, New Zealand
  6. 6 Strategy, Participation and Improvement Group, Auckland District Health Board, Auckland, New Zealand
  7. 7 Orygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
  8. 8 Centre for Team Based Practice and Learning in Health Care, Health Schools, King’s College London, London, UK
  9. 9 Department of Adult Nursing, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, UK
  1. Correspondence to Dr Victoria Jane Palmer, The Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia; vpalmer{at}


Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist—the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an ‘explanatory theoretical model of change’ that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities—narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome.

Trial registration number The Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results).

  • medical humanities
  • mental health care
  • philosophy of medicine/health care
  • social science

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  • Contributors VJP conceived the larger CORE study in conjunction with staff located in community mental health services. VJP, WW, RC and HH workshopped the activities of MH ECO to identify preliminary mechanisms of change. GR, RI, JG, JF, DP and LR reviewed and contributed to the refinement of these. VJP, WW and RC led the development of the explanatory theoretical model with expansion from RI, GR, LM, HB and HH. All named authors participated in the preparation of the manuscript, providing written comments on drafts and approving the final version.

  • Funding The CORE study was funded by the Mental Illness Research Fund and the Psychiatric Illness and Intellectual Disability Donations Trust Fund (MIRF 28). The Mental Illness Research Fund aims to support collaborative research into mental illness that may lead to better treatment and recovery outcomes for Victorians with mental illness and their families and carers.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The University of Melbourne Human Research Ethics Committee (HREC No 1340299.1-12) has approved this study. The Federal Government Department of Health has approved the collection of Medicare and Pharmaceutical Benefits Scheme data and the State Government of Victoria has approved the collection of hospital admission and triage data.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Unpublished data are available from the study related to action plans and improvement areas and codesign process evaluation work. Data requests are considered on a case-by-case basis and must include ethics approvals.

  • Correction notice This article has been corrected since it was published Online First. References 15, 17, 23, 24, 33-35, 40, 45 and 56 were updated.