The co-creative process of the “Outdoor Air and Health Atlas” project: stakeholder and user involvement in the definition of information and communication needs

Background

The World health organization (WHO) estimated that 4.2 million premature deaths each year are attributable to outdoor air pollution.¹ As such, air pollution represents a major global public health issue and is considered the most significant environmental risk factor for both mortality and morbidity, being associated with a wide range of adverse health outcomes, including respiratory and cardiovascular diseases, as well as an increased incidence of lung cancer.^2-4 

To deal with this issue, WHO provided global guidelines outlining threshold values and recommended limits for major air pollutants. Nevertheless, in 2019, 99% of the global population lived in areas where these air quality guidelines were not met.¹ This global challenge is mirrored in Europe, where several countries struggle to comply with air quality standards. Italy, in particular, faces persistent difficulties in meeting these thresholds and it is often sanctioned by the European commission for exceeding the recommended levels.⁵

The Outdoor Air and Health Atlas Project

In response to the persistent challenge of air pollution and its health impacts, the Italian Ministry of Health launched the project ‘ATLAS – Outdoor Air and Health: an integrated atlas to support decisions and research’. The initiative aims to develop national and regional interactive atlases that illustrate the relationship between air quality and health outcomes, providing evidence-based tools to inform policymakers, stakeholders, and citizens in decision-making processes.

This project is part of a broader national strategy. The Italian government adopted the National Plan for Complementary Investments (PNC), through Legislative Decrees 59/2021 and 101/2021, as a supplement to the National Recovery and Resilience Plan (PNRR). Within this framework, the study falls under Investment Line E.1 ‘Health, Environment, Biodiversity, and Climate’, which seeks to establish a systemic and institutional model for prevention that integrates health, environmental, and climate dimensions, aligned with the One Health and Planetary Health approaches. Specifically, the project corresponds to Area A, targeting priority health system programs, and is included in Project No. 2: ‘Prevention and reduction of health risks related to outdoor air pollution’, funded by the Italian Ministry of Health under PNC PREV-A-2022-12376981.

The initiative involves a consortium of 26 partners – 22 originally listed in the proposal and 4 added later – coordinated by the Department of prevention and public health of Emilia-Romagna Region (Northern Italy) and the Local health authority – IRCCS of Reggio Emilia. This report focuses on the process conducted by the coordinators at the regional level, specifically within Emilia-Romagna.

To ensure the Atlas aligns with the needs of its users, its contents were collaboratively defined by both the project’s working units and potential end-users. The project employed a co-creation methodology, a widely used approach in the public sector, business, and academia that encourages stakeholder participation and shared decision-making in developing products and services.⁶ Evidence indicates that co-creation enhances usability and bridges the gap between service providers and end-users.⁷

Study aims

This paper illustrates the co-creation-based decision-making process adopted to define the content of the Air and Health Atlas, with particular emphasis on the user consultation strategies. These strategies were grouped into two phases, as designed to assess stakeholders’ knowledge needs and identify the most effective strategies for communicating complex information on air quality and health.

The  objective was to explore the informational requirements of potential users regarding the relationship between air quality (AQ) and health, and to determine how these needs could be addressed through clear, accessible, and actionable communication. Specifically, the investigation sought to answer the following research questions:

• How is the issue of air quality and health perceived by key stakeholders in the Emilia-Romagna Region?
• What types of information are considered most relevant for communication to public decision-makers and citizens?
• Which communication methods are regarded as the most effective for different target audiences?

Methods

Design

The development of the Air and Health Atlas was guided by a co-creation approach aimed at ensuring scientific rigor while addressing the informational needs of diverse stakeholders. This design integrated multiple methodological strategies to define both the content of the Atlas and its communication framework.

