Co-destruction in social care services: how to identify and evaluate barriers arising from a co- production exercise with family carers living in rural and remote areas


 Background: Co-production has been widely recognised as a plausible means to reduce the dissatisfaction of citizens, the inefficacy of service providers, and conflicts in relations between the former and the latter. However, the enhancement of co-production has begun to be questioned: co-production has often been taken for granted, and its effects may not always be fruitful. To understand and prevent unsuccessful citizen and provider collaboration, the recent literature has begun to focus on the causes of co-destruction. This paper investigates how the barriers that may arise during the co-production of a new social service with family carers can be identified and interpreted.Methods: To investigate this topic, we undertook a single case study by considering a longitudinal project (Place4Carers) intended to co-produce a new social care service with and for the family carers of elderly patients living in rural and remote areas. We organised collaborative co-assessment workshops and semi-structured interviews to collect the views of family carers and service providers on the co-production process. As part of the research team that participated in the co-production process, we contributed to the analysis with a reflexive approach.Results: The analysis revealed four main co-production barriers: lack of trust, lack of effectiveness of engagement, participants’ inability (or impossibility) to change and the lack of a cohesive partnership among partners. Despite these findings, the project increases carers’ satisfaction, competence and trust in service providers by demonstrating the positive effects of co-production.Conclusions: Our article confirms that co-creation and co-destruction processes may coexist. The role of researchers and service providers is to prevent or remedy co-destruction effects. To this end, we suggest that in co-production projects, more time should be spent co-assessing the project before, during and after the co-production process. This approach would facilitate the adoption of adjustment actions such as creating mutual trust through conviviality among actors and fostering collaborative research between academia and organisations that are not used to working together.


Introduction Theoretical Background
Challenges involving vulnerable citizens in the health and social care eld The existing healthcare literature addresses the potential barriers and negative effects of involving vulnerable and fragile citizens (e.g., [1,21]). In line with Ludwig et al.'s ndings [1], Table 1 organises some of the main antecedents, process barriers and negative effects in four levels of analysis: citizens, providers or research, teams and system. Given the focus of this study, we have highlighted in grey the barriers and effects that refer to a co-production process (see Table 1).
In co-production, antecedent barriers may predate the process itself. First, the lack of necessary information, competence and skills may make citizens unable to understand providers' speech [22], providers incapable of collaborating with other participants [23] and valuing citizens' experiential knowledge [24,25] and facilitators fail to manage the discussion [26]. Second, the lack of motivation of participants [15] and clari cation of the purpose and roles of the process may facilitate co-production failure [22]. Third, the short and sporadic collaborations among actors with few resources and funding limit the possibility of creating trustful relationships among actors [27].
Moreover, process barriers may arise during the process of co-production. First, the exchange among actors may create con icts that, if not harmonised by the facilitator, risk affecting the success of co-production [28]. Second, the usage of technical language and the underestimation of citizens' suggestions may prevent the true involvement of citizens in decision-making processes [22].
Finally, co-production may have negative effects on citizens, providers/researchers and the system. In the rst case, it may make citizens feel railroaded [29,30] and may risk harming their privacy and rights [26]. Second, the adoption of co-production in research may have several costs and risks for researchers given its complexity and time consumption [26]. Finally, it may require considerable time and resources without guaranteeing clear and unambiguous results [26,31], compromising the health and/or research system. Table 1 Well-recognised shortcomings of public involvement and their possible negative effects in the health and social care field. In grey, the factors/outcomes revealed by the analysis of co-production processes.

