Co-creation Approach in Practice: Naming a Cafe Located within a Rural Health Service Provides Added Value to a Health Strategy

Objective . Te Victorian Government in Australia has developed Healthy Choices guidelines to ensure that healthy foods and drinks are ofered and promoted in places such as hospitals. Tis brief report aims to present complex theoretical attributes related to cocreation through an accessible example of a competition to create a new name for the previously understated hospital “kiosk.” Methods . A mixed-methods approach using an online survey and semistructured interviews were used to obtain detailed insights from hospital staf members to engage in a naming competition for a hospital-based cafe. Results . Te level of engagement in this activity was higher than anticipated by the management staf. Conclusions . Active involvement of staf members through a cocreation process can enable the development of innovative healthy eating strategies and increase staf engagement to further changes in the cafe. Implications for public health cocreation in public health promises efective stakeholder engagement and requires signifcant scientifc advancement. Tis brief report illustrates theoretical constructs of cocreation through a naming competition activity that occurred as part of a larger project to improve Wimmera Base Hospital’s food environment.


Introduction
Overweight and obesity are a complex public health problem that disproportionally afects rural and regional areas of Australia [1].Studies have identifed that healthier choices are impacted by the food environment (e.g., the number, type, location, and accessibility of food outlets in a community) and in-store characteristics, such as promotional materials [2][3][4][5][6].Tis suggests that food retail environments can be modifed to promote healthier food purchases.
Food retail environments are spaces where consumers purchase food and beverages and include food service operations, such as cafes or restaurants in health care settings [7].Many hospitals and health services have food retail outlets used by staf, patients, and visitors [8].Tese establishments could extend their remit to promote and protect the health and well-being of patients, staf and the broader community by providing healthier food choices in these outlets.
In April 2021, the policy directive for Victorian public health services (the policy) was announced.Trough the Healthy Choices initiative, public health services were required to provide healthier food and drink options in their in-house retail food outlets, including all vending machines and all catering for staf and visitors.Beverage targets were to be met by September 2022, and food targets by September 2023 [9].Rural health services will likely experience challenges accessing and supplying healthy food and beverages to comply with this directive.Tere is a need to look for creative ways to overcome these challenges.We described the success of one service that partnered with a disability service to provide more healthy options [10].Another service created over 150 recipes that align with the Healthy Choices guidelines to support staf and visitors in hospital environments and other organisations and communities to embrace healthier eating [11].
Tis short communication outlines how the theory of cocreation was applied to one element of a larger project to improve the healthiness of the food environment at Grampians Health-Horsham.What started as a prioritised action to provide a new name to the on-site cafe became a successful engagement strategy that boosted readiness for future healthy retail changes.Our aim is to present complex theoretical attributes of cocreation through an accessible example of a competition to create a new name for the previously understated hospital "kiosk." 1.1.Setting Description.Tis study was conducted in Horsham Rural City Council, a vibrant, multicultural community in the heart of the Wimmera region of Victoria, approximately 300 kilometres northwest of the state capital Melbourne, Australia.Te municipality has a population of 19,880, covering an area of 4,267 square kilometres, with around three-quarters of residents living within the urban area of Horsham [12].Te health service Grampians Health-Horsham and Dimboola employs 1,118 team members.It is the largest employer in the region, servicing an area of 61,000 square kilometres and a population of approximately 54,000 people.Te health service provides a range of acute, subacute, residential aged care, allied health, primary care, emergency, and critical care services, treating more than 10,000 inpatients, 16,000 emergency patients, and 123,000 outpatients annually [13].Te newly named Heartbeet Cafe is located of the front foyer of the Grampians Health-Horsham campus and provides food and beverages to hospital staf, patients, and visitors [14].

Background and Teoretical Framework. Grampians
Health, Horsham campus, has adopted a cocreation approach to improve the healthiness of the hospital's food environment.Cocreation is a collaborative approach for creative problem-solving between diverse stakeholders at all stages, from problem identifcation and solution generation to implementation and evaluation [15].Tis approach was chosen as it was anticipated that engagement with team members and all relevant stakeholders might result in a more collaborative solution with more signifcant potential for sustainment [16].Te power of cocreation includes the fexibility to adapt initiatives to context, including shared visions, plans, policies, initiatives, and regulatory frameworks [17].Figure 1 shows the cocreation process undertaken up to the point of the naming competition activity development, implementation, and evaluation.

