The present study is part of a larger research project, Intellectual Disability Integrating Digital Intervention Technology for Health (I DID IT), aiming to promote the health and well-being of people with intellectual disabilities.

This study is based on post–co-design reflection meetings with a purposive sample of co-design participants examining a co-design case involving the development of a digital intervention for health promotion for people with intellectual disabilities. The analytical approach draws on a reflection-on-action practice [36], through which the process was systematically revisited and critically interrogated to inform methodological insights relevant to co-design with people with intellectual disabilities in the development of digital interventions.

The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [37] guided the reporting (Multimedia Appendix 1).

The co-design process explored in this study consisted of 17 workshops aimed at developing the concept for a digital intervention for health promotion for people with intellectual disabilities, covering the first phases of the development. The development was guided by a co-design approach [38], grounded in participatory design principles [39]. Workshop activities were structured in line with the framework for co-design developed by Sanders and Stappers [21], interpreted as a “tangled ball of yarn” illustrating the iterative and nonlinear nature of a co-design process across 4 phases (Figure 1). The framework describes 4 phases of co-design: predesign (understanding current experiences), generative (generating future solutions), evaluative (testing and refining), and postdesign (use and implementation in practice). Although the framework includes evaluative and postdesign phases, the present study focused on the predesign and generative phases, during which the intervention concept was developed.

The research team that initiated and planned the workshops consisted of a group with combined expertise in intellectual disabilities, digital health promotion, digital intervention development, digital participation, human-computer interaction, and co-design practices involving people with intellectual disabilities.

In total, 24 coresearchers aged 16 to 40 years with mild to moderate intellectual disabilities participated across different phases of the co-design process, which took place between May 2023 and November 2025 in municipal and community-based settings, as well as at a university, in southeastern and central Sweden. In the predesign phase, 18 coresearchers with intellectual disabilities initially contributed through separate workshops, while in the generative phase, 6 coresearchers with intellectual disabilities participated in a multidisciplinary co-design team involving researchers, user experience (UX) designers, and support workers. One coresearcher with intellectual disability was involved throughout the entire process.

A detailed description of the process, recruitment procedures, workshop structure, and output is provided in Multimedia Appendix 2 and in our earlier published work [40].

The primary data for this study consisted of 5 audio-recorded reflection meetings involving members of the multidisciplinary co-design team that took place in February and March 2026 in southeastern Sweden following the completion of the 17 workshops. The co-design process described above and in Multimedia Appendix 2 served as the case reflected upon. Materials used to support and structure the reflection meetings included recruitment materials, planning documents, workshop summaries, field note summaries, and design artifacts from the workshops (Table 1).

Eight members of the multidisciplinary co-design team were purposively selected to capture experiences from different positions within the process, including planning, recruitment, facilitation, coresearcher participation, and design development. The sample included researchers, UX designers, and coresearchers with professional and lived experience of intellectual disability. The number of participants was determined by the intention to include all key perspectives from members of the co-design team who remained involved in the final workshops, including a coresearcher with intellectual disability who had participated across both the predesign and generative phases. All were approached directly by the first author by email and/or telephone and agreed to participate. The meetings were held with different constellations of participants (Table 2), including 4 researchers: R1, a PhD in occupational therapy with expertise in intellectual disabilities and digital participation; R2, a PhD in human-computer interaction with expertise in cognitive accessibility, universal design, and co-design; R3, a PhD student and physiotherapist working with people with intellectual disabilities; and R4, a PhD in public health and occupational therapist with expertise in digital health interventions and principal investigator of the project. Additional participants included 1 coresearcher with professional experience working with people with intellectual disabilities (CR1), 1 coresearcher with lived experience of intellectual disability (CR2), and 2 UX designers (UX1 and UX2) with experience in digital health applications and administrative systems. The composition of the meetings was guided by the focus of each discussion. Participants were grouped based on their involvement in specific phases and activities of the co-design process to enable reflection on planning and recruitment, workshop implementation, participation experiences, and design development.

The first author of this paper, a female PhD student and physiotherapist working with people with intellectual disabilities, was primarily responsible for facilitating the reflection meetings and preparing the materials used in the reflection meetings. Prior to reflection meetings 1-3 and 5, materials from the co-design process were compiled, including recruitment materials, design artifacts, and documented insights. In addition, workshop and field note summaries were developed based on recordings, transcripts, and notes, providing structured accounts of activities, decision-making, and materials used in each session.

