Methods

Participants

Purposive sampling was used to identify participants for these workshops. As part of a wider project, recruitment was initiated through Sláintecare Healthy Community Local development officers, working with communities in rural (Mayo) and urban (Finglas and Cabra) areas to recruit participants with lived experience of the health literacy strengths, needs and issues encountered in the Sláintecare Healthy Communities focus areas.

The stakeholders were specifically invited to involve a representation of the different demographics, local authorities and a range of experiences, in each respective case study area, this included participants who had previously been involved in earlier phases of the wider project and had indicated a willingness to continue their participation [16]. Stakeholders were contacted via telephone and/or e-mail and invited to register online for the workshop in their respective area. To actively mitigate inherent power asymmetries between institutional service providers (e.g., HSE medical staff, local authority executives) and service users (e.g., community members, marginalised groups), precise structural safeguards were embedded directly into the workshop architecture. Phase One utilized homogeneous groupings (same-stakeholder tables) so that participants could safely debate and define their lived experiences without risk of being overridden by institutional authority figures. Each table was overseen by a neutral academic researcher trained in participatory research methods. Facilitators utilized a semi-structured guide containing explicit prompts to distribute airtime equitably, disrupt dominant narratives, and amplify quieter voices. The ultimate prioritisation step used physical dot voting (dotmocracy), decoupling the merit of an initiative from the institutional or social status of its advocate. Despite these mitigations, certain systemic limitations to participation persisted. Due to localised transport deficits in rural regions and technology requirements for online pre-registration, highly isolated individuals, transient populations, and those experiencing extreme socioeconomic exclusion were underrepresented, with community agency advocates stepping in to voice their perspectives. All participants gave informed consent to take part in the study. Ethical approval was granted by Dublin City University (DCUREC/2023/156), and this study was carried out in accordance with this approval, and in line with the Standards for Reporting Qualitative Research (see supplementary material).

Overview

Two co-design workshops took place in March 2024, one in each case study area. At the start of the day, participants were provided with written information on the project to date (this included two options: a one-page summary, and/or a more detailed five-page overview). A brief presentation was delivered at the start of the day, which provided a description of the different work packages undertaken of the wider project which highlighted some key considerations. The presentation finished outlining the aims of the co-design workshop process and the format of day.

The DDDA was selected over other participatory methodologies (e.g., traditional focus groups or Delphi panels) because its structural alternating phases of divergent and convergent thinking are uniquely optimised for resolving complex, multi-stakeholder healthcare issues. It ensures that systemic root causes are explored extensively before narrowing down to practical solutions. In this study, the original British Design Council model was adapted to accommodate a time-constrained single-day format, this included retaining to core components of Discover (diverging to map challenges), Define (converging on core priority issues), and Develop (diverging to brainstorm solutions), and Deliver (converging to select final actions).

An adapted DDDA was divided into three phases with one or more tasks per phase (outline; Fig. 1). Within each phase, stakeholders worked in the same stakeholder groups (e.g. physical activity promotion) or mixed stakeholder groups. All discussions were recorded via Dictaphones on each table. Stakeholders were allocated to mixed stakeholder groups, ensuring at least one member from each of the initial same stakeholder groupings were present in each group (See Table 1). Dependent on attendance numbers, in some cases more than one member of the initial same stakeholder group may have been present in the mixed stakeholder group. In Mayo, owing to travel disruption, the decision was made to combine two similar, same stakeholder groups to maximise discussion, resulting in five same stakeholder groups. Each group had a researcher (experienced with qualitative and/or participatory research) present on their table to facilitate discussion (using a semi-structured interview guide), point towards provided resources outlining previous work, and to take notes. Flip chart paper, pens, post-it notes were provided on each table for the participants to engage with as they wished.

Fig. 1: Overview of the Adapted DDDA used within each workshop.

Mayo | Stakeholder Group | Description | Number of Participants
Group 1n = 8 | Service Provider | Community Development | 2
Service User | Language and Culture | 2
Service User | Community Service | 3
Service User | Community Member | 1
Group 2n = 6 | Service Provider | Family Services | 1
Service Provider | HSE/ Health Services | 1
Service Provider | Sport, Health and Wellbeing Services | 1
Service User | COPD Chronic Illness Community Member | 2
Service User | Community Member | 1
Group 3n = 5 | Service Provider | Sport, Health and Wellbeing Services | 1
Service Provider | Healthy Ireland | 1
Service Provider | Mental Health Services | 2
Service User | Community Member | 1
Group 4n = 4 | Service Provider | Community Development | 2
Service User | Community Member | 2
Group 5n = 7 | Service Provider | Community Development | 2
Service Provider | Public Participation Network | 1
Service Provider | Transport Development | 1
Service User | Community Older Person's Council | 2
Service User | Community Member | 1
Finglas and Cabra | Stakeholder Group | Description | Number of Participants
Group 1n = 9 | Service Provider | HSE/ Health Services | 9
Group 2n = 9 | Service Provider | Education Services | 3
Service User | Education Services | 6
Group 3n = 5 | Service Provider | Community Development Services | 4
Service User | Community Older Person's Council | 1
Group 4n = 6 | Service Provider | Drug and Alcohol Services | 2
Service Provider | Traveller Support Services | 1
Service Provider | Children Services | 1
Service User | Drug and Alcohol Services | 1
Service User | Community Development Services | 1
Group 5n = 5 | Service User | Community Member | 4
Miscellaneous | n/a | 1
Group 6n = 4 | Service Provider | Sport, Health and Wellbeing Services | 2
Service User | Community Member | 2

In Phase One, within the same stakeholder groups, the focus was to refine the key challenges to health literacy in their community. Reflecting on challenges identified previously [16], [17] participants were encouraged to reflect on the clarity and breadth of these challenges, while starting to prioritise the importance of these challenges within their local communities. Within phase one, participants were actively encouraged to avoid considering potential solutions. Moving to Phase Two, participants were asked to physically move to mixed stakeholder groups. This phase encompassed two tasks: 1) Identifying five main challenges to health literacy development in their communities and 2) Developing suggestions to support health literacy development in their communities. Participants were encouraged to consider their discussions in Phase One, the resources required to deliver on their health literacy recommendations, who this would impact, and what outcomes these recommendations could achieve. In Phase Three, participants returned to their initial same stakeholder groupings and were tasked with creating a shortlist of three potential recommendations. Phase Three condensed the Develop and Deliver components using structured table exercises, physical movement between mixed stakeholder groupings, and a rapid democratic voting technique (dotmocracy) to establish immediate community priority consensus within the session. At the end of this Phase, the researcher summarised the recommendations decided on by their same stakeholder groups, and participants were invited to vote for the recommendations they felt best achieved the aim of the brief, using a dotmocracy approach. Each participant received three votes (dot stickers) with a maximum of two votes being allowed for any one recommendation. After voting, the lead researcher concluded the day, reminded participants of how this process was fitting in with the wider project, and informed them that they would all be sent a copy of the lay summary of the project's final report.