Chapter 8: Applying a Public Health Lens to Co-production with the Military Connected Community

In this chapter, we demonstrate and reflect on how co-production as a research method can be applied to health and social care research within the military-connected community and offer an interpretation of how co-production could be practised within service development and service implementation. Presented is a method of systematically layering Beattie's model of health promotion with a stepped iteration of the co-production process used to create a bricolage of understanding into the experiences of conducting research with the military-connected community. As a research method, co-production is complex; however, applying a public health lens using Beattie's model provides clarity and conceptualises a bottom-up trajectory to address the areas of public health need within this community. The conceptual application of theory and process is a favoured methodology. It is used across multiple national projects within the northern hub for veterans. Family research, such as the one, is too much (Kiernan et al., 2024) (reducing military suicide), developing a common approach to assessment (Watson et al., 2024), and reducing social isolation and loneliness in the veteran population (Watson & Farrell, 2023). Using a scaffolded approach, this chapter demonstrates the iterative process of how findings emerge and inform the subsequent phases of research.

The military constitutes a distinct cultural entity, characterised by its own history, legal frameworks, values, traditions, language, and customs (Meyer, 2015). Individuals are socialised into military culture from an early stage, with this cultural immersion influencing nearly all aspects of their lives and resulting in a high degree of acculturation. Notably, veterans who served for only a few years frequently report a strong identification with the military even decades after leaving service (Johansen et al., 2013). As Heward et al. (2024) describes, military culture is a dynamic construct shaped by shared beliefs, values, behaviours, norms, symbols, and practices, which in turn influence individuals’ identities, worldviews, and social interactions. The military's pervasive role in the lives of its personnel is designed to ensure operational effectiveness; however, this also entails a reduction in personal freedoms and privacy; constraints that civilians may find difficult to comprehend (Dandeker, 2021). Military culture does not only reside within serving and veteran personnel, but it also permeates the family and significant others surrounding that individual. For military families, military life presents a range of situations that others seldom face and embodies a culture that is unique to them (Mancini et al., 2020). Their private family life is synonymous and not separate suggesting all family members collectively play a role in military life (Watson & Osbourne, 2025) and very often display the same militarised values (Cree, 2020). Due to the complexities of military culture, health and social care providers often navigate dual responsibilities, balancing the needs of the patient, and their families alongside the broader operational requirements of the military.

Beattie's (1991) model of health promotion offers a theoretical public health lens, and provides the conceptual framework for this work, due to its ability to identify the ‘level’ of health promotion, health protection and identify areas within health and social care to prevent poor health outcomes using contemporary and future intervention. The rationale for Beattie's model over other health promotion models, such as the health belief model (Rosenstock, 1974) or Tannahill (2008), was the model's ability to make clear links between the underpinning values and principles of public health practices, in line with co-production methodological practices. Moreover, unlike other models of health promotion, Beattie's model allows theory to drive the development of health promotion interventions and is not purely a description of existing activity (Rowe et al., 2009). Crucially, Beattie's model provides an understanding of collaborative intervention, which is important as it recognises the influence and involvement of the individual, their family, their communities, and those who deliver services (Hubley et al., 2021).

Beattie's (1991) model describes four paradigms for health promotion, including health persuasion, legislative action, personal counselling, and community development. Moreover, the four paradigms are generated by two axes, ‘mode’ and ‘intervention’, that range from authoritative (top-down) to negotiated (bottom-up) on the vertical axis. The horizontal axis focusses on intervention, which ranges from individual to the left, moving right to groups of people. Moreover, Beattie's model allows for the layered practicalities of the co-production process to be placed within each corresponding part of the health promotion model. Importantly, Beattie's (1991) model allows the health promoter (micro, meso, and macro levels) to locate existing activity and then consider action at the individual level, recognising the impact of the broader social and cultural practices on health, specifically in this case, military culture.

Service users’ and their families’ expectations of quality health and social services being provided to them continue to grow amidst increasing demands on service provisions, caused by an ageing population and a significant rise in long-term chronic health conditions (McMullin & Needham, 2018). This increase in service demand and quality has compelled policymakers to highlight the importance of and develop more patient and public involvement in service design, delivery, and research (Involve, 2012). One method of service user involvement is co-production.