Co-destruction
Co-destruction is an interactional process [19] that aims to explain how the direct or indirect interactions between actors belonging to the same service system may reduce the well-being of at least one of the systems [14]. Since co-production captures a wide variety of activities in which citizens and other service system stakeholders interact [47], it can be considered an interactional process, and the co-destruction theoretical framework can support the identi cation and explanation of how its barriers can generate negative effects [18].
Co-destruction may arise during exchanges among actors and can lead to negative effects at both the individual and system levels [48]. However, recent studies have enlarged this view by considering two other possible reasons for failure. Co-destruction may occur before the interactional process due to the presence of pre-existing conditions that negatively in uence the process [17,49]. For instance, a lack of time or of participants' motivation may reduce the success of the co-production process [15,28]. Moreover, co-destruction may arise after the interactional process for perceptions created individually by participants after collaboration [17,50].
Given the scarce health literature investigating co-destruction [20], to better understand this concept, we should examine the private and public service literature. Two authors have investigated co-destruction empirically: Jarvi et al. [17] and Engen et al. [14].
Jarvi et al. (2018) studied the factors that facilitate the failure of interactions between customers and providers (i.e., co-destruction) and when they emerge in business-to-consumer, business-to-business, business-to-government and government-to-consumer markets. They did so by considering the service provider's perspective in the private and public sectors. Through this analysis, they identi ed eight causes of co-destruction: absence of information, lack of trust, lack of clear expectations, inability to serve, inability to change, mistakes, customer misbehaviour, and criticising that can occur before, during and after the collaboration process. The rst cause, i.e., the absence of information, arises from the inability of providers and users to understand and share information. The second cause, i.e., insu cient level of trust, occurs when participants do not rely on each other. The third cause, i.e., lack of clear expectation, is determined by users' inability to express their expectations clearly. The fourth cause, the inability to serve, arises from the incapacity of providers to achieve users' expectations effectively and on time. The fth cause, i.e., inability to change, refers to the incapacity of both providers and users to modify their routine activities and approaches according to new environments. The sixth cause, i.e., mistakes, arises from unintended events such as the application of incorrect assumptions or the purchase of incorrect products. The seventh cause, i.e., customer misbehaviour, refers to the misuse of resources or the negative behaviour of users. Finally, the last cause, i.e., blaming, arises from users complaining about products or services [17]. Thus, this research clari es that barriers may arise at different times and may be continuous over time.
Engen et al. investigated the causes of co-destruction in the public service literature by studying the direct interactions between service users and the Social Insurance Agency and the Tax Agency in Sweden. Unlike Jarvi et al. (2018), the causes were investigated using both citizens' and providers' perspectives. Their research identi ed four reasons for co-destruction: inability to serve, mistakes, lack of bureaucratic skills, and lack of transparency. The rst two causes of codestruction are aligned with the framework identi ed by Jarvi et al. in 2018. The other two causes arise from the adoption of a broader perspective that includes service users and third parties. This demonstrates the importance of investigating the causes of co-destruction by including the perspectives of all actors in the service network. Moreover, this novel research clari es the link between barriers and their effects. Co-destruction may change over time, moving from co-creation to co-destruction of value, and its effects may have different impacts, from value diminution to irreparable loss [14,49], con rming previous ndings.

Data And Methods
To investigate the barriers to the co-production process, we used a case study methodology, which facilitates the understanding of contemporary phenomena before, during and after co-production, making the phenomena inseparable from the context [51,52]. More precisely, we investigated the barriers to coproduction by using co-destruction as the theoretical lens to understand and reveal them. The adoption of this particular lens of analysis overcomes at least two existing limitations of the health and social care literature. First, as a process, it highlights when barriers arise and how they generate negative effects [17].
Second, from a system view, it collects the perspectives of all actors of the networks, including citizens who are usually excluded from the assessment process of co-production [46].

