# Co‐Production, Co‐Creation and Co‐Design in Primary Health Care: A Scoping Review of Design, Implementation, Impact and Sustainability

## TL;DR

This review explores how co-production, co-creation, and co-design are used in primary health care, finding that while these approaches are widely applied, evidence on their impact and sustainability is limited.

## Contribution

The study provides a scoping review of Three-Cs approaches in primary health care, highlighting gaps in evidence regarding sustainability and impact.

## Key findings

- Three-Cs approaches are commonly used for health promotion and improving equity and access.
- Only a small percentage of studies evaluated the long-term sustainability of these approaches.
- The review suggests a need for a primary health care-specific framework to guide implementation and evaluation of Three-Cs models.

## Abstract

The terms coproduction, co‐creation and codesign (called the ‘Three‐Cs’ in this article) are applied to activities that include stakeholders in the design and implementation of health services. This scoping review sought to understand how Three‐Cs approaches have been designed and implemented sustainably in the primary health care context.

Three databases (Medline, Embase and CINAHL) were searched for articles published between 2013 and 2024 using key words related to the Three‐Cs and primary health care (Appendix A) and limited to articles available in English. Dual blind review against specific inclusion and exclusion criteria was carried out at both title/abstract and full text screening stages. The SPICE Framework was used to consider design, implementation, impact and sustainability. An assessment of quality and risk of bias was completed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist [1]. The Framework to Assess the Impact of Translational (FAIT) health research [2] was used to review and assess the impact of the design and implementation of Three‐Cs approaches in each study.

Thirty articles were included in this review with 33% (n = 10) providing a clear definition of their Three‐Cs approach: 10% (n = 3) identified their approach as Coproduction, 20% (n = 6) as co‐creation, and 70% (n = 21) as Codesign. Implementation contexts included clinical settings (10%, n = 3), for example prediabetes programs; community settings (50%, n = 15) such as care navigation support; and health systems settings (40%, n = 12) including health service development. Approaches were implemented across metropolitan (37%, n = 11), regional (43%, n = 13), and rural (17%, n = 5) settings.

Three‐Cs approaches in primary health care settings were most typically used for health promotion, and to support improved health equity and health access. Key outcomes included novel solutions to problems, improvements to health and health systems, and solutions that met consumer needs. While nine of the 30 studies undertook some form of evaluation, limited evidence on impact and sustainability was found (7%, n = 2), where only two studies assessed whether the change that was implemented using a Three‐Cs approach was maintained in the longer term.

Three‐Cs approaches have been adopted across a variety of primary health care settings, yet evidence for impact and sustainability is currently limited. More research is needed to evaluate how the Three‐Cs may best be implemented to support the long‐term sustainability of programs designed by such approaches. Future work should focus on developing a primary health care specific framework or guidance for implementing and evaluating Three‐Cs models, particularly in low‐resource settings and in typically underrepresented populations. This study will extend to consider how the FAIT assessment process can help to support the development of much needed implementation guidance.