Co-design in mental health services planning : the perspectives of the stakeholders in Malta

Abstract

Background: Despite increasing international endorsement of co-design as a participatory approach in mental health services development, its practical adoption remains inconsistent, particularly in systems historically dominated by hierarchical and medicalised models of care. In Malta, co-design has yet to be systematically implemented, and the emotional, cultural, and structural readiness for such reform is largely unexplored. Objective: This study aimed to explore how co-design could be implemented in the Maltese mental health system by examining the perspectives of key stakeholders, namely service users, healthcare professionals and managers, on the implementation feasibility, perceived benefits and possible barriers. Design: A qualitative, exploratory, single embedded case study design, incorporating withincase analysis, underpinned by an interpretivist paradigm and informed by the frameworks of Arnstein’s Ladder of Participation, the Four Key Elements of Co-Design, Critical Theory and Systems Theory. Setting: Four mental health-service organisations were chosen to carry out this study, which included state-run, private and non-governmental services. Participants: A purposive sample made up of 23 participants was recruited from the different services: 11 service users, 4 managers and 8 healthcare professionals with diverse roles within the mental health sector. Methodology: Semi-structured interviews were conducted and analysed using thematic analysis. Data were coded using structural coding techniques in ATLAS.ti, with emerging themes examined in relation to the study’s theoretical frameworks. A reflexive, iterative approach was employed throughout the study to ensure transparency, credibility, and emotional sensitivity. Results: Five themes emerged from the findings: (1) Valuing Lived Experience: A Foundation with Fractures, (2) Trust and Psychological Safety: The Emotional Prerequisites, (3) Structural and Logistical Barriers: The Weight of the System, (4) Relational Barriers: Communication Breakdowns and Conflicting Visions, and (5) Motivational Drivers and Perceived Impact of CoDesign. Whilst participants generally expressed support for co-design in principle, embedded mistrust, emotional fatigue, systemic resistance and pragmatic challenges were identified as potential hindrances to meaningful implementation. Service users often prioritised basic needs and emotional safety over participatory involvement, and concerns about tokenism, underrepresentation, and institutional inertia were recurrent. Conclusion: Even if it is theoretically embraced by stakeholders, the study identifies that codesign requires significant systemic transformation for it to move beyond tokenistic engagement and be meaningfully implemented in Malta. The process needs fundamental structural changes, leadership buy-in, emotional readiness and trauma-informed practice. These findings provide a foundational understanding for developing contextually appropriate participatory mental health strategies in Malta.