Lessons learned about co-design in mental health care

In this section we present seven lessons learned regarding co-design in mental health care, drawing on over ten years of co-design projects conducted by our Digital Innovation in Healthcare research group in the Netherlands. In these projects we collaborated with diverse groups of individuals with lived experience, professionals, and researchers. These lessons are organized into two domains: (1) the co-design process and (2) collaborative knowledge production. Although this distinction is somewhat artificial, as the co-design process serves as the vehicle for knowledge production, it clarifies how co-design processes generate both design outcomes – hereafter referred to as ‘design artefacts’, ‘design outcomes’, or ‘purposeful change’, all denoting the tangible results of the design process – and encapsulate knowledge and learning. This essay is a practice-based conceptual synthesis (i.e., not a systematic review or formal empirical analysis) informed by published studies, our own project documentation, and our long-term experience with involvement in co-design projects. Throughout these lessons, we address the various perspectives (experiential, professional, and scientific), and the conversational lenses we associated them with in the introduction (resonance, relevance, and rigour), to illuminate the tensions we encountered in the process. While presented as seven distinct lessons, these insights are closely interconnected and collectively motivate the need for co-design rationales.

Lesson 1: The co-design process is about productively working with differences

Co-design processes in mental health must accommodate multiple, potentially divergent perspectives, as these are crucial for achieving meaningful and sustainable innovation. The prefix “co-” in co-design signifies that diverse viewpoints are integral to a collaborative exploratory process. Sometimes, this exchange involves only two perspectives, while in other contexts, it encompasses a broader array of viewpoints. The prevailing paradigm in health sciences emphasizes theoretically generalizable concepts, or rigour (which we return to and expand on later in Lesson 5), which significantly shape the knowledge base and, by extension, professional practice in mental health. The literature, however, offers limited accounts of how experiential perspectives are elicited, primarily because it is often assumed that professionals or researchers identify these requirements [44]. Even when requirements are identified through ‘person-based’ approaches [45], it is still relatively rare for qualitative user study findings to be reported independently or valued equally with quantitative results in the health sciences [46]. Instead, there is a pronounced focus on developing and extending theoretical frameworks, such as those related to behaviour change or decision-making, to guide the design process. For this reason, the system perspective, typically upheld by professionals and researchers, tends to dominate, increasing the risk of superficial and tokenistic involvement of experiential perspectives [26].

This tendency is further reinforced by the fact that many innovation and implementation frameworks prioritize consensus [44,47–52]. The pursuit of consensus is not seldom approached from a single perspective, and occasionally from an assumed all-encompassing viewpoint, where all stakeholders are expected to be convinced of the innovation’s value from a particular standpoint. In practice, this is most often the professional or the scientific perspective, which are rooted in practical (relevance) and generalizable knowledge (rigour). Although this approach may effectively promote innovation within specific disciplines, it frequently restricts the inclusion of experiential perspectives (resonance), thereby undermining the collaborative intent of co-design [39].

Star and Griesemer [53] introduced the concept of the “boundary object”, which was originally intended to enable constructive collaboration between different sites or social systems without demanding consensus. Rejecting the assumption that consensus regarding goals, values, needs, and preferences is always required offers a helpful line of thinking for co-design in mental health. This boundary object perspective legitimizes the coexistence of multiple viewpoints for systemic awareness [54]. For professionals, an innovation may be relevant if it serves as a recognizable tool to facilitate care delivery, whereas for clients or people with lived experience, it may show resonance if it functions as a means to articulate their unique experiences and first-person perspectives [55] or to address everyday challenges [56,57]. For researchers, it is rigorous if it is backed by empirical evidence and theories. These perspectives can exist in harmony – the one does not exclude the other. At its core, participation in design and the presence of dissensus are inherently linked [18,58]. Embracing dissensus may allow epistemic pluralism in mental health care to flourish [28].

A systematic review [56] demonstrates that genuine curiosity about differing perspectives, coupled with active discussion and exchange, significantly increases the likelihood of successful adaptation and implementation of innovations, tools or change in health care contexts [59–63]. Engaging with a shared learning space that accommodates multiple perspectives promotes collective ownership of both the problem and its solutions and encourages ongoing consideration of diverging viewpoints. The exchange of dissenting perspectives is a critical component of the co-design process, especially in complex environments with diverse stakeholders, needs, and interests. When these factors are addressed through the framework of a boundary object and integrated into the design, mutual understanding is enhanced. Collaborative inquiry requires an environment conducive to change, in which all stakeholders are motivated to progress together as a team, which is imperative for design [3].