The process unfolded through three complementary actions (Figure 1):

1. Consultation of scientific and practitioner communities: A Delphi method, complemented by targeted meetings, was used to engage healthcare professionals, environmental protection operators, and other subject-matter experts. This step aimed to build consensus on critical technical aspects, including the selection of data sources, content definition, and methodological approaches. The details of this phase have been extensively documented in a previous publication.⁸

2. User consultation: To identify stakeholders’ informational needs and the most effective communication strategies, a two-phase mixed-methods approach was adopted. To engage stakeholders and potential users, the coordination team – including the Emilia-Romagna Region, the Local health authority-IRCCS of Reggio Emilia, and ART-ER – adopted a mixed-methods approach involving interviews, questionnaires, and focus groups. ART-ER supported Emilia-Romagna Region in the process as part of its mission. In fact, Art-ER is Emilia-Romagna’s Joint Stock Consortium Company born with the purpose of fostering the Region’s sustainable growth by developing innovation and knowledge, attractiveness and internationalization of the territory. Although conducted at the regional level, this phase provided critical insights for the design of the national Atlas. The Emilia-Romagna Region oversaw the process, while ART-ER designed the investigation plan, mapped stakeholder categories, and moderated focus groups, leveraging its expertise in communication within complex environmental contexts. User Consultation is the topic of this report and will be detailed below.

3. Prototype presentation to regional control rooms: The preliminary version of the Atlas was presented to regional control rooms composed of health and environmental authorities, decision-makers, and technical staff. These bodies represent potential end-users and play a strategic role in guiding the ongoing development of the Atlas, including its periodic updates and integration into policy-making processes.

Points 1 and 3 are not object of this report.

User consultation: first phase

Stakeholder map and ‘thermometer’ tool

All the institutions participating in the Atlas project were asked to contribute to a stakeholder map. They were required to identify individuals, groups, and organizations having a role in the environment (specifically air quality) and public health sectors that could contribute to the Atlas or that could be affected by the Atlas once published. This process led to the identification of a list of entities and groups of people at local, regional, and national level.   

Based on this list, particularly the Emilia-Romagna local and regional stakeholder list, the selection was guided by two primary criteria aimed at leveraging collective intelligence while mitigating groupthink:

• Participants were chosen to maximize diversity in perspectives and experiences relevant to the topic (e.g., professional background, age, geographic location, gender);
• Inclusion of knowledge holders (such as, in this, case, air quality experts and physicians), champions (i.e., environmental activists), and unconventional participants (stakeholder that can bring a different point of view) to foster a more systemic understanding. Specifically, knowledge holders are individuals possessing technical expertise on the topic, providing fact- and evidence-based insights; champions are those with influence and authority who can promote the desired actions; unconventional participants (or ‘unusual suspects’) are those typically excluded from traditional engagement processes, but who offer alternative perspectives capable of challenging the status quo or prevailing assumptions on key issues. This last group includes the Clust-ERs which are networks of research centres, businesses, and training institutions that are part of the innovation ecosystem of Emilia-Romagna Region. Clust-ERs are coordinated by ART-ER, which collaborate to promote territorial innovation. Following the open innovation model, partners share expertise, resources, and tools to increase competitiveness in global markets.

The selection of stakeholders for the consultation was determined by the responsible personnel from the Department of Prevention and Public Health, in collaboration with the individuals in charge of the Air Quality and Physical Agents area of the Emilia-Romagna Region and with the assistance from Art-ER facilitators. The criteria for stakeholder selection were established using the ‘thermometers’ tool, which enables the positioning of individual opinions along a continuum defined by two opposing poles. These poles, defined in collaboration with the project referents, represent the strategic macro-decisions essential for developing a more precise map of engageable stakeholders. The thermometer-oriented reflection during the decision-making process was complemented by specific guiding questions.

The thermometers are on a continuous scale: it is possible to choose any distance between the two poles.  

The poles of the thermometer tool are the following:

Stakeholders of the Health sector – Stakeholders of the environment sector: The thermometer answer to this question: Do you want to involve stakeholders from the health sector or the environment sector or a mix between the two sectors?

Sector based stakeholders (healthcare) – System based stakeholders (organizations or individuals that are involved in activities connected to health/environment topics): In this context, sector-based stakeholders are healthcare professionals and their organizations or associations specifically engaged on healthcare issues (i.e., National Cancer Association). System-based stakeholders are organizations that have to deal with environment/health topics, but it is not their main scope (i.e., Schools, Care Homes, etc.).

Organizations already engaged on the topic – neutral organization: On one pole “Organizations already engaged on the topics” includes environment and health activists’ associations, on the other pole are more institutional organization that brings a more neutral approach (i.e., association of municipalities, universities and research groups, etc.).

