Written by Katrina Messiha
In recent years, co-creation has become a widely used approach in public health research. This approach engages stakeholders such as local communities, policymakers and practitioners directly in the research process to develop interventions that are not only relevant but also sustainable and impactful. However, despite growing interest, many co-creation efforts in public health lack a clear theoretical foundation. There is often limited use of theory to guide how co-creation is done and how it can be evaluated effectively.
One promising solution is the use of critical realism, a philosophical approach that offers a strong framework for understanding the complex nature of health issues. As a meta-theory, critical realism helps researchers go beyond surface-level observations and dig deeper into the underlying factors that shape public health outcomes. This makes it especially useful for guiding co-creation projects and producing more meaningful, evidence-based results.
What is Critical Realism and How Can It Help Public Health?
Critical realism, first introduced by Bhaskar (1975) and later developed by scholars like Wynn and Williams (2012), focuses on uncovering the hidden structures and mechanisms that cause observable events. In public health, this approach allows researchers to move beyond simply treating the symptoms of a problem (such as obesity or smoking) and instead look at what drives these issues in the first place. For example, rather than only encouraging people to exercise more, a critical realist approach would explore how access to green spaces, cultural norms and economic inequality might affect people’s ability or motivation to be physically active.
Five Key Principles of Critical Realism in Co-creation
Following a systematic review of critical realist literature, I adapted five methodological principles from Wynn and Williams – originally used in the Information Systems field – for the context of public health co-creation. These were then applied retrospectively to a real-world project called Kids in Action (KiA), which aimed to tackle childhood obesity through co-creation but lacked an overarching theoretical framework.
Principle 1 – Explicating Events: Identifying the Key Components of a Health Issue
Critical realism views health issues as events made up of actions, actors, settings and outcomes. In KiA, researchers conducted focus groups with children, interviews with parents and discussions with professionals to uncover the main causes of childhood obesity in a specific neighbourhood. They identified unhealthy eating habits, low physical activity and contributing environments such as schools and homes.
Principle 2 – Understanding Structure and Context: Recognising Broader Influences
Health behaviours are shaped by wider social, economic and cultural contexts. In KiA, researchers found that factors such as local safety concerns, financial pressures, cultural norms and marketing of unhealthy food all played roles in shaping children’s behaviours.
Principle 3 – Retroduction: Hypothesising Underlying Causes
This principle involves thinking backwards from what we see to what might be causing it. The KiA team developed a logic model that suggested environmental and cultural norms were key drivers of childhood obesity. These informed the development of tailored interventions.
Principle 4 – Empirical Testing: Using Data to Confirm or Refine Theories
KiA used both qualitative and quantitative methods to evaluate their interventions, including fitness tests, surveys and interviews. These helped confirm whether their ideas about the causes of obesity were correct and whether their interventions were effective.
Principle 5 – Triangulation and Multiple Methods: Strengthening Findings Through Diverse Sources
Critical realism encourages the use of different theories, methods, stakeholder groups, data types etc., to build a more complete picture. In KiA, combining objective measures (like accelerometers) with interviews and surveys ensured a more reliable understanding of the problem and the potential solutions.
Why Critical Realism Is the Door to Co-creation in Public Health
By applying critical realism, co-creation becomes more than just stakeholder engagement – it becomes a way to deeply understand the causes of health problems and develop better-targeted solutions. In KiA, involving children, parents and professionals in the research helped ensure the interventions were grounded in local realities and thus more likely to succeed. However, there is still room to improve, for instance, through applying an explicit meta-theory from the outset of the project. Some interventions may be more contextually appropriate, but may not yet fully achieve long-term behavioural change. Critical realism supports this kind of reflection and encourages ongoing development through a lens that respects complexity, difference and uncertainty.
Critical realism can be argued to provide a robust theoretical foundation for co-creation in public health as it encourages meaningful collaboration, helps avoid superficial engagement and ultimately seeks to lead to better health outcomes for stakeholders. Refer to the reference paper that inspired this blog, here.
Acknowledgement
This blog post is based on the findings from my PhD research: Enriching the Evidence Base of Co-creation Research in Public Health with Methodological Principles of Critical Realism (Messiha et al., 2024). The study was conducted with the valuable contributions of Teatske M. Altenburg, Margrit Schreier, Giuliana R. Longworth, Nicole Thomas, Sebastien Chastin and Mai JM Chinapaw. The full study is available in the journal Critical Public Health (Received 5th February 2024; Accepted 13th June 2024; Published online 16th July 2024) with reference: Messiha, K., Altenburg, T.M., Schreier, M., Longworth, G.R., Thomas, N., Chastin, S. and Chinapaw, M.J., 2024. Enriching the evidence base of co-creation research in public health with methodological principles of critical realism. Critical Public Health, 34(1), pp.1-19.
About the Author
Katrina Messiha is a Marie Skłodowska-Curie PhD fellow based at the VU University Medical Center in Amsterdam. As part of her PhD work, she aims to systematically establish theory-based principles for co-creation in public health. She is an early stage researcher at the EU Health CASCADE project, funded by Horizon 2020. Her research interests encompass improving health inequalities, achieving health promotion through co-creation, addressing “wicked problems” via research and policy development as well as advocating for inclusive, robust participatory research in public health
References
Messiha, K., Chinapaw, M.J., Ket, H.C., An, Q., Anand-Kumar, V., Longworth, G.R., Chastin, S. and Altenburg, T.M., 2023. Systematic review of contemporary theories used for co-creation, co-design and co-production in public health. Journal of Public Health, 45(3), pp.723-737.
Messiha, K., Altenburg, T.M., Giné-Garriga, M., Chastin, S. and Chinapaw, M.J., 2025. Enriching the existing knowledge about co-creation: identifying dimensions of co-creation using explicit theory in various research fields. Minerva, pp.1-24.
Messiha, K., Altenburg, T.M., Schreier, M., Longworth, G.R., Thomas, N., Chastin, S. and Chinapaw, M.J., 2024. Enriching the evidence base of co-creation research in public health with methodological principles of critical realism. Critical Public Health, 34(1), pp.1-19.
Bhaskar, R., 1975. Forms of realism. Philosophica, 15.
Wynn Jr, D. and Williams, C.K., 2012. Principles for conducting critical realist case study research in information systems. MIS quarterly, pp.787-810.