The reflection meetings were based on a shared experience of the co-design process in which all participants had been involved, although from different perspectives. The discussions were open and exploratory in nature, while structured around an after-action reflection approach [41]: (1) what was planned and what was the intention with this approach? (2) What actually happened during the workshops and why? (3) Why did the process unfold in this way, including adaptations and collaborative dynamics? and (4) What do these observations imply for co-design with people with intellectual disabilities? Additional prompts to support the reflections addressed decision-making, perspectives from coresearchers, power dynamics, accessibility, and necessary adaptations and were included in the semistructured reflection guide (Multimedia Appendix 3).

For reflection meeting 4, materials were adapted to support the participation of the coresearcher with intellectual disabilities. It followed a more narrative-oriented format supported by visual materials representing different aspects of the process (eg, settings, activities, time structure, and collaboration) alongside design artifacts and photographs from workshops (excluding identifiable individuals) to support recall. Visual scales were used to facilitate expressions and ranking of experiences.

All meetings were audio recorded and transcribed verbatim.

Transcripts from the reflection meetings were read several times to gain a sense of the whole. As an initial organizing step, meaning units relevant to the aim were mapped according to the first 2 phases of the co-design framework described by Sanders and Stappers [21]: the predesign phase and the generative phase. Data that did not fit meaningfully within either the predesign or generative phase, but instead cut across both phases, were analyzed separately to capture cross-phase reflections. Within each phase, the data were then analyzed inductively guided by Elo and Kyngäs [42], using Microsoft Excel. The meaning units were coded, and codes with similar content were compared and grouped into categories. In a next step, categories were further abstracted into higher-order categories corresponding to the predesign, generative, and cross-phase aspects of the co-design process. This abstraction involved moving from descriptive categories toward more analytical interpretations of patterns across the material. Table 3 illustrates examples of this process of analysis.

The initial coding and categorization were primarily conducted by EN. Throughout the analysis, categories and emerging interpretations were discussed iteratively with UM and refined through ongoing dialogue. In a later stage of the analysis, the categorization and abstraction were also discussed together with SJ and KAÅ until agreement was reached on the final category structure. These discussions also included reflexive consideration of how the researchers’ involvement in the co-design process and reflection meetings might have influenced the interpretations.

This research project involving the co-design process examined in this study was approved by the Swedish Ethical Review Authority (Dnr 2022-06682-01 and 2026-00982-02). Participants received information about the reflection meetings and were informed that participation was voluntary and that declining would not affect their continued involvement in the co-design process. Verbal informed consent was obtained before participation in the reflection meetings. Data were handled confidentially and deidentified during analysis and reporting. Potentially identifying information was omitted or generalized. No compensation was provided for participation in the reflection meetings.

In line with the analytic approach, findings are presented in relation to the predesign and generative phases of the co-design framework [21], together with cross-phase findings. Within each phase, the analysis resulted in a set of categories capturing aspects of how co-design was experienced, described below and illustrated with representative quotations. An overview of the categories for each phase is presented in Figure 2.

This study explored experiences from a co-design process involving the development of a digital intervention for health promotion with people with intellectual disabilities.

The findings indicate that the co-design process with people with intellectual disabilities involved an extensive preparatory phase requiring substantial work and suggest that enabling participation begins well before collaborative design activities commence. Recruitment did not involve direct access to potential participants. Instead, access was preceded by an initial assessment carried out by others, such as support workers or managers, who evaluated whether the project might be appropriate for a particular person. Here, gatekeeping was understood as both facilitating access and potentially limiting who was invited to participate, as support workers could help build trust and ensure appropriate support while also shaping access to the project. This may have limited access for people with intellectual disabilities who are not already embedded in service-based contexts. This aligns with previous research [43] showing that gatekeeping practices are shaped by support workers’ attitudes, knowledge, and organizational conditions, and that access to research is often mediated by relational and contextual factors rather than direct participant choice. Recruitment therefore places particular demands on the research team, including prior knowledge of intellectual disability, familiarity with organizational contexts, and the ability to develop recruitment materials understandable and accessible to both gatekeepers and potential participants. The need to clarify the role of support workers was not limited to recruitment but also applied during the workshops themselves. Previous research has similarly emphasized that support workers need clear information about their role in co-design activities [31]. In the present study, support workers were found to be important for supporting memory, communication, orientation, and practical participation, but their role needed to be framed carefully to avoid unintentionally filtering or steering participants’ contributions.