Regional level – local level: On one pole, organizations that works at a regional level or regional branches of national organizations; on the other pole, organizations actives at a provincial or at city levels.

Emilia-Romagna Region acting as a promoter – Emilia-Romagna Region acting as a listener: This thermometer does not influence the decision on the stakeholders to be involved, but on the role that Emilia Emilia-Romagna Region intended to play.

For each one of the poles of the thermometer, a list of local and regional stakeholders was compiled according to the general stakeholder map already identified. Then, the thermometers tool has been submitted to the referent persons of the Department of prevention and public health and the Air quality and physical agents’ area of Emilia-Romagna Region, who were asked to choose a position for each of the thermometer.

The aim of the thermometer tool is to facilitate stakeholder selection by breaking complex decisions into simpler dual contrapositions; as such, it is not a rigid tool, but more a support tool to explore different options toward a decision.

Kick off meeting

The kick-off event was held on 17th May 2024, and the event aimed to:

• Share the general challenge behind the ‘Outdoor Air and Health’ project and introduce its conceptual framework;
• Present the composition of the stakeholder group, the overall process, and the expected outcomes;
• Introduce the survey methodology, including interviews and questionnaires;
• Outline a common knowledge base on the topic, clarifying the starting points for participant discussions.

The event opened with presentations on the Outdoor Air and Health project and the Regional Integrated Area Plan (PAIR 2030). Part of the meeting was dedicated to an initial exchange with stakeholders regarding the project, and the discussion was guided by the following key questions:

• Highlights: What did you learn or find particularly striking?
• Good practices: Are you aware of successful examples of communication and data sharing? What are their defining features?
• Impact: If this project achieves its goals, what changes do you foresee in five years? How do you imagine the future?
• Risks: What potential risks do you identify?

The insights and contributions gathered during the event offered a knowledge base for the subsequent phase of the investigation.

Twenty-three people participated to the kick-off meeting representing 14 stakeholder groups plus the host organizations (Emilia-Romagna Region, ART-ER, and Social Seed). The list of stakeholders’ organizations involved in the kick-off meeting is reported in Appendix 1 (see online Supplementary Materials).

Stakeholder semi-structured interviews

Eight semi-structured interviews were carried out with selected stakeholders in the Environment and Health sector.

The interviews were conducted via Google Meet by Social Seed professionals under the supervision of ART-ER. An outline of the interview guide is provided in Appendix 2 (see online Supplementary Materials). 

The list of stakeholders’ organizations interviewed is reported in Appendix 1.

Online questionnaire

The online qualitative questionnaire was administered to the eight of the selected stakeholders for which it was not possible to schedule the interviews. It was structured around the key themes of interest of the investigation phase, such as AQ and health at the organizational level, general knowledge of the topic, type of information, methods of communication, and potential impacts. The questionnaire was administered after the first round of interviews, allowing the incorporation of new questions and relevant topics that emerged throughout the interview process.

The questionnaire included 22 questions overall:

• 5 regarding the anagraphic data of the respondent and privacy;
• 17 regarding the topic, of which:
  • 8 open-ended questions;
  • 9 scale or multiple-choice questions.

An outline of the online questionnaire administered is provided in Appendix 2.

The list of stakeholders’ organizations that were asked to answer the questionnaire is reported in Appendix 1.

First Focus group

A first focus group took place at the end of the first phase, after all data from the interviews and questionnaire was collected, during the Research to Business (R2B) event, which took place in Bologna on 26^th June 2024.  

The list of stakeholders’ organizations involved in the first focus group is reported in the Appendix 1.

Data analysis for the first phase

Data from the first consultation phase were generated through multiple qualitative sources, including field notes from the kick-off meeting and focus group, selective transcripts of semi-structured interviews, and open-ended responses from an online qualitative questionnaire. This multi-source design supported triangulation across different forms of stakeholder input.

Field notes captured key discussion points, shared concerns, and emerging themes during collective moments. Interviews were audio-recorded and selectively transcribed, focusing on analytically relevant segments aligned with the study aims; transcripts were returned to participants for verification and correction. Questionnaire responses were analysed as textual qualitative data and integrated with interview material.

