As a term, science refers to the systematic study, organization, and synthesis of knowledge of phenomenon and the mobilization of theories, concepts, and methods to better understand the what, why, and how that phenomenon works [10]. Calling for a science does not mean that existing theories and concepts are not available or relevant to building a systematic evidence base, or to synthesizing knowledge; indeed, there are long-standing traditions in the participatory paradigms [11]. Instead, the call for a science of participation suggests that there are currently three critical gaps that exist in the examination and interpretation of the phenomenon of participation. These gaps relate to:

A science of participation will, by nature, be interdisciplinary, and it will intersect with paradigms across participatory design, participatory medicine, participatory research methods, and across approaches for engagement, collaborative decision-making, and change. A science of participation will mobilize existing knowledge, theories, and frameworks with a focus on unification, not replication, and synthesis, not reinvention. It will allow the identification of value creation in terms of impacts and outcomes from within the field. The following parts of this viewpoint will outline how a science of participation can contribute to addressing the three critical gaps of the phenomenon of participation.

A core rationale for a science of participation is that we are amid a scientific revolution in the participatory paradigm. Kuhn described the scientific revolution as a process by which normal science continues while there is a consensus about a framework, at least until anomalies emerge. Here we can use two examples to illustrate this point about anomalies. In the first case, coproduction and co-design frameworks in health care quality improvement have continued to be used as normative quality improvement methods. However, anomalies and facts that are difficult to explain in the context of the current paradigm have started to emerge and generate weaknesses. For example, cracks are emerging in the increased calls for evidence of impact and outcome from coproduction and co-design. Now, various authors suggest that it is the outcomes of coproduction and not the processes that achieve those outcomes that should be measured [12]. Coupled with this is a growing concern that the terms coproduction and co-design are losing meaning and creating weaknesses in the standard science too because they are being overused without attendance to the values, principles, and practices that ought to underpin them [13-15]. Indeed, there is variability in how coproduction and co-design are defined, so determining the different effects, impacts, and outcomes of various approaches is a challenge that will require an agreed upon vocabulary [14].

The second case for an emergent anomaly in the current science is illustrated in a recent article by DeBronkart on patient engagement [16]. In this paper, DeBronkart described how medicine has an outdated paradigm of the patient as a passive recipient, which has created weakness and the possibility for a new paradigm, that of the e-patient. This e-patient is a responsible driver of health, who shares part of the work as appropriate to their role and abilities [16]. Thus, in Kuhn’s revolution, weaknesses in science provide the opportunity for a paradigm shift where underlying assumptions are re-examined, and a potentially new paradigm emerges [17]. This new paradigm in health care design, delivery, and improvement is a science of participation.

To date, participation in health care planning, design, delivery, and improvement has been primarily explained and examined through existing paradigms of implementation science, improvement science, and citizen science. While these are important sciences from which we can learn, they do not provide the field with the explanatory theories and models needed to re-examine the participation paradigm in conjunction with the anomalies and weaknesses outlined above, or concerning the phenomena of participation that is occurring in health care. That is, a science of participation is needed to identify the impacts and outcomes we ought to expect of coproduction and co-design. Moreover, it is needed to identify if participation (according to particular methods and approaches) in design, delivery, and improvement results in better patient experiences, quality care, and improved health outcomes. This includes understanding and evaluating the role of health care professionals in the participatory Zeitgeist.

To address these complexities, models and theories that have explanatory force for the phenomena of participation are required. In Table 1, the three currently existing and dominant paradigms used to describe participation in health care design, delivery, and improvement are briefly outlined [18-20]. Each of these paradigms has established traditions that are not entirely covered in their brief descriptions; however, the aim is to highlight the gaps in these sciences for attending specifically to participation. It is also acknowledged that there are several intersecting traditions across these sciences (eg, participatory design or distributed thinking and participatory medicine itself) that have influenced their development, which has not been covered in this summary.

In our re-examination of the assumptions that underpin participation in health care, there is an opportunity to synthesize what is a largely fragmented and inconclusive evidence base [19] and apply explanatory theories developed from our field. Existing work in participatory design can assist. Steen, for example, articulated the importance of virtue ethics in participatory design practice [21]. He outlined the essential virtues of cooperation, curiosity, creativity, empowerment, and reflexivity for designers and noted, drawing on MacIntyre’s work in ethics, that virtues are not only about a disposition to “act…but also to feel in particular ways” [21]. More recently, an explanatory theoretical model of change identified eight mechanisms seen to be critical for facilitation of change in co-design and coproduction in health care improvement: recognition, dialogue, cooperation, accountability, mobilization, creativity, enactment, and attainment [2]. The explanatory theoretical model positioned these mechanisms within the relational contexts of co-design and coproduction activities and described some ideal transitions that might be expected in these activities. These included moving from being isolated (I), to somewhat recognizing experiences might be shared (I to Them), to sharing experiences and developing understanding (Them to You), to embracing a collective sense of change (You to Us), to all working together to achieve that change (Us to We) [2]. Such theoretical models are essential for building the conditions for participation and to interpret the impacts and outcomes.

The call for a science of participation is coupled with the need for systematic examination and observation of impact and outcome. There has been a growth in literature outlining an expectation that we should see evidence of impact from coproduction [22-26], and there is an expectation that participation from patients, carers/families, and service users increases patient-centered outcomes, improves professional morale, and increases health and well-being; however, the measurement of this has been inconsistent and almost absent. To date, one cluster randomized controlled trial has been conducted to test the assumption that a participatory, co-design, quality improvement method may improve individual, psychosocial, recovery outcomes: the CORE Study (2013-2017) [23]. Some evidence indicates that collective coproduction reduces diagnostic error in hospitals [24], and survey results from the United Kingdom and from Australian and European nations have shown that a turn to participation via coproduction is more likely when government shortfalls in performance prevail [25].

When Don Berwick called for a science of improvement for health care over ten years ago, he highlighted that disputes for the development of a science were more likely to be about epistemological disagreement rather than the type of research required to generate an evidence base [27]. A distinguishing feature of the current participatory times is the increased recognition of the importance of lived-experience (experiential knowledge) and patient-led change [11]. This has traditionally raised an epistemological tension between advocates for participatory paradigms and evidence-based paradigms. It is time to cross the epistemological bridges and establish a science of participation that helps to explain impacts, document outcomes, and bring theories together into a unifying whole.

Almost 25 years ago, Ostrom also concluded that “contrived walls separating the analysis of potentially synergetic phenomena into separate parts misses the potential for synergy” [10]. The current state of play in participation in health care offers good ground for synergies among diverse theoretical and practical approaches from participatory design, participatory medicine, participatory action research, co-design and coproduction, to patient engagement, the e-patient movement, and enabled health care professionals. The next steps involve our building of a science of participation that contributes to the identification of the components and features of an elegant [6] health system to support participation. These steps include but are not limited to: (1) knowledge synthesis of the current phenomena of participation in health care design, delivery, and improvement to organize our somewhat disparate and divergent strands of fragmented evidence; (2) systematic study of participation to identify impacts and outcomes; and (3) harnessing existing theories, concepts, and methods to explain and interpret phenomena so that we might develop new models based on our science as appropriate. Now is the time for a science of participation.