61 Designing with and for people with limited health literacy 3 Introduction Over the past decades, digital health (eHealth) interventions have been developed to support self-management. Such interventions can combine patient monitoring and education and include multiple behaviour change strategies (1-5). Examples of such applications are SMS text messaging systems to reinforce self-management skills, pill boxes generating alert messages when medication is missed, and interactive voice responses (6). One specific group of people that would benefit from such interventions are people with low health literacy (LHL). A large-scale survey showed that, in Europe, nearly half of all adults reported having problems with health literacy (7). People with LHL have problems obtaining, processing, and understanding basic health information and communicating their needs to healthcare professionals (HCPs) (8). Furthermore, LHL is associated with lower patient activation. Patient activation refers to the “knowledge, skills, and confidence” of a person in managing their health and has also been called the “mindset” needed to change behaviour (9-11). This is amplified by the fact that people with LHL have differentiating illness perceptions and beliefs about their medication (12-15). As a result, they experience difficulties in following treatment recommendations, for example taking medication as prescribed (16-18). Approximately 50% of the people taking medication for chronic illnesses such as chronic obstructive pulmonary disease, diabetes, or cardiovascular disease are considered non-adherent (19). Medication non-adherence has a significant impact on patients’ quality of life and has been shown to lead to poor health outcomes and increased use of healthcare services (20). Medication adherence in patients with asthma is consistently low, which results in unfavourable health outcomes such as an increase in experiencing symptoms and hospitalization (21). Previous reviews have shown promising results on the effectiveness of eHealth interventions to enhance patients’ adherence to asthma medication (6,22-24). Yet, these interventions are mostly designed for patients with sufficient motivation, health literacy, and selfmanagement skills and fail to address the needs, skills, and preferences of patients with LHL. Within the design domain, it is acknowledged that involving users in the design of eHealth interventions facilitates alignment with their needs and preferences. Besides action- and community-based approaches (25), participatory design and its methods are increasingly receiving attention. These approaches are based on the notion that when users are involved in the design and development of interventions, they are more likely to be successfully adopted (26-28). Participatory design could uncover potential reasons for non-use and allow designers to discover, through their participants, how technologies could be acceptable and engaging (29). Participatory design is human centred and especially useful in the context of LHL. First, participatory methods are visual, interactive, and concrete. This benefits people who have difficulties thinking in abstract terms or who have language barriers to understand and engage with the process (26,30). The flexibility of a participatory
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