Case and context description
Since the purpose of our research was to investigate the causes of a speci c process, we chose a case for which we had good access to the data [53]. We decided to investigate a project (called Place4Carers) in which we were involved directly as project partners. This research enabled us to re ect critically on the achievements of the project by considering the barriers encountered during its implementation. The project investigated is a longitudinal project launched to co-produce a new social and community service for the family carers of elderly citizens in a remote and rural valley in northern Italy, Vallecamonica. The project is being conducted by the Università Cattolica del Sacro Cuore, a local home care agency 'Azienda Territoriale per i Servizi alla Persona' (ATSP), Politecnico di Milano University and the Need Institute, and it is funded by Fondazione Cariplo. Four local assisted living facilities collaborate with this project [54].
This research is part of a larger study intended to make a substantial contribution to the debate on the involvement of vulnerable citizens in co-production activities [55]. This research was performed in the latest phase of the study, in which we considered the transferability of the project to similar remote and rural areas. To re ect on the lessons learned during the development of the overall project, we adopted a distinctive lens of analysis that helped us to identify the possible barriers arising from the co-production of social care services with family carers. Moreover, given the fragility of family carers and the limited accessibility of local health and social care facilities in remote and rural areas, we can consider this case study a useful empirical example of how to investigate co-production with vulnerable citizens.
During the project, the ATSP and the researchers involved the family carers of older patients residing in Vallecamonica in the co-design of a new public service for them. On the basis of the results from co-design workshops, the project team envisaged the new public service as comprising four activities: a training programme, mutual help meetings, citizens' committees, and project and service information. The training programme was a set of practical courses for family carers of elderly persons. The mutual help meetings were groups of family carers, coordinated by a psychologist, who shared their feelings and fears with each other. The citizens' committee was a group of family carers, researchers and ATSP representatives set up to support the implementation of the pilot.
The project and services' information consisted of online and o ine channels (i.e., Facebook page, project website, brochure) created by the project team to spread awareness of the project and local services for the elderly. The new service was designed according to carers' suggestions by valuing their contributions; researchers organised and summarised the service proposals that had arisen during the co-design workshops and discussed their feasibility with ATSP representatives.
The table below summarises the quantitative drivers used to obtain a preliminary overview of the new social care service. To assess the effectiveness of the training programme, we collected the participation rate, the level of understanding of the content (by asking participants before and after each meeting to answer questions about the content of the course) [56] and the level of satisfaction with the course (by asking participants at the end of each course to complete a satisfaction survey) [57]; self-help meetings, we studied the participation and satisfaction of family carers with regard to this activity [58]; the citizens' committee, at the beginning of the service pilot, we self-de ned, together with the ATSP, a set of expected achievements from this activity, and at the end of the pilot, we jointly checked their realisation; the project and service's information, we ascertained knowledge about the project and the service online and o ine by checking how many new patients of the ATSP had been informed through the project's channels. Moreover, we integrated the analysis by collecting the level of usage of the online project channels [59]. Although, on average, satisfaction with the pilot was high (i.e., above 85% on average), the number of meetings organised and the number of carers involved seemed quite low. The access to and use of the channels created to inform the local community about the project and the local services also seemed unsatisfactory. To achieve a satisfactory number of activities and participants, the project team had to extend the pilot by two months to help the ATSP, which was in charge of implementing the pilot, in organising additional service activities. However, the ndings should be contextualised within the eld of the analysis, i.e., a remote and rural valley. The logistic di culties [60] and the "distrustful culture" [61] typical of this context might have in uenced the participation rate. The successful and unsuccessful results reveal that the interactional process among participants generated both co-creation and codestruction processes. On the one hand, the project increased citizens' well-being by enhancing family carers' satisfaction. However, it failed to increase the well-being of the project team because the time and resources invested did not balance the number of family carers reached with the service pilot.
On the basis of these considerations, we deem this project suitable for investigating our research questions for three main reasons. First, it re ects on the adoption of co-production with vulnerable and marginalised citizens in the health and social care sector. Second, the time horizon of analysis is medium-long, facilitating the evaluation of co-production activities during execution and beyond. Third, the involvement of citizens in the co-designed service yields both positive and negative effects, making the investigation of the drivers of co-creation and/ or co-destruction interesting and important.

Data collection
Following Engen's approach, we used different methods for data collection by involving all the participants of the co-production network [14]. To understand the opinion of the ATSP, we used semi-structured interviews with three ATSP representatives responsible for implementation of the new service. To collect the perspectives of family carers, we organised two co-assessment workshops with ATSP representatives, researchers and family carers. Throughout the analysis, we adopted the re exivity approach suggested by Bradbury et al. (2020) to gather our points of view as researchers [62].