Co-production is not a new concept however, co-production has renewed importance in contemporary policy reform and is widely considered as best practice for dealing with current health and social care sector issues; especially when practical and financial resources are significantly reduced (Marsilio et al., 2021). Originally coined in the 1970s by economist Elinor Ostrom, ‘co-production’ became a designation of process, in which contributions from ‘individuals who are not “in” the same organisation are transformed into goods and services’ (Ostrom, 1996). This process according to Ostrom, also included the assessment, management, and delivery of public services by ‘users’ and ‘providers’. Academics and social activists such as Cahn (2000) developed the idea of co-production from Ostrom's work and identified that participation and the involvement of all within any sector was indispensable to getting real results and was the only way to truly maximise effectiveness in completing any mission (Cahn, 2000). Cahn later proposed in a letter to the non-profit sector, that the only way the world is going to address its problems is by enlisting the very people who are now classed as clients and re-enlist them as co-workers, partners, and rebuilders (Cahn, 2005). Cahn's (2005) work provides a radical shift in the thinking among those who ‘help’, to move away from a top-down approach to an environment where change is value-based. This then blurs the barriers between the state, services, and its people; and involves relationships of reciprocity and mutuality; therefore, becoming an asset-based model for change (Boyle et al., 2010). As an asset-based model, Marsilio et al. (2021) explain policy makers have created new relational models, in which service users, their families, and local communities share responsibility with care providers and local governments bodies. That is, service users and their families are asked to actively participate in service design, its development, and the implementation processes. Therefore, service users work next to and in interaction with service providers and other stakeholders to enhance service provisions (Durose et al., 2017) thus being a collective for positive change.

Over the last 20-plus years, there has been an exponential growth of academic publications on all aspects relating to co-production (Loeffler & Bovaird, 2021) and an increase in the discourse of what co-production means (Fusco et al., 2020). Health and social care within the United Kingdom (UK) has become a continually changing landscape, which is awash with policies, strategies, practices, and mission statements stating that change within this sector must be developed through co-production (Repper & Eve, 2023). There is much talk about co-production and its need; however, as Repper and Eve (2023) explain, there are multiple descriptions of what co-production is and what co-production does, along with added complications that are sector-dependent. The discourse of what co-production is and what it does has been a continual historical discussion and continues today. Filip et al. (2017) explain that despite the apparent consensus regarding the potential for co-production, it is not always clear as to what counts as or what it means to co-produce services, for development, and/or practice change.

According to Boyle and Harris (2009), co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families, and their communities. Penny et al. (2012) extend Boyle and Harris's work by emphasising that all those involved become effective change agents. Slay and Stephens (2013) further describe the concept of co-production as one of equal and reciprocal relationships, to a relationship where professionals and citizens share power and plan and deliver support together, recognising the synergy in equal contributions to improve life for people and communities. Co-production continues to be a hot topic in policy making, governance, and research. In health, alongside user and community participation, co-production is described as improving health and creating user-led, people-centred services (Kickbusch & Gleicher, 2012). As Wilton (2021) explains, there is a desire for people to have more control over decisions which affect them and that system leadership and public service management need to diverge from traditional ‘top-down’ approaches to service development and delivery, to more inclusive and collaborative practices, which are more suited to achieving change in complex systems.

In their systematic scoping review Masterson et al. (2022) map the different definitions of co-production and its partner co-creation, stating these are terms which have been used individually, interchangeably, and collectively. As Masterson et al., note from the works of Williams et al. (2020), the increasing interest in co-production has also seen the emergence of a plethora of ‘co’ words, which has promoted a conflation of meanings and practices. For example, the term co-design has also been considered interchangeable with co-production and co-creation. The concept of the development of ‘co’ words is not something new, and several authors including Van Eijk and Steen (2014) and Bradwell and Marr (2017) break down co-production into its component parts with terms such as co-creation, co-management, co-planning-, and co-assessment to highlight the different stages of which service user involvement can occur. It can therefore be argued there are a range of perspectives and typologies on each working element of the co-production process based on its component parts.

When the aforementioned parts are identified as a methodological concept, there is a layering of understanding to the practicalities of co-production delivery. For example, the breakdown of co-production allows us to see; who is co-producing; how many people are involved; at what stage co-production takes place; what is contributed; and how co-production relates to other forms of citizen participation (Needham & Carr, 2009; Pestoff, 2014) which provides further credence for the use of Beattie's model with this community. Even with the continual development of co-production theory, the origins of co-production as a ‘whole’ methodological process revisits the understanding of public service provision, suggesting that services are joint products of providers and users, that is, it emphasises of users in the design, implementation, and/or delivery of services (Ostrom & Ostrom, 2019).