Data analysis followed an iterative thematic approach. The research team conducted initial familiarization with all data sources; an initial coding framework was developed based on themes discussed in the first focus group. Codes were applied across interviews, questionnaires, and focus group notes, with constant comparison to identify convergent and divergent perspectives among stakeholders. Findings from all sources were then synthesized to inform both the content of the Atlas and its communication strategy, including tone of voice, level of detail, and spatial scale of information.

User consultation: second phase

The second phase of user consultation took place after the prototype of the Atlas has been developed, and the outcomes, pollutants exposures, and impact metrics have been defined.

For the second focus group, all the stakeholders who were involved in the questionnaire/interviews phase was invited.

The second focus group was held at the conclusion of the investigation phase, during the R2B event, which took place in Bologna on 26th June 2025; 21 people participated to the meeting representing 8 stakeholders’ organizations plus Emilia-Romagna regional representative, ART-ER’s facilitators, AUSL-IRCCS- Reggio Emilia as partner of the project and POLIMI developer’s team.     

The list of stakeholders’ organizations involved in the second focus group is reported in the Appendix 1.

The session offered an opportunity to present the results from the analysis of semi-structured interviews and questionnaires administered to selected stakeholders and representatives of the Emilia-Romagna Region. This was followed by a collective discussion guided by two key questions:

• The Atlas will be published: how can data presentation and interpretation be improved for non-expert users?
• The Atlas aims to raise awareness about air quality issues, enhance data sharing, and promote virtuous behaviour both at the individual level and within policymaking: what are the risks or barriers that could hinder the achievement of these goals?

The exchange provided an opportunity to critically evaluate specific design decisions made during the development of the Atlas. The meeting also aimed to present a series of case studies regarding online portals presenting complex information as a reference for the development of the ATLAS.⁹

Data analysis for the second phase

Data from the second consultation phase were collected through a focus group conducted after the presentation of an advanced prototype of the Atlas. Data consisted of structured field notes capturing participants’ feedback, critical observations, and suggestions for improvement.

Analysis followed a focused evaluative thematic approach. Field notes were reviewed and organized according to 4 predefined domains:

• data comprehension by non-expert users;
• alignment with the aims of the Atlas;
• map design and interpretability;
• data-related transparency.

Key issues, shared concerns, and actionable suggestions were identified within each domain and synthesized to inform refinements of the Atlas content, visualization, and communication strategies.

Ethical considerations

The findings reported in this paper are part of the process for the development of the Atlas under routine conditions. Even if some methods often used in the field of qualitative research were adopted, the present activity was not a research activity and the participants in the process could not qualify as subject of any study. All the participants gave written consent to take notes of the meetings and to report their thoughts in this public report.

Results

Stakeholder selection

Stakeholders were selected through the thermometers tool as shown in Figure 2. 

As indicated by the slider positioning, a balanced involvement of stakeholders from both the health and environmental sectors was pursued, giving preference to stakeholders directly engaged in these areas over system stakeholders. Additionally, the stakeholder engagement included both organizations already active on the topic and more ‘neutral’ participants and was conducted at the regional level.

It is important to emphasize that the final thermometer reflects the Emilia-Romagna Region’s aspirations to be a listener, more than a promoter within the process.

The positioning of the thermometer tool has been a shared decision between the Department of prevention and public health and the Air quality and physical agents Area of Emilia-Romagna Region.

Figure 3 presents the selected stakeholders, classified into environmental and health groups.

First phase results

Key thematic areas to explore

The thematic analysis of the first phase identified four main thematic areas to address awareness and knowledge, behaviours and lifestyles, information dissemination, and the geographical scale of reference. A schematic representation of the key insights derived from the interviews and questionnaires are presented in Table 1. A more detailed description of the contents is provided in Table S1 (see online Supplementary Materials).

Emerging elements of convergence and divergence

The first phase highlighted that leveraging health as a communication strategy can be effective, as health directly impacts individuals and can serve as a motivator for change. The involved stakeholders revealed both converging and diverging elements, summarized in Figure 4.

On some points, such as engage individuals, objectives, tone of voice, channels, approach and communication style, the group agreed as objectives of the Atlas or characteristics that the Atlas should satisfy. For other points, the group identified diverging directions of benefits and risk for the Atlas success; in some cases, this implies to find a trade-off (i.e., the territorial scale or for amount of technical details included); other diverging points highlight the different angles of different stakeholders (i.e., the level of interactivity or the focus on health promotion or on communication of risks).