Lesson 2: The co-design process and its outcomes are unpredictable

Researchers frequently approach projects with a specific solution or direction for change in mind, informed by prior research findings and established theories. This practice is common, as researchers are recognized as scientific experts in their fields. When seeking funding from grant providers, for example, they must submit extensive and detailed proposals that clearly outline the expected outcomes in exchange for investment. In contexts where innovation is central and the involvement of multiple stakeholders is much-needed, researchers increasingly adopt co-design methodologies to refine the already thought-out concept. Although this approach may initially seem appropriate, it collides with the core principles that underpin the value of design [18].

From a design perspective, one explores potential solutions through iterative experimentation and prototyping to assess their fit with the situation at hand, something Schön [64] called a “reflective conversation with the situation.” Problem and solution thus co-evolve [2], and testing prototypes is meant to learn, literally “a question embodied” [65]. In short, designers observe the current situation, formulate alternative ways forward, consider their likely impact, and test promising options to determine what works in practice [66]. Wartena and Kuipers [27] describe this as rapidness. If the problem definition is predetermined and the solution is fixed, it becomes impossible to learn from and respond to the unique needs of people in these contexts [67], as well as the constraints of the context itself (see Lesson 4). The unpredictability – which allows serendipity – in co-design is precisely what makes it transformative for human-centered innovation. The solution should therefore surface as the co-design team engages in collaborative learning through ‘rapid[ness]’ design and testing in situ [27].

Co-design dynamics are best characterised by intensity and uncertainty due to diverse perspectives and co-design’s emergent and generative nature [68]. Again, in mental health care, co-design involves working with individuals who may lack a design background, within teams of people with experiential, professional, and scientific knowledge, which ideally operate on equal terms in a unique context. Some co-design initiatives complement this process by providing training or capacity-building activities that help stakeholders understand the design process and collaborate more effectively across disciplinary boundaries [9]. These teams should collectively determine how to frame the problem, which concepts to develop into prototypes, and the criteria for testing those prototypes [18]. Rapid testing – while in tension with more rigorous research methodologies (see Lesson 1) – may reveal that a concept fails to address the problem adequately or that the problem itself requires reframing due to new insights gained during the process. Accordingly, both the problem and the solution must remain open to challenge and revision, as they co-develop throughout the process. The co-design team cannot fully anticipate discoveries in advance, and it is often through this iterative process of exploration and learning that ‘real’ innovation emerges.

Lesson 3: Co-design is one approach among many to integrate stakeholder perspectives

Co-design is a valuable and established method for integrating stakeholder perspectives into mental health care innovation; however, it is not universally applicable. In contexts involving vulnerable or less verbally expressive populations, alternative design research approaches – often requiring additional methodological steps – can also facilitate the authentic inclusion of stakeholder perspectives [39]. Since the integration of lived experience and experiential knowledge is widely recognized as a key driver in the design of health interventions, particularly within mental health [9,10,69,70], co-design is frequently positioned as the preferred or ideal approach for achieving this integration. Nevertheless, the concept of “co-” in co-design presupposes a level of participation in which various stakeholders act as partners throughout the design process. In practice, this assumption does not always hold. Certain groups in mental health may be unable to participate as equal partners due to age, cognitive or functional limitations, language barriers, vulnerability, or contextual constraints. Similarly, in experience-based co-design in mental health care approaches are often adapted to accommodate trauma-informed, contextual, and population-specific conditions [71].

Nevertheless, Terlouw and Veldmeijer [39] indicate that design and innovation projects can achieve genuine stakeholder involvement even without full partnership. In fact, challenges surrounding participation and involvement should never be used as an excuse to exclude experiential perspectives. When individuals are less able to participate as equal contributors, several strategies exist to ensure their perspectives are integrated into the design process. These strategies often involve indirect elicitation of lived experience, iterative validation through testing, and expert interpretation to translate insights into design decisions. In these scenarios, the facilitator’s role becomes more complex, requiring additional methodological steps to surface, interpret, and validate stakeholder perspectives. This complexity is particularly apparent when direct involvement is limited or only feasible at later stages [39]. In such cases, perspectives can be accessed through proxies or informants and subsequently validated through structured testing with the target group. Reduced direct participation thus does not preclude relevant inclusion of experiential perspectives but requires a more deliberate and methodologically layered approach to ensure adequate representation.