From a theoretical perspective, the “preparatory phase” resonates with, but also extends, the co-design framework by Sanders and Stappers [21]. Although the framework visually suggests activity taking place before the formal predesign phase, the boundaries of this stage appeared less linear when co-designing with people with intellectual disabilities. Rather than a brief preparatory moment, this early phase involved ongoing learning and adaptation from the researchers’ point of view, during which decisions about when, where, and how to initiate workshops were shaped through dialogue with support workers. This finding resonates with previous co-design literature emphasizing preparatory work as a distinct and important part of co-design, including activities such as defining roles, preparing facilitation approaches, and establishing conditions for participation before design activities begin [44]. In co-design with people with intellectual disabilities, being attentive to this early, largely invisible phase may be particularly important, as it is central to creating the right conditions for engagement and supporting genuine participation [45].

Relationship-building is widely recognized as a core component of successful co-design processes, regardless of participant group, as it shapes trust and collaboration and mediates power imbalances [46-48]. In this context, relational efforts to foster togetherness and creative interaction can be understood through the concept of conviviality, defined as autonomous and creative interaction among people and their environment [49] and highlighted as a key quality in co-design [50]. Our findings, aligning with earlier studies [32], suggest that such relational work may be even more important when co-designing with people with intellectual disabilities. Previous research has shown that people with intellectual disabilities may be inclined to provide affirmative or agreeable responses, particularly in unfamiliar or hierarchical contexts [51]. In this study, what could be interpreted as conviviality appeared to be associated not only with a greater willingness to express oneself openly but also with the ability to voice critique and disagreement, also found in other co-design research [31]. The findings indicate that conviviality was shaped to a considerable extent through low-threshold interactions that occurred around the formal workshops, fostering not only familiarity but also a sense of shared belonging among participants, while also illustrating how the role of support workers may at times constrain the development of direct convivial relations between participants. This suggests that fostering convivial collaboration may require a gradual shift from reliance on intermediary support toward direct relational engagement once participation has been established.

Although systematic evidence remains limited [52,53], simplified language and visual support are commonly used within accessible communication practices for people with intellectual disabilities. Research suggests that such support may help people express opinions and preferences when used flexibly and adapted to individual communication needs and preferences [54]. In this study, the value of using pictorial support not only for comprehension but also for comparison of different options and evaluation was highlighted, preferably in small-group discussions. From a design perspective, this made value judgments and trade-offs more visible and discussable, as ideas were considered in relation to one another rather than in isolation.

Building on this, the findings further suggest that working in a concrete and idea-based way already in the predesign phase may be particularly important when co-designing with people with intellectual disabilities. In the framework by Sanders and Stappers [21], predesign is primarily described as a phase for understanding people’s experiences in the context of their lives, building empathy, and preparing participants for later co-design activities. In the present study, participants were introduced early to design-oriented activities, with the intention of creating empathy through direct engagement with ideas rather than through abstract discussion. Activities commonly associated with the generative stage, with more focus on exploring ideas and design opportunities together [21], were used already during the predesign workshops and functioned as a means of understanding participants’ perspectives at an early stage. Rather than bypassing empathy-building, working with concrete and speculative idea generation seemed to provide an accessible way for the workshop participants to articulate experience, need, and desire that presumably might have been difficult to express through open-ended questioning alone, in line with previous findings [30,31,55]. These findings suggest that, in co-design with people with intellectual disabilities, methods typically located in the generative phase may productively be moved into predesign. Rather than viewing this as a deviation from established frameworks, it may be understood as an adaptation that aligns the design process more closely with participants’ communicative and cognitive strengths.

Co-design processes are often portrayed as time- and resource-intensive across contexts [23,33,56], also noted in this study. However, the findings suggest that time demands were not primarily related to working with people with intellectual disabilities, but rather to the nature of co-design and the research process itself, as also reported in previous disability research [57]. While additional time was needed in early phases, particularly for recruitment and preparation to enable participation, the design activities themselves did not appear to require more time than anticipated. At the same time, reflections within the team suggest that the overall duration of the process might have been reduced through further refinement of the research process, including a clearer overarching structure. Importantly, time was not experienced solely as a constraint, but as a resource that supported reflection, iteration, and a deeper understanding of participants’ perspectives. Seen in relation to research showing that many digital health solutions fail to meet accessibility needs [20], the time devoted to participatory and visually grounded design work may instead represent a responsible use of resources.