Potential benefits on individuals, decision-makers, and business activities

Stakeholders discussed and hypothesized the main actors who could potentially benefit from the development of an operational Atlas, which relates air quality data and health outcomes. Three main categories were identified: individuals, policy decision-makers, and business activities.

Individuals. Stakeholders noted that the effective communication of information on the relationship between air quality and health outcomes may generate several relevant effects: • improving the accessibility and clarity of such information could strengthen public knowledge, including those who are sceptical on the health impacts of air pollution; • a clearer understanding of the actual determinants of atmospheric pollution may help reduce social tensions that are often sustained by limited or inaccurate information; • enhanced awareness may encourage the adoption of more sustainable everyday behaviours (e.g., choosing public transport instead of private vehicles) by promoting a more proactive orientation toward personal and collective health. 

At the same time, participants underscored the importance of coupling the communication with concrete and feasible recommendations, to prevent reactions of fear or resignation and to encourage individuals to recognize the personal relevance of the risks and the possibility of taking preventive actions.

Policy decision-makers. Regarding public decision-makers, the potential benefits can be considered at several levels: • an enhanced understanding of the topic may contribute to broader cultural development, thereby promoting greater awareness and a strengthened sense of responsibility toward the population; • decision-makers may recognize that is important considering air quality in the construction of infrastructure or the authorization of specific activities, highlighting the necessity for policy choices to be evidence-based; • the awareness can stimulate the development of effective policies, including the creation of working groups with relevant stakeholders aimed at obtaining dedicated funding and structuring short-, medium-, and long-term action plans. It should be noted that the impact on public decision-makers is likely to be largely indirect, arising from increased sensitivity within the general population. In other words, as citizens become more informed and concerned about the issue, the more decision-makers are expected to respond with coherent and evidence-based actions.

Business activity. The stakeholders identified two potential impacts of including up-to-date evidence of the health impact of air pollution in planning and regulating the business sector: • an increase in the awareness of the risks associated with air pollution and a greater understanding of the benefits for the community; • an increase in the sense of responsibility, which may lead businesses to identify and reduce specific sources of emissions.

These benefits are likely to be largely indirect, given that polluting activities primarily respond to individual demand. Therefore, it is crucial to promote greater awareness among both policymakers and the public, who may translate this awareness into social pressure for change. Furthermore, any potential increase in awareness is expected to be contingent upon the existence of regulatory obligations and should be accompanied by systematic monitoring and enforcement by the relevant authorities.

Subsequently, the main benefits identified for the three categories of actors were associated with three of the four main thematic areas outlined above (Figure 5) (indeed the thematic area of geographic granularity was not relevant for the benefits).

Directions for change

Following the identification of the four main thematic areas to be addressed and considering the key insights that emerged from the interviews and questionnaires, stakeholders discussed the directions for change to be pursued for each of the four thematic areas (Table 2). A more comprehensive description of the directions to be pursued for each thematic area is provided in Table S2 (see online Supplementary Materials).

Second phase results

As mentiones, before starting the second focus group, an advanced prototypical version of the Atlas was presented to the group by the team of the developers (Figure 6).

The key elements drawn from the consultation were grouped in four main areas:

1. Comprehension of data by non-experts: the discussion underscored that the Atlas is a useful tool for fostering a shared language between citizens and policy-makers. Although the dedicated website is user-friendly, greater accessibility for non-specialists is required, while avoiding oversimplification that could lead to misinterpretation (e.g., inappropriate use of mortality data). Dedicated communication and explanatory sessions were considered essential to ensure informed interpretation.

2. Alignment with the Atlas’s aims: the online publication of maps and data may increase the risk of misunderstanding, particularly among citizens. Participants stressed the need for providing guidelines and a practical manual outlining the scope and limitations of the Atlas. While the Atlas can be a tool for enhancing awareness and disseminate ‘positive behaviours’ to the general audience, it can be harmful if used as guidance for individual decision making (i.e., moving residence away from polluted areas but also from work and hospitals). The need to clearly explain the difference between WHO guideline values and EU limit values, as well as complex concepts such as population weighted exposure, was also emphasized.

