Co-Design in Action: Engaging Children, Families and Schools in Program Development

Abstract Background Co-designing health literacy (HL) and health promotion interventions with families, teachers, and health professionals can significantly improve relevance, legitimacy, and sustainability. The BeE-school project provides a school-based example of how participatory methods and behavioral theory can be applied to develop contextually adapted and culturally responsive HL interventions. Methods Drawing on the UK Medical Research Council's (MRC) framework for complex interventions, BeE-school placed particular emphasis on understanding context, engaging stakeholders, and iteratively refining the intervention. Early in the process, contextual challenges were identified through six focus groups which allowed the team to align the intervention with the sociocultural realities of children, families, and school professionals. These insights guided the co-creation of realistic, actionable strategies adapted to school routines and values. Results Stakeholder involvement was central. Children aged 6-10 were active contributors, not just recipients, shaping content, language, and design features, including the character “BeE,” a symbolic and emotional prompt designed to foster motivation and adherence. The refinement process was continuous and systematic. The final intervention included teacher training, classroom activities, and take-home family challenges. Feedback collected during the health promotion action informed real-time adaptations and led to the production of an open-access e-book to support dissemination and scalability. A cluster randomized trial with 735 children evaluated the effectiveness of the program. Conclusions The inclusion of stakeholders was an innovative step that brought creativity and legitimacy to the intervention. Findings demonstrate how participatory, theory-driven design, grounded in real-world school contexts, can enhance both the feasibility and impact of HL interventions.