Data analysis
The interviews took place in January 2020 in Breno (Brescia, Italy) in Vallecamonica and lasted 201 minutes overall, with an average of 51 minutes each. One interview was conducted by telephone and was the same duration as the face-to-face interviews. The co-assessment workshops took place in July and December 2019 and lasted 138 minutes overall. The interviews and the workshops were analysed using a deductive approach [63]. Each interview and workshop was audio-recorded with the participants' consent and analysed by investigating their perspective on the co-production outcomes and the pros and cons of co-design. We analysed the perspectives of all participants in the service network who were involved both directly and indirectly in service delivery, as suggested by Engen et al. (2020). In particular, we enriched the analysis by investigating collaboration and the possible di culties in communication or role identi cation within the research group, with family carers and with the other stakeholders of the service network. The compilation of this paper followed the Standards for Reporting Qualitative Research guidelines [64]. NM and EG, who conducted the data collection, were supervised by CM and GG to maximise the re exivity and transparency of the process.

Findings
Inductive analyses of the interview and workshop data led us to identify four barriers to co-production related to trust and engagement, barriers to change and the importance of a cohesive partnership.

The importance of trust
Lack of trust emerged as a powerful initial obstacle to co-production that in uenced many refusals to participate in the rst stage of the project. Both carers and research team members a rmed that in the context of Vallecamonica, it is still di cult to speak about personal problems and to ask for help from both friends and local institutions. This dimension emerged in multiple forms: towards the institution (ATSP) and towards the project team. During the rst co-assessment workshop that took place during the pilot scheme, carers identi ed insu cient external information and communication about the project as a barrier to the project's effectiveness. They declared that many social workers and general practitioners were not informed about the project. "I usually go to the support group for carers of patients with dementia [at the hospital], and they didn't know about the project. I think it is important to connect different initiatives that all together can reach all carers" (Carer, female, 9).
After that claim, members of the ATSP went to practitioners' conferences in the valley and informed the coordinators of social workers. However, during the second co-assessment workshop, carers still reported that information was not widespread. Therefore, lack of trust certainly in uenced the participation of carers in the initial phase, but the positive relationship established with the ATSP and research team members convinced carers to participate in the entire project because they were positively impressed by the role that the ATSP was assigning them.
Carers who had not been convinced did not participate in any of the organised appointments. In this case, neither the ATSP nor university researchers managed to reduce the initial mistrust of carers towards themselves, negatively in uencing the effects of coproduction.

The importance of effective engagement
The results from our analysis of the interviews and workshops reveal di culties in establishing effective engagement. In particular, carers who participated felt truly involved in the co-production, but in some cases, the research team made decisions without asking them for their opinion, creating friction. For example, the research team decided to postpone some education/training and support events due to the expected low participation of carers. The decision was made "not to involve trainers for only a few people, considering that all of them came for free" (Research team member, male, 1). However, carers contested this decision by stating, "Even if there is low participation, we have to start with something. It is important, for otherwise we'll never get started. I absolutely understand the reasons why you cancelled some meetings, and I was not angry but sorry because I need these moments and I would have preferred few participants but maybe the possibility to speak, get some relief" (Carer, female, 4).
This claim highlights that carers felt insu ciently involved in the decision and asked for explanations. In this case, the relationship between providers and carers established in the co-production prevented this mistake from becoming a cause of co-destruction. Since this problem emerged during the rst coassessment workshop, which took place in an initial phase of service delivery, we were able to adjust the decision-making mechanism.
It also shows that although there were misunderstandings, the climate within the co-productive team was good because everyone felt at ease in explaining what they believed was wrong and required explanation and, more importantly, they were aware of the importance of participation in the project.

Barriers to change
A signi cant barrier to successful co-production that could lead to co-destruction is the incapacity, of both carers and providers, to change. Interviewees revealed that carers nd it di cult to leave their care receivers alone for four main reasons. First, carers usually cannot leave their care receivers alone at home, so they must nd a substitute who is both professionally trained and accepted by the care receiver. Second, carers usually feel responsible for and engaged in caring activities and do not trust any other person. Third, the distinctive culture of Vallecamonica often encourages citizens to hide their family's problems, which might be taken as signifying a personal moral failure or weakness. Fourth, the ATSP as a service provider was unable to offer additional home services to encourage participation.
"Leave him (care receiver) alone at home? It's not possible, and also when the professional carer comes or the social worker, if I go away he starts to scream and cry" (Carer, female, 5).
"I understand you, and I also do not feel comfortable; my professional carer is not able to manage the feeding tube, and so I am always worried" (Carer, male, 10).
"I would like to nd a professional carer to have some relief and to participate in these events, but it is very expensive" (Carer, female, 2). Is this, using Jarvi's terminology, an impossibility to change or an inability to change? It is likely both; in fact, when the social worker came to the home, our carers could quickly go out to do some shopping or run errands, but only when they felt comfortable with the social worker (which was often not the case). Moreover, it was not possible to provide a speci c service for carers involved in the project's activities because this would have required additional human and economic resources that were not available.
Finally, carers suggested using local mass media to disseminate information about the project; this was done, although in a weak format (some interviews and short news items in local newspapers). As stated by the ATSP, the fees required for iterative publications and investments in marketing campaigns were particularly expensive. Since fees were not foreseen in the project budget, the project team was unable to meet the requirement.
"I was a little bit disappointed by local journalists because they asked for a fee like it was a normal commercial spot. This is a free service to our people!" (Research team member, male, 1).