3. Map-specific considerations: while the Atlas maps were judged well designed, they remain complex and not always immediately interpretable by non-experts. It was deemed necessary to clarify the meaning of each indicator, enhance legends and histograms, and link maps to detailed explanations. The group commented positively that additional health indicators – i.e., hospitalizations for COPD, stroke, and heart attack – will be included in future updates. Public meetings will also be valuable for supporting an accurate interpretation of the cartographic representations.

4. Data-related aspects: participants highlighted the importance of clearly communicating that the attributable death is computed assuming a counterfactual of pollutant levels equal to the WHO guideline values. The decision of showing only deaths attributable to PM_2.5 and not reporting mortality attributable to PM₁₀ was considered acceptable by the group once explained the stronger association with mortality for all cause, cardiovascular causes, and respiratory causes and lung cancer incidence and the higher level of certainty about the strength of the association of PM_2.5. Suggestions included making regulatory limits more visible in the maps and assessing the inclusion of data on the incidence of cancers associated with PM_2.5. The exclusion of data for individuals under 30 was considered acceptable for mortality, given their statistically negligible contribution to this outcome. Nevertheless, some noted the lack of any indicator about paediatric outcomes, also for hospitalization, and highlighted the need to explain why it was not possible to report any effect on children, i.e., lack of information about outpatient paediatric visits for asthma. 

Overall, the Atlas was perceived by the participants as a tool with high potential impact: it was perceived positively, because it makes systematically available data that were previously not accessible, but also with risks, because it contains complex information that could be misinterpreted and may cause alarm.

Stakeholders agreed that the Atlas is primarily targeted at advanced users and decision-makers, including not only politicians, but also citizens engaged in public debate, with the goal of guiding decisions. Nonetheless, since the Atlas will be publicly available to everyone, it is essential to ensure its readability even for a general audience, through explanatory materials and tailored communication strategies.

The Atlas should aim to convey the complexity of the subject in a way that can be easily understood, while avoiding simplistic interpretations. The group highlighted the challenge in explaining that pollutant concentrations near or even below current legal limits, notably for PM_2.5, may still be associated with a significant number of attributable deaths. This is a major problem in the relationship between institutions and citizens, in which different interests must be kept together, the acceptable level of risk has been agreed and this should be communicated without generating unwarranted alarm.

Discussion

In this study, the co-creative approach was adopted for the development of the Air and Health Atlas, which involved stakeholder and citizen representatives to define both content and communication strategies. Stakeholders were identified and engaged using the thermometer, a method that starts from the objectives of the product to be developed and from the contribution that is expected from the stakeholders to identify roles, interests, and point of view that should be included. Both the health and environmental sectors were included to assess their information needs and enhance the effectiveness of communication on a complex topic such as the impact of air pollution on human health. The engagement process included qualitative interviews and questionnaires, as well as participation in two focus groups. These activities led to the identification of four main thematic areas of greatest interest, which guided the discussion about the strengths and weaknesses of the Atlas, as well as the contents that were missing or that should be modified. The analysis also highlighted areas of convergence and divergence among stakeholders concerning communication providing valuable insights for the design of more targeted and inclusive communication strategies.

In recent years, the need to actively involve non-experts, including citizen representatives and other stakeholders, in decision-making and communication processes related to air pollution and human health has become increasingly evident. Recent literature shows that structured stakeholder engagement not only improves the effectiveness of communication formats, but also allows for a more appropriate response to the information needs, expectations, and interests of non-specialist communities.¹⁰ In the field of environmental epidemiology, communicating the relationships between pollutant exposure, health outcomes, and associated risks to the general population represents a complex challenge, in which both the content of the message and the communication approach, as well as data representation methods, play a crucial role.¹¹ 

In recent years, there has been a significant increase in projects promoting the active involvement of non-experts in environmental epidemiological studies, recognizing the added value of participation in both the production and communication of scientific evidence.^12,13 In Italy, the experiences most frequently described in the literature concern citizen involvement in the conduct of studies, commonly referred to as citizen science, such as the epidemiological investigations carried out within the European CitieS-Health project, in which citizens participated in the collection of health and environmental pollution data.¹⁴ 

The Air and Health Atlas differs from other experiences, as the central focus of the co-creation process was the community information needs and how information should be conveyed to ensure effective communication. The dialogue among stakeholders, particularly between decision-makers and citizen representatives, reflected the broader political debate between institutions and citizens. Several of the main themes that emerged developed along with this dialectical dualism, including the need to avoid generating unjustified alarm, the distinction between compliance with legal exposure limits and the resulting health impacts, and the need for transparency, which ultimately led to abandoning the differentiated approach of presentation for technical audience and the general public.