Project leads should therefore carefully deliberate on methodological selection. If abductive design reasoning, iterative making/prototyping, artefact or service development, problem–solution co-evolution and explicit design decision-making is needed, co-design is a great choice. However, a broad range of adjacent approaches and traditions exists, each with distinct strengths and limitations relative to specific contexts and target groups. Not every project necessitates shared decision-making, and co-design should not be applied by default. Designers should maintain the capacity to reframe problems based on insights from both practice and theory. Project leads are encouraged to transparently justify how their chosen approach aligns with the characteristics of the target group and the specific design challenge.

Lesson 4: Contextual constraints are indispensable inputs in the co-design process

Designers do not create solutions in isolation from the context in which they will be used, particularly in projects involving human behaviour. Instead, designers develop potential solutions in context and test these options early and often, enabling them to quickly learn about their match with the situation and the consequences they cause [64–66]. In mental health care, this context may for example include the therapy room when developing a therapeutic intervention, the digital systems clients use to access records and appointments, or broader system-oriented processes such as the pathway from referral to intake. These various domains share a common objective: addressing challenges by initiating purposeful change through the co-design of potential solution directions.

Even minor contextual constraints can require significant adjustments to framing, briefing, principles, and choices during the co-design of concepts, tailored to the specific situation. For instance, developing an innovative therapeutic intervention requires understanding the attitudes and needs of both professionals and patients, the implications for clinical practices, the demands placed on patients/clients, and the strategies for effective integration within the broader care system. Designing an intervention in isolation and subsequently implementing it is insufficient; the outcome must encapsulate experiential, professional, and scientific perspectives as a coherent narrative deployed within a unique ecosystem [18]. The value of potential solution directions should be assessed early in the co-design process by evaluating whether the artefact or design outcome resonates with the people it is designed for and fulfils its purpose within the relevant context. With this notion, involvement and participation in co-design are processes of collective learning and reflection to generate shared knowledge and understanding [72,73], embedded in broader institutional, organisational, and systemic structures, including funding mechanisms, research governance, disciplinary norms, and prevailing conceptions of evidence. Small-scale, context-specific qualitative tests are particularly valuable for revealing the underlying values of stakeholders in relation to the proposed solution or change.

Lesson 5: Align early on the epistemological paradigm through which knowledge is understood

Misunderstandings between experiential, professional, and scientific perspectives frequently arise because they hold different, often implicit, assumptions about what counts as valid knowledge and how it should be generated. Much of the mental health care literature is oriented toward effectiveness (rigour), a focus that aligns with the historical and scientific foundations of health research. The medical field has established a robust tradition of effectiveness studies across diverse health issues, which has driven significant disciplinary evolution and medical advancements. However, Blandford et al. [74] and Groeneveld et al. [75] highlight the challenges that emerge from cultural clashes in interdisciplinary collaboration, particularly between medical research and design research. Medical science and design culture differ fundamentally in their perspectives, approaches, and research methodologies. In mental health research, these epistemic imbalances are especially significant, as co-design can reinforce instead of transform existing hierarchies of power and knowledge when experiential knowledge is only recognized if it conforms to dominant scientific or professional reasoning, making co-practices ‘untenable’ and potentially harmful [76].

Research paradigms vary in their ontological assumptions (what reality is), epistemological criteria (what counts as knowledge), and methodological approaches (how knowledge is generated) to knowledge production [77]. Common paradigmatic lenses include for example (post-)positivism, social constructivism, pragmatism, and the participatory paradigm [78]. Much mental health research is conducted from a (post-)positivist perspective, which assumes a single reality characterized by order, patterns, and cause-and-effect relationships, where events are not random. Within this paradigm, the pursuit of truth is the primary value of research (rigour), and a variety of methodologies and methods may be employed to achieve this objective.