The strengths and weaknesses of partnership
One of the innovative features of this project was a strong partnership with two universities and the local services provider. To identify its strengths and weaknesses, it is important to include the perspectives of all participants: carers, ATSP representatives and researchers.
Carers were enthusiastic about the partnership. They felt at ease with someone who, for the rst time, listened to them. Moreover, even in co-production, carers gained indirect bene ts because they could speak with peers who were experiencing the same di culties and had direct access to more information.
"When I came here the rst time I felt alone and did not know what to do. After hearing other people with the same troubles and some good suggestions, I felt more empowered" (Carer, female, 8).
"Having the possibility to give advice, suggestions and ideas was great even if not easy because it was di cult to nd time to participate, but it was the rst time that I took some time for myself. Also, having universities was something strange, but it helped us greatly to give ideas" (Carer, male, 10).
"Understanding the point of view of carers helps us to identify their needs better; you receive more attention. At the same time, it helped us understand what kind of doubts they had about existing services" (Research team member, female, 2). "I felt very surprised and grateful for this, although I knew that I was not doing this for myself because my mother is now in a nursing home, but I hope to help someone not to experience what I felt in terms of loneliness and lack of information. Usually, there is not much interaction with service providers, so it was an important new opportunity" (Carer, male, 13).
"Laws, projects and services are usually deliberated and approved by people who live in large cities. This project directly involved and put us as thinkers and developers of a new service for a rural valley. This does not mean that we do not need universities from cities. Universities help us to look to the future, to grasp future directions" (Research team member, male, 1).
Unlike interviewees who expressed great enthusiasm for the cooperation and sense of belonging created by the project, these interviewees evidenced di culties in collaboration and coordination within the research team. First, the ATSP complained of a lack of clari cation about the team's roles and coordination.
"There is a difference in work style between universities and local service providers. Universities are more exible, giving more autonomy to partners to achieve their results. We (the local home care agency) need more supervision, someone that clearly states what we have to do and at what times" (Research team member, female, 1).
Re ecting on these criticisms, researchers admitted that universities usually give full autonomy to each coordinator of a work package; close supervision would be an act of intrusion or lack of trust by the other partners.
Second, the meeting style had an impact on the discussion of problems and ways to manage di culties.
"We (the ATSP) are not used to making rapid Skype or conference calls. I was not comfortable in explaining di culties and problems about the piloting" (Research member, male, 1).
"We usually have a weekly meeting, not long, but just to share news and di culties within each project. We missed that part. We need constant feedback (Research member, female, 1).
Different organisational cultures led to this di culty that unfortunately created less cohesion within the research group [65] and caused misunderstandings in the co-production process.

