62 Chapter 3 3 approach also allows to adapt and align research methods if judged inappropriate. Second, participatory methods can also bridge the gap between researchers and participants by creating a more equal and collaborative environment. This can help reduce distrust, friction, and misunderstanding that can arise due to differences in social, cultural, and economic backgrounds. Finally, a participatory design approach is iterative, which allows multiple engagements with the end user. This benefits the development of rapport and mutual trust between researcher and participant, which is known to be a strong facilitator for participant retention (31). Nevertheless, participatory design is still seldom applied in intervention design among people with LHL. Only a few examples exist of participatory design studies on people with LHL (32,33). The time, resource, and skill intensity of such a process, in combination with its results being difficult to generalize, decrease the attractiveness of the approach (34), and evidence regarding why and how to conduct such an approach in intervention design is falling short (35). In addition, effectively involving disadvantaged groups, such as people with LHL, in research efforts is challenging. It has been marked by several barriers, such as participants having difficulties understanding the content of the study (36), finding it difficult to think in abstract terms (37), language or literacy problems (36), anxiety toward research or the research team (38), feelings of stigmatization (39,40), and limited exposure to technology and internet (41). While participatory design methods have the potential to overcome these barriers, the scientific literature is unclear about which forms of participatory design can be used to develop eHealth (35). Consequently, there is also no clear methodology on how to involve people with LHL in the participatory design process of an eHealth intervention. Hence, the aim of this paper was to demonstrate how participatory design can be used to design an eHealth intervention that fits the needs and preferences of people with LHL. We present the development of an asthma medication adherence intervention for people with LHL to illustrate our approach. Methods The study was conducted between February and September 2019. The study was framed under the five stages of design thinking by Hasso Plattner Institute of Design (42) and consisted of the following stages: (1) empathize to understand the user, (2) define to analyse and interpret the data, (3) ideate to explore and identify innovative solutions, (4) prototype to explore feasibility and develop a research instrument, and (5) test to evaluate usability and acceptance of the prototypes. While defined as distinct modes, in practice, the stages are iterative. This allows the researcher to reflect on previous activities and incorporate knowledge from the different stages. Figure 1 displays an overview of the overall design process. It shows how the five design thinking stages were structured across two major design iterations, including design activities used and outcomes generated. Throughout this paper, we distinguish between the three participatory design activities and the other generic
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