Within this section, we look to use a scaffolded approach to provide a stepped guide to illustrate each aspect of our approach to the iteration processes of co-production, resolving some of the typologies of the co-production process while using Beattie's (1991) model to support its development and implementation through a public health lens. As highlighted earlier, this methodological approach has been used in several projects. Ethical approval must be in situ prior to any co-production process.

The studies conducted within the Hub start with an initial phase, which is primarily where the research team explores the experiences of those affected or impacted by the identified phenomenon, for example, lack of holistic assessment of need, military families bereaved by suicide, and reducing social isolation and loneliness within the veteran population. Within this phase of the study, members of the research team meet with those at the heart of the issue, the veteran, their family, and those who are close to the family to listen to their ideas to understand how best to prevent or change current practice by those delivering service provisions. This consultation informs the beginning of the co-production process, which identifies the starting point for and the development of an appropriate research method. Moreover, this phase of the project allows those affected by the phenomenon to identify who they believe are the most appropriate stakeholders to engage with.

The methodological approach underpinning this phase is Narrative Inquiry, due its abilities to enquire into the meanings people make of their lived experiences, in the context of their social environment, and where the study relates to a new and relatively unexplored area within the existing academic literature (Patton, 2002). To support the capture of narrative data, a modified ‘life-grid’ (Richardson et al., 2009) approach can also be used for the interviews in this initial phase. A ‘life grid’ provides a structure from which to elicit a narrative and diagrammatic chronography of the significant events in a person's life. In addition to the ‘life grid’ a series of structured prompts serves to scaffold the storytelling and map the temporal journey of the phenomenon. Within the wider co-production process this element has been labelled the co-design element. Co-design sits between the collective and negotiated axes and within the community development quadrant of Beattie's model. It is this positioning which has underpinned a bottom-up approach to identify, explore, and understand the presenting phenomenon.

The goal of Phase 2 is to build upon the findings from Phase 1 and integrate overarching factors to co-produce an evidence-based intervention model. In line with the co-production methodology, it is essential to involve stakeholders who have relevant experience and expertise (Involve, 2012). This requires a purposive sample of individuals with direct experience of the phenomenon to ensure the study's aims are met (Campbell et al., 2020). For example, one study involved surviving families of military veterans who had died by suicide, health and social care sector representatives, statutory agencies, third sector organisations, politicians, retired military personnel, funding bodies, and other key stakeholders. With such diverse representation, event management is critical from the outset.

For the research team facilitating these events, the first step is to set the agenda and establish clear expectations, ensuring that all delegates understand the co-production methodology and the importance of exploring viewpoints and experiences. Facilitators must reassure participants that their contributions are equally valued, heard without discrimination, and documented. Given the diversity of delegates, there is a risk that some may dominate discussions, and conflicting views may arise, potentially making others uncomfortable. Facilitators must ensure that all participants have an opportunity to contribute in an open, non-judgemental setting.

Co-production events can be held in-person or online, each with its own set of advantages and challenges. In-person events offer opportunities for networking, greater engagement, and deeper exploration, but come with higher costs and time commitments for delegates. Online events, while more accessible and cost-effective, require considerations around digital literacy and technology access. In our co-productions, we have used a combination of both, starting with online events to reach a broader audience and followed by in-person events for more in-depth discussions. To ensure national coverage, each in-person event was held in a different devolved nation.

Each co-production event in Phase 2 is designed to answer specific questions arising from Phase 1's findings. The process is iterative, with each event informing the next. For instance, the superordinate themes from Phase 1 shaped the questions for the co-production event 1, which then influenced the focus of event 2, and so on. This iterative, collaborative process helps build a holistic understanding of the findings and contributes to the co-development of a solution-focussed framework for addressing the identified challenges.

Within the co-production cycle, this phase is labelled the co-creation phase, as it involves not only those who have experienced the phenomenon but also stakeholders such as public health commissioners, military-connected service providers at various levels, frontline staff, and specialists. This phase spans both collective and individual axes of Beattie's (1991) model, covering the community development and personal counselling quadrants, while remaining firmly on the bottom-up axes.

Phase 1 focussed on collecting narratives from those who directly experienced the phenomenon. Key themes were extrapolated from these narratives, such as in the One is Too Many study, where themes on the breakdown in care formed the superordinate themes of service provision and care coordination. These themes then guided the questioning in the co-production event 1.