Concurrently, the mental health literature encompasses a wide array of studies employing co-design methods. While some of these – more medical focused – studies pursue ‘truth-finding,’ many – more design focused – studies are implicitly informed by pragmatic and participatory paradigms, where usefulness and practical impact for people in their contexts are prioritized (resonance and relevance). In such instances, research is expected to address real-world problems directly by intervening through making and testing. This divergence in paradigmatic orientation often results in misunderstandings, particularly in a field where the medical paradigm remains predominant. For example, designers may consider iterative prototyping and contextual testing as suitable methods for generating knowledge, while researchers operating within a (post-)positivist paradigm may primarily expect predefined hypotheses and standardized procedures. Epistemological differences like these frequently shape design decisions, methodological approaches, and the assessment of study quality. These disputes also reflect deeper differences in worldview. Firestone [79] accurately notes that “[t]here are, in fact, several reasons for selecting a methodological approach, but one’s decision often expresses values about what the world is like, how one ought to understand it, and what the most important threats to that understanding are.”

Paradigmatic differences are also evident in disciplinary orientations. Medical researchers typically focus on understanding and establishing current realities and practices, grounded in (post-)positivist assumptions. In contrast, designers aim to shape or represent new or improved practices through abductive reasoning. Consequently, these disciplines make distinct choices throughout the design and research process, including stakeholder involvement, the timing and nature of participation, and the role of evidence and knowledge. For medical researchers, evidence and theories serve as a central evaluative framework, whereas for designers, they provide guidance and a foundation for developing contextually impactful solutions [18]. Thus, greater attention to alternative paradigms and their interrelationship in co-design is advised – paradigms should be regarded as interconnected, each with a legitimate role in contributing to a more comprehensive understanding of mental health challenges and potential innovations.

Lesson 6: Power relations need to be negotiated and reported from the outset

Co-design teams may collaborate through various methods and configurations. Meaningful co-design requires agreements regarding decision-making authority. Frequently, such agreements are absent and rarely documented in mental health studies [9]. Genuine participatory design calls for a shift from involving participants solely as informants to recognizing them as integral contributors to the design process [80]. Achieving meaningful co-creative inquiry, design, testing, and research – where each team member is acknowledged as an expert in their own knowledge and perspective [16] – demands shared power and transparent reporting of power dynamics [26]. Nevertheless, research indicates that the involvement of individuals with lived experience remains insufficiently reported [9,69,70,81]. Moreover, experiential perspectives are often adapted to fit prevailing hermeneutical frameworks and established research structures [82], and although their participation in decision-making is considered crucial, it is infrequently realized [26].

Such power sharing arrangements should be established prior to initiating a co-design project, not during or after the project. These arrangements may include jointly defining decision-making authority, clarifying who is responsible for different design decisions, and agreeing how disagreements will be negotiated and documented throughout the project. Power is not a binary attribute but it is shaped by multiple factors, including one’s social location, intersectional identity, and the specific context in which one operates. Epistemic pluralism in mental health [28], where each stakeholder maintains a degree of authority over their ways of knowing, is vital for co-design [18]. Innovation relies on the inclusion of divergent perspectives (see Lesson 1), which may not always align but should be valued, even when they generate friction. Examining these perspectives and the rationale behind them forms the foundation for productive collaboration, where dissensus serves as a guiding principle for establishing common ground [83]. Publicly documenting these discussions and clarifying decision-making processes are crucial for transparency regarding the collective development of ideas [18].

Lesson 7: Maintain transparency about principles, choices, roles and responsibilities

A central reporting issue surfaces regarding the documentation of underlying design choices and principles, as well as the processes by which these are established and the roles and responsibilities of different stakeholders in these processes. As mentioned in Lessons 1 and 5, in much of the mental health literature, interventions are primarily described by their intended purposes and evaluated for effectiveness. Although outcome-focused reporting is valuable, it often obscures the design process itself, making it frequently unclear which design choices were made, how these decisions were informed by theory and practice, and why certain directions or perspectives were selected over others [9,27]. This pattern is also evident in a comprehensive review of behavioural design by Nielsen et al. [84], which found that theory-informed decision making was prioritized, while stakeholder-informed decision making was rarely reported.