Conclusions
This paper has re ected on the shortcomings of the co-production process when dealing with vulnerable, marginalised communities. It has done so with an empirical analysis of a path-breaking project that aimed to co-produce a support service for vulnerable family carers living in the remote and rural context of Vallecamonica. More precisely, we adopted the theoretical framework of co-destruction as a lens for identifying and interpreting barriers.
We identi ed four main barriers that arose before, during and after the co-production process. First, the dimension of trust emerged as a powerful barrier in engaging carers before, during and after the co-production process. Throughout the projects, the participation rate was unsatisfactory due to the "distrustful culture" [61] typical of rural areas [66]. However, carers who overcame their initial mistrust experienced positive outcomes from the service delivered. Second, the lack of effective engagement of family carers may negatively affect them. However, our research showed that the early and rapid identi cation of this barrier and the presence of trustful relationships among parties reduced its impact. Third, the inability to change both carers and providers may negatively in uence the effects of co-production. However, participants may sometimes be unable to change because it is impossible for them to do so. In this case, it is the duty of researchers or providers to check the feasibility of services and their activities and to prevent impracticable solutions. Fourth, universities and providers may have different organisational cultures, which can generate incoherent strategies and practices in co-production regimes.
However, our experience showed that different organisational cultures can be mitigated by clarifying team members' roles and boundaries and by sharing methodologies and tools of co-production with the entire research group (not only among members who are already knowledgeable about engagement and co-production).
Despite these considerations, it would be ungenerous to say that we experienced co-destruction. Carers who decided to start participating in the project were very pleased with their active role in the new service, and the assessment of service activities revealed that they were useful and interesting for participants (e.g., the rates of satisfaction with and understanding of course content). This research con rms public and private studies by highlighting that the two dynamic processes of co-creation and co-destruction may coexist [16] ( Figure  1). Thus, co-destruction is a temporary status that may change over time and in terms of the intensity of its effect [14,49,67]. For instance, the lack of effective engagement of family carers would have led to more absolute co-destruction if providers and researchers had continued to adopt the same unfair decisionmaking mechanism over time.
Researchers of providers have the duty to limit and prevent co-destruction by adopting co-assessment methods for preventing, identifying and adjusting any possible barriers arising before, during and after co-production. To this end, it is important to collect the perspectives of all the participants of the service system involved in co-production. In particular, including citizens' perspectives would enhance the understanding of co-production process and prevent its failure. Figure 1 Co-destruction and co-creation in social care service co-production by adopting a service system perspective This research revealed new barriers and demonstrated existing ones, highlighting that barriers may vary from context to context. However, the innovativeness of this research does not refer to the barriers per se but to the approach for supporting researchers and providers in detaching and preventing barriers before, during and after the co-production process.
There is a need for more empirical studies in remote and challenging scenarios and with vulnerable populations to identify better solutions for critical issues. Moreover, it is important to strengthen a bene cial link between universities and providers to create greater effectiveness towards and with vulnerable people. In this case, it could be particularly important to foster funding for research projects aimed at collaboration between these two groups of participants.
We identi ed some powerful limitations in our research. First, we were not able to reach carers who participated in initial workshops but later did not attend events. It was particularly di cult to access carers who had abandoned the project due to their isolation and reluctance to speak with institutions and universities. We do not know whether they did not participate due to a lack of interest, a lack of time, or the death of their care receiver. On our side, we properly informed every carer about the importance of participating in every workshop for the assessment of the project. We believe that providers and all participants involved with carers should spend more time building trust relationships with carers and patients. This would have the bene cial effects of greater familiarity, the ability to provide better advice, and a greater ability to speak about needs and requirements to foster a more e cient health and social care system. Second, to assess possible barriers to co-production, we interviewed carers twice, but research team members interviewed carers only once. In the rst round of interviews/workshops, carers had a crucial role in modifying and rethinking some services. It is likely that an intermediate round of interviews with research team members would have highlighted prior problems in creating a cohesive partnership. We believe that it would be better to devise an assessment plan for co-production at different stages of the co-production process and involving all participants. Moreover, the evaluation of a collaborative research project is strongly recommended, not only at its end but also as part of a successful research team culture. In particular, speci c co-assessment of the cohesive partnership should become a widely used tool in these projects. Only in this way can the barriers to co-production be uncovered to prevent co-destruction.

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Competing interests
This study is part of the Place4Carers project funded by Fondazione Cariplo. The authors declare that they have no competing interests.
Authors' contributions EG and CM developed the scienti c background on co-production and co-destruction that led to workshops and interviews and to this article. NM and EG designed the schemes of the co-assessment workshops with carers and of the semi-structured interviews with research members. Moreover, they led interviews and workshops with the supervision of CM and GG. NM analysed the collaborative workshops and interviews and structured the results. All authors contributed to the discussion.