3 Participatory design for and with patients with low health literacy 55 to adequately represent the concept’s core functions and interaction scenarios. A combination of paper and video prototype would be more effective in communicating the concept toward people with LHL than paper-based prototypes alone (Maceviciute et al., 2019; Zwinderman et al., 2013). Videos have proven to be an effective tool in other intervention research and design efforts for asthma patients with LHL (Olanrewaju, 2014; Sobel et al., 2009). 3.2.3 Participants and recruitment The participants involved in the study included patients with asthma who have LHL and stakeholders. Patients with asthma and with LHL (n=5) were recruited by the first author and an HCP working in a disadvantaged neighborhood in The Hague, Netherlands. Qualitative and explorative approaches that aim to develop a pragmatic and in-depth understanding of a small number of participants have been argued to be effective in research approaches where not the generalizability, but the values, beliefs, and attitudes of individuals are central. This benefits the study by allowing for more flexibility and in-depth investigation of the included participants (Johnston & Johnston, 2013; Sandelowski, 1996). The patients were purposively sampled based on a selfreported diagnosis of asthma, being prescribed medication, and a subjective health literacy assessment based on the person’s characteristics (e.g., migration background, occupation, educational level, and cognitive disorder) by the involved HCP. We decided to not objectively assess participants’ health literacy as this was likely to be perceived as stigmatizing and imped building a trustful relationship. The first and second authors also recruited other stakeholders, consisting of respiratory nurses (n=5), health literacy experts (n=2), design experts (n=3, TD, NRH, VTV), and eHealth researchers (n=4, NHC). These stakeholders were selected because they had a long-standing experience with treating asthma, people with LHL, or participatory design methodology. We recruited 5 “language ambassadors” through an expertise center in health disparities to evaluate the final concept. 3.2.4 Ethics approval The study protocol was cleared by the Ethical Committee of the Leiden University Medical Center (approval number: P18.158). Informed consent was obtained prior to study participation. If written informed consent could not be given, participants provided verbal informed consent, which was recorded.
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