The absence of design rationales and comprehensive descriptions of stakeholder involvement, and thus a lack of transparency in design reasoning, is particularly concerning in mental health care. To reiterate, design studies in this field focus prematurely on evaluating design outcomes – often after only the first iteration – to demonstrate average effects [9]. As a result, the reasoning underlying the artefact remains insufficiently understood. This reasoning is arguably the most critical aspect to make transparent, especially for co-design, as it is important in early stages to determine and understand whether the design outcome results from a deliberate, iterative design process and forms a coherent concept before large-scale testing and subsequent implementation. Instead of focusing primarily on design outcomes, it is recommended to document the decision-making process: which choices were made, how were they made and by whom, and how do they relate to existing knowledge and the principles upon which the design outcome is based [18]. Articulating this rationale enhances falsifiability and enables other researchers to understand, replicate, and extend previous design work, thereby strengthening cumulative and transferable knowledge development in mental health design.

Collectively, these seven lessons reveal a consistent and recurring pattern of design processes that are – explicitly or implicitly – guided by a combination of experiential, professional, and scientific stakeholder contributions, design principles, theories, and evolving design hypotheses, yet these elements are rarely reported in an integrated and transparent manner, including the roles and responsibilities of the participating stakeholders [9]. This lack of transparency in reporting needs attention, as it restricts the ability of others to learn from, reproduce or build upon the work. These reporting challenges motivate the need for a structured co-design rationale. The following section translates these lessons into a preliminary architecture that captures what was co-designed, how design decisions were reached, whose perspectives informed them, and how disagreements and responsibilities shaped the final outcome.

Two illustrative cases: Bias Blaster and In Picture Approach

The first case examines Bias Blaster [91], a project that sought to develop a serious game to address implicit bias. While a range of stakeholders participated throughout the design process, key decisions – including the framing of the challenge and the solution direction – were primarily influenced by scientific and professional perspectives. Experiential perspectives contributed mainly to aesthetic elements, such as colour schemes and game features, whereas alternative suggestions were dismissed for lacking sufficient evidence. As a result, opportunities for reciprocity and reframing were limited, and stakeholder influence, in particular the impact of experiential perspectives on decision-making, was uneven. These dynamics ultimately shaped the final artefact, which reflected the initial framing as opposed to a co-evolved, collaboratively developed alternative. In the absence of a documented co-design rationale, it remains unclear how stakeholder input affected specific design choices, which alternatives were considered or rejected, and how power relations influenced the artefact. Bias Blaster thus demonstrates that the lack of a co-design rationale can obscure collaborative design reasoning, even in projects with significant stakeholder participation.

The second case, conducted more than ten years later, concerns the In Picture Approach [55]. This project aspired to co-design a method that enables individuals experiencing mental distress to represent their experiences in ways that meet their specific needs. Design choices were developed through iterative collaboration among individuals with lived experience, professionals, and researchers, with each perspective – experiential, professional, and scientific – jointly informing the evolving artefact. While stakeholders did not always reach consensus, they consistently engaged with tensions and negotiated decisions, which fostered reciprocity throughout the design process. These collaborative interactions produced a booklet and method that reflected context-specific choices and facilitated collective learning. The resulting publication documents much of the underlying design reasoning by making stakeholder contributions, design decisions, design principles, and theoretical considerations, such as the supporting and working theories, explicit. Although epistemic positioning and paradigmatic assumptions remain implicit, this case highlights the value of documenting collaborative design reasoning and demonstrates the potential contribution of co-design rationales to transparent and accountable co-design practice.

Reciprocity as ‘sine qua non’ for co-design in mental health care

In addition to the need for co-design rationales in mental health care innovation the seven lessons also show that co-design is fundamentally concerned with the quality of relationships through which design decisions are shaped. We are, however, not the first to postulate that reciprocity and participation in design processes go hand-in-hand. For example, Dreessen et al. [92] define reciprocity in participatory design as “[..] a mutual exchange, which can entail a direct gain for the participant or a form of reciprocity in which each participant acts with the interest of the other in mind.”

We expand on this definition by arguing that co-design processes depend on the ongoing exchange of dissenting perspectives, experiences, interpretations, and expertise among stakeholders from experiential, professional, and scientific backgrounds. Researchers, designers, clinicians, managers, service users, caregivers, individuals with lived experience, and so on, do not by default participate in co-design processes with the same goals, values, and worldviews. Accordingly, the collaborative production of design knowledge relies on relational and social conditions such as reciprocity that encourage such knowledge exchange through perspective-making and -taking and promote mutual learning [57,93]. From this perspective, reciprocity in co-design in mental health care refers to the mutual recognition of diverse stakeholders as legitimate contributors to the co-design process by making design choices and the ‘gameness’ to both influence and be influenced by others. This bidirectional exchange allows participating stakeholders to contribute their expertise while remaining open to having their own viewpoints, assumptions, interpretations, and priorities reshaped through interaction and discussion (Fig 4).