Study Design.
A mixed-methods approach was used to obtain detailed insights on engagement from hospital staf members.An online survey was used to measure team members' engagement with this activity and to elicit votes for the new cafe logo.Semistructured one-on-one interviews were chosen as an acceptable and appropriate method to inform motivations, opportunities, and ability to participate in and conduct the naming competition.

Participants and Recruitment.
Te online survey was directed to all Grampians Health, Horsham, team members through social media (a Facebook group) and e-mail (n � 700).For the semistructured interviews, we used convenience sampling to recruit participants who submitted an entry in the naming competition (n � 2) and members from the planning committee (n � 2).

Survey Instrument.
Te research team developed an online survey comprising 16 questions on consumers' purchasing practices at the cafe which was distributed via email and social media to all Grampians Health, Horsham, team members.A subset of 4 questions, codesigned with Grampians Health staf, asked participants about their involvement in the cafe naming competition and allowed them to vote for a new cafe logo (Supplementary Table S1).Te naming competition winner and a professional graphic designer coproduced the three logo options.Te fnal survey (20 questions) was designed and delivered through Qualtics [18] survey platform.Quantitative survey data were analysed by CVH using descriptive statistics (i.e., frequency and proportions to response options).Here, we report only on the subset of questions related to the cafe naming competition.

Interviews.
One-on-one semistructured interviews were conducted by JW using an interview guide that was based on a framework the authors developed from the cocreation literature [16,19] and the motivation, opportunity, and ability model [20].Te combination of these two theoretical approaches in the interview guide sought to reveal factors that infuenced inclusive engagement within the local community (Supplementary Table S2).During interviews, written notes were taken by a note taker (CV) to capture insights and ideas from participants.A copy of the interview notes was returned to each participant for edit and checking if desired [21].Two participants reviewed and returned their notes with desired amendments and additions.All accepted notes were deidentifed and included for analysis.Researchers used conventional content analysis [22,23] to synthesise interview material with the assistance of NVivo Software [24].Interview notes were double-coded by two independent researchers (CV and JW).Individual interview notes were summarised according to key emerging concepts by the frst author (CV).Tese emerging concepts were grouped and refned into categories.A second researcher (JW) verifed these categories and double-coded each interview note.

Ethics. Ethics approval was obtained from Deakin
University's Human Ethics Advisory Group (Reference number: HEAG-H23_2022).All participants were informed of the purpose of the study and the data to be collected.A plain language statement was provided at the start of the survey/interview.Participants gave their informed consent for data collected to be used and analysed in a nonidentifable form.

Results
A hundred and sixty-three out of 700 members (23%) consented to use their answers for this analysis.Table 1 summarises the participants' general characteristics and the responses for the naming competition subset.Most respondents were female (90%, n � 146), most lived in Horsham (63%, n � 103), and nurses were the highest response group (44%, n � 72).Specifc to the cafe naming competition, 93% of respondents (n � 151) were aware of the competition, with 38% (n � 57) participating in it, by submitting and voting for a name (40%, n � 23).Te choice of cafe logo engaged 99% of respondents (n � 162), and the winning logo received 45% of the votes (n � 74).
Four participants were interviewed in June 2022, and the duration of the interviews ranged from 25 to 35 minutes.Tis sample size was considered sufcient to understand this topic due to the specifcity of the initiative [25][26][27].Table 2 summarises the key themes related to cocreation theory and includes extractions of the interviews that illustrate the topic.
Teme defnition can be found in the codebook provided in the supplementary fle Table S3.
Te themes relate to participants' motivations to plan the activity or submit a name entry and enable the participants to participate and beneft from the activity to create unique personalised experiences that could lead to ownership and engagement in subsequent activities (value cocreation).