One of the main challenges of co-creation processes applied to the development of scientific products, even when oriented toward public communication, concerns the preservation of methodological rigor. Core technical elements, particularly those related to best estimates of dose response relation between exposure and outcome, the best mathematical models to obtain attributable deaths, are not suitable for co-creation with non-expert users, because they require specialized expertise and compliance with established standards of scientific validity. This underlines the need of clearly define, since the very beginning, the scope of co-creation with all involved participants. Furthermore, the final product must maintain transparency in communicating which choices are based on expert consensus and which are grounded in shared decision-making with end users. This distinction, applied both during the development phase and in the presentation of the final product, can help ensure scientific credibility within a co-creative process.

In the Air and Health Atlas, limits in data availability, quality, and updating, as well as the accuracy of dose-response functions, restricted the content and communication objectives that could be addressed through co-creation. A significant example concerns paediatric outcomes, which, although identified as a priority by users, could not be included in the Atlas. This exclusion, with asthma being a notable example, does not reflect a lack of evidence for a causal relationship between air pollution and health outcomes, but rather the current inability to robustly quantify these effects using routinely collected, nationwide data required for the development of the Atlas.

An issue that emerged relates to the initial project constraints, since the co-creation process started after funding had been awarded and overall objectives had already been defined. This setting inevitably limited the scope for integrating some of the proposals that emerged during the early stages of stakeholder engagement. However, these constraints were gradually understood by participants and, during the second focus group, where a semi-structured version of the Atlas was presented, a constructive approach prevailed, focusing on improving the proposed product rather than criticizing the non-inclusion of some initial suggestions.

A further challenge relates to the risk of stakeholder overload, as stakeholders are often involved simultaneously in multiple initiatives, frequently without coordination and with overlapping objectives. This risk has increased in recent years, as many European Union-funded projects require stakeholder engagement either as an indicator for impact evaluation or as a mandatory component of project coordination. Such an overload may undermine the quality and continuity of engagement. In this context, the decision to limit engagement to the regional level represented a partial but effective solution, reducing the concentration of initiatives targeting the same actors and fostering more informed participation. Moreover, the Atlas foresees the establishment of regional ‘control rooms’ to coordinate the use of Atlas data in the development of local policies; therefore, the regional scale is likely to best reflect its final use and impact.

Engaging citizens and non-institutional end users through associations rather than on an individual basis presents both advantages and limitations. From one perspective, this approach facilitates interaction with citizens who are generally well informed and already aware of environmental and health issues, leading to more focused contributions. On the other hand, it may reflect a relatively high level of expertise, with the risk of not fully addressing the information needs of the less engaged general population.

The application of this co-creative approach taught several lessons, some of them had significant impact on the final structure of the Atlas, while other could be useful for future experiences of public involvement:

• It is necessary clearly distinguishing what is defined by scientific consensus, what reflected user participation, and what was constrained by technical limitations or gaps in available data. This distinction clarifies which are the objects of discussion by the stakeholder, supports transparency, and allows the final users to understand the confidence and scope of the evidence provided;
• Engaging stakeholders at the regional level enabled a more focused and practical process, allowing interaction with concrete examples and local data, which could increase the approach’s relevance and applicability in other regions;
• Two differentiated interfaces for experts and the general public can decrease transparency and undermine the trust on the tool;
• Stakeholders contributed actively to both the textual content and graphical representations, often providing targeted questions and clarifications that improved precision and usability;
• Throughout the process, attention was given to communication tone: information must be presented in a neutral, clear manner, avoiding unnecessary alarmism;
• The co-creation process can be effective only if a balance between scientific rigor and user input is maintained.

Conflicts of interest: none declared.

Funding: Project implemented with the technical and financial support of the Ministry of Health – PNC PREV-A-2022-12376.

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