Challenges and Opportunities in Coproduction: Reflections on Working with Young People to Develop an Intervention to Prevent Violence in Informal Settlements in South Africa

"The evidence suggests that coproduction has the ability to create more user-friendly interventions and evaluations..."

Increasing attention is being paid to coproduction - the involvement of potential end users in the design, delivery, and evaluation of interventions - in the field of global health. Coproduction provides a means of challenging power relations and ensuring that the intervention being implemented accurately reflects lived experiences. This article reflects on the experience of codeveloping Siyaphambili Youth (Youth Moving Forward), a 3-year project to create an intervention to address the social contextual factors that can lead to high rates of intimate partner violence (IPV), HIV, and poor mental health young people living in informal settlements in KwaZulu-Natal (KZN) province in South Africa. The study offers practical advice for researchers involved in codeveloping interventions and highlights the need to approach coproduction as a transformative process for both researchers and participants.

Siyaphambili Youth is a partnership between the South African Medical Research Council (SAMRC), a South Africa non-governmental organisation (NGO) called Project Empower (PE), University College London (UCL), and a team of 17 young peer research assistants (YPRAs), 18-29 years of age, living in urban informal settlements and rural communities in KZN. YPRAs were recruited to the project through an iterative hiring process designed to maximise possibilities for vulnerable youth to participate. Since November 2020, the YPRAs have participated in four phases of development of an intervention:

1. To help reveal how social contexts create overlapping risks characterised by poverty, violence, mental health vulnerabilities, and gender inequalities, YPRAs individually took photographs representing their daily lives ("artefacts") and participated in in-depth interviews to discuss their meanings.
2. YPRAs were involved in a series of workshops where they drew on their personal experiences to develop fictional characters, which were then used for facilitated discussions on young people's daily lives.
3. To develop a theory of change for the intervention, YPRAs identified risk and protective factors for HIV and IPV as part of a problem tree participatory workshop activity. The YPRAs created visual maps outlining the problems, their intervention ideas, and intended outcomes (ideal-world scenario). These maps were then shared with the broader research team to refine the intervention pathways based on existing evidence.
4. The research team introduced the YPRAs to an evidence-based intervention to reduce HIV and IPV. The theory of change process pointed to the need for a gender-transformative intervention with varying degrees of livelihood creation, mental health support, and broader structural change for each of four groups: men vs. women and urban vs. rural. Working closely with YPRAs, the research team adapted the Stepping Stones and Creating Futures intervention, which has been shown to reduce men's perpetration of violence in the South African context, to incorporate broader mental health support and to be more aligned with the theory of change developed with the YPRAs.

The authors identify four methods or techniques that may help improve the methodological practice of coproduction:

• Building trust in involving potential end users as researchers - The challenges that were encountered related to YPRAs' willingness to share personal information with the research team were overcome to a certain extent by a small group of expert facilitators on the research team. These expert facilitators used a range of techniques, including formal methods such as community mapping, character creation, and photography, as well as informal techniques to create a non-judgmental and trusting space. Informally, the facilitators achieved a sense of comradery and group belonging by sharing examples from their own personal lives and pulling the YPRAs aside for private group chats away from the rest of the research team and the recording equipment.
• Strengthening research capacity by involving end users in the interpretation of data and explaining research concepts in a way that is meaningful to them - The research team selected methods to facilitate more open conversations about the YPRAs' lived experiences, leading them engaged with aspects of the data conceptually; for example, the rural YPRAs felt that the violence they had personally witnessed within their families was higher than that found in previous studies. The research team also explained key research concepts and discussed data interpretation.
• Embracing conflicts that arise between researchers' perspectives and those of people with lived experiences - The YPRAs openly disagreed with the research team at several points in the project, and at times, this was challenging for the research team. For example, the young men living in the rural area openly condoned sexual harassment, including rape, if women dressed or acted in a particular way. The research team tried to overcome these conflicts during the codevelopment process by revisiting activities multiple times from different angles and with different questions.
• Challenging research epistemologies by creating spaces for constant reflection by the research team - For instance, the emphasis on methodology and evidence made it difficult for the YPRAs to engage with the research team in the ways originally planned as part of the project. The solution was to structure meetings between the YPRAs and individual academics (rather than the entire team), which helped address these barriers and provided lively spaces of conversation but did not facilitate YPRAs' full involvement in project activities.

In Table 1 of the paper, the researchers share several strengths and some weaknesses of the codevelopment methods used. None of the methods used effectively challenged power inequities. However, as a result of the increased confidence that the YPRAs gained through the coproduction process (and if the right individual was facilitating), they were more able to challenge the evidence, as they weighed up proposed findings against their lived experiences in suggesting potential intervention options. The ideas of the YPRAs also changed over the course of the project, with several YPRAs openly challenging their previous conceptions about gender norms, HIV, and mental health. Methods such as photo elicitation, community mapping, and story creation helped to develop different understandings of young people's daily lives than would have been achieved through in-depth interviews, which provided a new point of comparison and depth to the data.

Yet the research team reflects that "perhaps the most important methodological insight arising from the project is that coproduction is an intervention not only for the potential end users but also for the researchers involved....The researchers involved in the coproduction process must be prepared to re-evaluate their own assumptions about how and why interventions work to make space for the alternative approaches that potential end users may bring to the table....The coproduction process provides not only an opportunity for researchers to listen to what potential end users want from the interventions that affect their lives but also a fundamental shift in research practices and epistemologies."

The research team concludes: "These methods are not a magic chalice of codeveloping complex health interventions, but rather an invitation for a wider conversation that moves beyond a set of principles to interrogate what works in coproduction practice. In order to move the conversation forward, we suggest that coproduction needs to be seen as its own complex intervention, with research teams as potential beneficiaries."