Discussion
Te level of engagement in this activity, compared to other activities implemented in the hospital, was recognised by staf members as unprecedented.Understanding the values of this activity through cocreation theory can support the practical and systematic development of future changes in the cafe.
Intrinsic motivation and enjoyment were enhanced by cocreation through creative contribution, such as creating a name for a shared space [28].We identifed motivations from two stakeholder groups (hospital staf and planning team).A common motivation between these two groups may have occurred because of the COVID-19 pandemic.Te planning team perceived the naming competition as an activity to release some of the ongoing COVID-19 pandemic pressures, and the hospital staf embraced it similarly.Motivations to be involved in this activity may also relate to the hospital community's needs for the cafe to have a more balanced concept with a hospital and community element.For example, the most voted logo was the less hospital-like image (without the ECG graph).Tapping into the value associated with this new name and logo is the frst step in engaging the hospital staf in the upcoming changes within the cafe.Te identifcation and alignment of motivations enable the optimisation of stakeholders' priorities and the design of initiatives that cocreate value [29].

Advances in Public Health
A vision of collaboration and interactions is well articulated in cocreation theory [15,30,31].Yet, in practice, these principles may be difcult to identify, describe, and operationalise.We identifed that the social interactions enabled by the naming competition cocreated unique experiences for participants.For example, each participant chose how to interact with the activity through the multiple naming submission options made available by the planning team (i.e., e-mail, box at the cafe, and QR Code).Tis multistrategy opportunity to participate worked in parallel with the communication and dialogue strategy, which enabled high engagement among the hospital community.Tese practices align with empirical and theoretical literature on value cocreation.For example, Prahalad and Ramaswamy state that an information plan must encourage active participation in all aspects of cocreation [30].While participants regarded the process as transparent and clear, the planning team acknowledged that, at times, communications could have been more transparent.Open and transparent communication can keep hospital staf informed, connected, empowered, and active in future cocreated eforts [15,30,32].
Tis study describes attributes of cocreation to an activity of this type in a hospital setting, which can help to progress cocreation research in public health.A limitation of this study relates to the survey's low response rate compared to the total number of staf members, which limits the representation and generalisation of our results.Te convenience interview sample may have introduced further bias (e.g., availability, desirability to participate, or recall bias).this was a soft approach to communicate the project and get team members involved in it.I think that it was a really good approach (P − 3) Participate I think after COVID everyone was looking for something to smile about, so I think the timing was good (P −

2)
Te hospital has been through very tough times.I was very pleased to see so many people getting engaged [. ..] everyone loves a competition, and it was fun (P −

4)
When you talk about the cafe, there is where the people gather and meet, it is the heart of the hospital (P −

4)
Opportunities Access I think that it was hard to miss.Tey could participate while waiting for their cofee (P −

2)
Entries could be submitted via a QR code, an entry ticket or via e-mail (P −

3)
Tere were some groups that normally don't come to the cafe, or don't use e-mails and we saw them putting their nominations in.It was an option for people that are not tech savvy (S − 1) Dialogue In the beginning, there was some confusion regarding the promotion of the competition, and it think this was because of some change of responsibilities (P −
It is a good way to get messages across the staf quickly (P − 2) Probably, more information and communication of selection criteria and timeline (P −1)
After we got so many entries, we had to put in place a selection criterion that we didn't outline in the entry details (P − 3)

Interactions
Te fun part was viewing other people coming in, it just created a buzz (P −1) Participation To see the amount of people coming in surprised me.Te amount of people that wanted to be part of it (P −1) I thought that we would get about 20 entries and if so, thought that would have been good.I expected engagement, but not like what we got (P −

2)
Value co-creation I cannot think on any other competition activities [. . .] this was very easy, engaging, and fun.It was not pages of questions, even the follow-up survey for the logo, I liked it, it is simple (P −

4)
I was excited that the cafe is getting its own personality and its own name.Having the staf being part of it and contributing to choose (P −1)

Conclusions
Community engagement and participation in hospital settings can be challenging.A fun activity brought hospital staf together and communicated organisational changes.A cocreation approach can provide a way to systematically understand the active involvement of staf members and enable the development of innovative healthy eating strategies.

Table 2 :
Temes and key illustrative quotes from participants' interviews.