3 Participatory design for and with patients with low health literacy 53 literature is unclear about which forms of participatory design can be used to develop eHealth (Vandekerckhove et al., 2020). 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. 3.2 Methods 3.2.1 Study design 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 (Plattner et al., 2011) and consisted of the following stages: (1) empathize to understand the user, (2) define to analyze 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 3.1 displays an overview of the overall design process. It shows how the 5 design thinking stages were structured across 2 major design iterations, including design activities used and outcomes generated. Throughout this paper, we distinguish between the 3 participatory design activities and the other generic design activities, with a specific focus on the former to illustrate how people with LHL can be involved in a participatory design process of an eHealth intervention. We specifically chose to embed the participatory activities at the beginning (to develop an understanding) and end (to evaluate this understanding) of the design iterations. Figure 3.1 Schematic overview of the process, illustrating the different design thinking stages and their iterative character. *a participatory design activity. CS: co-constructing stories; IM: intervention mapping
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