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Fig 4. Reciprocity as the relational condition that is necessary for meaningful co-design.

Reciprocal co-design is characterised by the mutual influence of experiential, professional, and scientific perspectives throughout framing, prototyping, testing, and decision-making. Reciprocity makes differences in perspectives visible and negotiable, enabling collaborative learning and the co-evolution of design decisions across iterative design cycles.

https://doi.org/10.1371/journal.pmen.0000689.g004

Within a co-design rationale, reciprocity is evident in the documented evolution of stakeholders’ ideas, framing, design choices, prototyping, and testing throughout iterative design cycles. In reciprocal co-design processes, perspectives influence each other over time and co-evolve, which demonstrates openness to mutual learning and adaptation among participants. Correspondingly, mental health co-production studies also indicate that reciprocity relies on relational and emotional mechanisms, such as establishing safe spaces, facilitating decision-making, encouraging shared reflection, fostering vulnerability, and continuously renegotiating power dynamics as opposed to presuming that power can be equalized at the outset of a project [94,95]. Importantly, reciprocity should not be interpreted as eliminating existing power asymmetries but as creating conditions in which power relations become explicit, open to reflection, and negotiable throughout the co-design process. Ongoing critical reflective practice and dialogue are known to be essential to facilitate equal relational processes in co-design [96]. Unlike rigour, relevance, and resonance [27], reciprocity does not primarily characterize a qualitatively distinct perspective of a participating stakeholder in the co-design process but should be regarded as the hallmark that enables the co-learning between those ways of knowing.

Let us provide an example of why reciprocity is most important by illustrating a few common tensions one can encounter in co-design processes. Imagine a co-design project with diverse stakeholders in mental health care. An excessive emphasis on rigour in the co-design process may shift the objective toward producing generalizable knowledge or truth finding, potentially overlooking important nuances as required for innovation. This also creates tension with resonance, as the emphasis on rigour risks promoting scientific and professional knowledge over experiential knowledge. On the other hand, an uncritical overemphasis on resonance can deliver novel and unique first-person perspectives yet may also result in misleading representations of specific groups, while at the same time pushing professional and scientific perspectives to the background. Similarly, a predominant focus on relevance can lead to adequate considerations of pragmatic and contextual goals and needs for professional purposes, however, established scientific knowledge and first-person perspectives may as a result be set aside. This all takes place within a paradigm that prioritizes rapidness, as an inherent methodological feature of design, which promotes swift iteration and development in the co-design process, but may compromise thoroughness on the research end from a (post-)positivist stance.

Co-design processes always involve such tensions [73], which all result from valid and legitimate perspectives. These tensions thus need to be productively explored at their deepest core, as the clash and exploration of tensions is exactly where innovation occurs. As Palmer et al. [97] argued, co-creating knowledge requires respectful dialogue, navigating differences, and – what we perceive as most crucial – working through such disagreements, which is precisely why reciprocity is a necessity.

In sum, reciprocity can be understood as the necessary relational mechanism, or hallmark, through which the co-design process enables mutual learning as well as generating new knowledge by influencing and being influenced, even if this is uncomfortable for the stakeholders. It establishes the conditions required for epistemic pluralism by enabling stakeholders to move beyond consultation toward productive exchange of insights and perspectives in a delicate balancing act, without pursuing consensus or prioritizing one perspective or activity system. To quote Freire [98]: “Knowledge emerges only through invention and re-invention, through the restless, impatient, continuing, hopeful inquiry human beings pursue in the world, with the world, and with each other.”

Thus, reciprocity in co-design extends beyond mere participation or presence; it is ‘sine qua non’ (a necessary condition without which something, i.e., co-design, is not possible), and it requires that all perspectives have the capacity to influence collective understanding and subsequent design decisions. Again, as argued throughout this section, co-design rationales can make reciprocity visible by documenting how stakeholders influenced one another throughout the process, how disagreements were negotiated, how experiential, professional, and scientific perspectives shaped design decisions, and whether opportunities for mutual and collective learning were created.