Recognizing the work of coresearchers with lived experience through compensation is an important part of co-design [58,59] and is pointed out as an important ethical consideration also in this co-design process. This is consistent with international expectations in patient and public involvement and participatory research, where contributors with lived experience are increasingly expected to be recognized and compensated for their time and expertise [60]. While not problematic in this study, compensation required careful coordination to ensure it aligned with participants’ financial situations and did not negatively affect their access to welfare benefits, a complexity of compensation in participatory research noted in previous literature [61]. This points to a broader ethical and structural tension. While funding bodies and journals increasingly encourage or require the involvement of people with lived experience as coresearchers, existing ethical review processes might not be well aligned with compensating coresearchers as paid contributors rather than as research participants receiving minor compensation. If these issues are not addressed, there is a risk that coresearchers with lived experience are either compensated at levels that do not reflect their contributions, despite performing comparable work to other team members, or that receiving wages creates personal or financial difficulties. From this perspective, questions of compensation should be recognized not only as a project-level ethical issue but also addressed as a systemic challenge for inclusive research practices.

The implications of this study are primarily methodological and draw on the participating team members’ reflections on how co-design of digital interventions can be organized to support accessibility, usability, and meaningful participation when working with people with intellectual disabilities. Based on the findings, several practical implications (Textbox 1) can be proposed for how both research and practice can be planned and conducted when involving people with intellectual disabilities. Figure 3 illustrates the findings of this study, interpreted in relation to the co-design framework by Sanders and Stappers [21].

This study is not without limitations. Although the reflection meetings included different perspectives from the multidisciplinary co-design team, only one coresearcher with lived experience of intellectual disability participated in the reflection meetings. The limited inclusion of lived-experience perspectives therefore restricts the extent to which the findings can reflect the diversity of experiences among participants with intellectual disabilities. Furthermore, as the meetings were conducted retrospectively, the findings may have been influenced by participants’ interpretations of the process and selective recall of events. At the same time, considering the focused aim on a specific case, the study was considered to have sufficient information power [62], as key perspectives were represented across the reflection meetings. In addition, participants reflected on a range of materials from the co-design process, including workshop summaries, field notes, planning documents, and design artifacts, which supported recall and helped mitigate retrospective bias. Trustworthiness was further supported through several measures guided by Kyngäs et al [63], including the involvement of researchers with different disciplinary backgrounds in discussing and refining interpretations, and transparent documentation of the analytical process.

A key methodological consideration concerns the researchers’ dual role as both participants in the reflection meetings and analysts of the material, raising concerns regarding the confirmability of the study. While this perspective provided rich contextual knowledge and supported nuanced interpretation, it also required reflexive attention to potential bias. Reflexive discussions within the research team contributed to confirmability by making it possible to question and make explicit how interpretations were developed. However, no external researcher reviewed the coding, and the generally positive reflections on how the process functioned may partly reflect the team’s investment in the work and the collaborative nature of the reflection meetings, which may have encouraged socially desirable responses. Involving an external facilitator in the reflection meetings or an external reviewer of the coding could have further strengthened confirmability. At the same time, the findings may also reflect the research team’s substantial experience in co-design and in working with people with intellectual disabilities, which likely helped anticipate and address potential challenges in advance.

Further, while the findings reflect a single, context-specific case, transferability was supported by a thorough description of the co-design process, together with interpretation of the results in relation to an established co-design framework.

Drawing on experiences from a multidisciplinary design team working collaboratively to develop the concept for a digital intervention for health promotion, this study found key considerations for co-design with people with intellectual disabilities, interpreted in relation to an established framework. The primary contribution of this study is methodological, offering insights into how co-design processes can be organized to support meaningful participation in digital intervention development. Rather than relying on preparatory user research conducted at a distance, meaningful co-design can be enabled through careful preparation, knowledge of the target group, idea-based activities early on, and sustained direct collaboration with participants throughout the process. When co-design processes are intentionally conducted, people with intellectual disabilities can gain meaningful access to the design arena. These methodological insights may support future co-design processes in which accessibility and usability are considered from the earliest stages of digital health intervention development, with the potential to contribute to more equitable access to health. As this study focused on the predesign and generative phases, continued involvement of people with intellectual disabilities will be important in later technical development, evaluation, and implementation to assess whether the intervention concept translates into practice as intended.