Event 2 built on the themes identified in Phase 1 and Event 1, exploring the barriers and responses from multiple stakeholders. These discussions led to more informed, solution-focussed conversations later in the event.

To better engage delegates at both co-production events, evidence is presented at the start of each session, recapping progress and providing reminders of the initial narratives. In some cases, these narratives are brought to life through vocal performance, where anonymised quotes are performed by an actor. This approach effectively enhances the emotional and visceral impact of the participants’ stories.

Within the co-production cycle, this phase moves into the co-assessment phase as it requires the attending delegates to assess the presenting issues of the solutions discussed previously, conduct root cause analysis, and develop solutions to the presenting issues. This phase of the co-production process continues across both collective and individual axes of Beattie's (1991) model, while also moving and residing in the health persuasion quadrant. Within this event, the participants’ specific recommendations surrounding the phenomenon arising in Phase 1 are addressed, for example, what would have worked for them during their experience? What are the complexities that need to be considered?

In the co-production cycle, we label this phase the co-assessment and co-planning phase, which leads into the co-implementation phase. This phase brings together findings from previous stages, contributing to the development of an evidence base and identifying key components of the emerging concept. During this final event, the data from earlier co-production stages are assessed and analysed by senior public health advisors, service providers, and government officials. Delegates use this data to solve problems and discuss the development and implementation of the intervention or framework.

The focus is identifying implementation barriers and defining ‘good’ practice – what factors are essential to creating positive or preventative environments at all levels of service delivery, from government policy to frontline care. This phase spans both collective and individual axes and includes negotiated axes, allowing a move towards the authoritative axes of Beattie's (1991) model. The completion of the co-production cycle ensures that Beattie's model is maximised, addressing all four quadrants: community development, personal counselling, health persuasion, and legislative action.

Working with the military-connected community highlights the importance of cultural insight for those engaging with this population. For external stakeholders, understanding military values, language, and experiences is essential to building trust. Without this, service design risks being superficial, and research may feel like an external imposition rather than a meaningful collaboration. The military community values authenticity, and trust is earned when service providers and researchers demonstrate a genuine commitment to their needs.

Trust-building requires consistency, integrity, and transparency. The military-connected community has faced repeated consultations with what some note has had little meaningful change, leading to scepticism and resistance. Our research shows that honesty, active listening, and a commitment to real impact will gain their trust. Researcher positionality – whether having an ‘insider’ connection to the community – also aids in trust-building.

A key lesson is the importance of value-based practice. Research should drive improvements in policy and service delivery for the population. Co-production should be more than a tick-box exercise; it must be a process for real change. This requires an iterative, long-term approach where findings inform future innovations. We recognise that no single organisation can fully meet the needs of the military community, so cross-sector collaboration is vital. However, accountability must be shared to ensure tangible action.

Setting clear expectations is crucial. Co-production takes time, and sustainable change does not happen quickly. Honest, transparent communication helps manage expectations and prevents disillusionment. While co-production identifies gaps and proposes solutions, implementation requires commitment beyond the design and assessment phases. Collaborative relationships that address limitations and challenges help maintain trust.

Co-production bridges the gap between policy rhetoric and reality, bringing the lived experiences of military personnel, veterans, and families to the forefront. By including diverse stakeholders, co-production can identify gaps, challenge assumptions, and foster solutions (National Institute for Health and Care Research, 2024). Ultimately, research must drive meaningful change, ensuring policy aligns with the lived experience of the military-connected community.

This chapter presents a compelling case for the use of co-production with the military-connected community, focussing on health and social care service design, development, research, and implementation science. The significance of co-production is particularly apparent in addressing public health challenges, where engaging communities directly in the creation of solutions ensures the relevance and impact of interventions. As demonstrated, each phase of the co-production process facilitates the development of trust and collaboration between the military-connected community, service providers, and researchers, which is crucial for successful outcomes.

We recognise that, as cultural insiders, we have some ‘buy-in’ to the military-connected community, a group that can be sceptical and resistant to external services. However, our experience shows that involving the military-connected community from the outset in the co-design process empowers them as active participants, rather than passive subjects. This shift in agency allows the community to have a central role in defining and addressing issues that are significant to them, resulting in more sustainable and effective solutions. This approach aligns with the argument that the success of co-production is contingent upon the meaningful inclusion of all relevant stakeholders, particularly those directly impacted by the issues under consideration. Therefore, our work demonstrates the power of collaborative, value-based approaches in transforming health and social care services for the military-connected population.