"We Don't Normally Go Down This Avenue; This Is Normally Taboo": Using Co-Design to Develop a Training Intervention for Spiritual Health in Primary Care.

introductionSpiritual health is an important component of holistic health and social care provision; however, previous research highlights a training gap in this area. The SHARP (Spiritual Health Awareness and Recommendations in Primary Care) project used co-design processes informed by the Person-Based Approach (PBA) to develop a training intervention to address this gap. This paper evaluates the process of using co-design within this sensitive, stigmatised topic area that faces challenges in terms of language, identity, power and strongly held values-based opinions.

methodsFive co-design workshops were held with a diverse mix of participants including GPs, social prescribers, primary care staff, chaplains, carers, patients and members of the public. Data sources included workshop transcripts, observer notes and post-workshop participant surveys. Thematic analysis was conducted deductively in line with a co-design evaluation framework, where we considered people-level outcomes within and without the co-design group, process outcomes and system-level and sustainment outcomes. RESULTS AND ANALYSIS: Thirty-eight participants took part in the workshops. Analysis identified co-design outcomes at people, group, research process and system-level. Participants valued having space to express views on a sensitive and often taboo topic, with 'being heard' functioning as a prerequisite for engagement and reported high levels of engagement. Professional hierarchies and outsider status persisted despite conscious facilitation efforts, while pragmatic design choices shaped participation, continuity and collective action. The professional mix of participants supported whole-team thinking about implementation, although recruitment of motivated participants may have limited the identification of additional barriers to change.

conclusionThe SHARP project provides important lessons on the use of co-design in sensitive and value-laden research topics. Specifically, for researchers to be attentive to participants' need to be heard, active management of power and hierarchy, and explicit negotiation of pragmatic constraints. Mixed-group co-design can support whole-team thinking about implementation, while reflexive awareness of who is included remains critical to understanding what barriers may be surfaced or missed. PATIENT AND PUBLIC CONTRIBUTION: Patients, carers and members of the public were actively involved in the design, conduct and interpretation of this study. Public contributors and people with lived experience of primary care were recruited as equal participants within the co-design workshops alongside clinicians and other stakeholders, where they contributed to discussions, activities and decision-making that shaped the content, format and implementation considerations of the SHARP training intervention. Patient and public contributors also informed interpretation of findings through their reflections on workshop processes and perceived relevance to patient care. In addition, members of an established patient and public involvement group were consulted prior to and following the co-design process to advise on acceptability, burden on primary care services and communication of the intervention to patients and the public. Their feedback directly informed refinement of the intervention and dissemination materials.