Co-designing digital health for older adults: a practical guide to effective engagement

1. The Core Problem: Where Digital Tools Misunderstand Older Adults

Digital health tools frequently fall short for older adults. Barriers such as limited digital literacy, accessibility issues, and interfaces not designed for age-related cognitive or sensory changes often hinder effective use (Wilson et al., 2021). This creates a significant gap, leaving a crucial demographic underserved by innovations meant to improve health.

While co-design—involving older adults directly in the development process—offers a powerful solution, its full potential is often hampered. A systematic review by Cole et al. (2022) highlighted that while older adults are engaged in co-design of electronic healthcare tools, significant reporting gaps limit the reproducibility and scalability of successful approaches. This inconsistency makes it difficult to generalize findings, apply effective strategies universally, or build upon previous work. Without clear, comprehensive documentation, the field struggles to learn and improve.

Many digital health initiatives describe their design processes without clearly linking them to user outcomes, leading to tools that may not truly address user needs. This disconnect between design intent and practical application underscores the critical need for ongoing evaluation, adaptation, and, most importantly, transparent reporting of co-design efforts.

To truly empower older adults, digital health tools must evolve beyond mere functionality. They require an iterative, user-centered approach that incorporates feedback throughout development, fostering a sense of ownership and engagement. Addressing the barriers faced by older adults in digital health demands a complex strategy, prioritizing strong co-design and ensuring comprehensive, reproducible reporting.

2. The Co-Design Fix: A Practical Framework

Co-design offers a powerful mechanism to bridge the digital divide for older adults by directly involving them in the development of digital health tools. This approach ensures solutions are not only usable but also genuinely useful, addressing the unique cognitive and sensory needs that often go overlooked.

Three Pillars of Inclusive Co-Design:

• Tailored Engagement: Older adults frequently experience age-related changes in vision, hearing, and cognitive processing speed. Effective co-design must account for these, employing strategies like larger fonts, simplified interfaces, and auditory feedback to enhance usability and accessibility.
• Active Integration & Inclusive Facilitation: The active integration of older adults in the design process is paramount. Darley et al. (2022) provide valuable methodological guidance for conducting digital co-design sessions with older adults, emphasizing facilitation techniques that accommodate varying literacy levels and promote inclusive participation.

Pre-Session Tech Check: One key technique is the 'Pre-Session Tech Check,' where a facilitator contacts the participant a day before the session to test the software, microphone, and camera. This proactive step reduces anxiety, troubleshoots technical issues in advance, and ensures participants feel comfortable and prepared to contribute.

Anchoring Language: Another crucial technique is using 'Anchoring Language.' Facilitators avoid jargon and relate digital concepts to physical-world analogies. For example, describing a 'menu' as a 'list of choices at a restaurant' or a 'folder' as a 'filing cabinet' helps ground abstract digital concepts in familiar experiences, making them more accessible.

Literacy Checks: Incorporating 'literacy checks' ensures that instructions and materials are understood. This might involve asking participants to rephrase instructions in their own words or using visual aids to confirm comprehension, fostering an environment where all voices can contribute meaningfully.

• Community-Based Participatory Models: Beyond individual sessions, community-based participatory design models offer promising frameworks. Van Velsen et al. (2015) developed a participatory design framework for a community-based frailty detection and prevention service, showing that incorporating older adults and care stakeholders from the earliest design phases surfaced implementation barriers that top-down approaches consistently missed. This ensures tools are not only user-friendly but also address real-world health challenges, increasing adoption and effective utilization.

By integrating these layers, co-design becomes more than a token gesture it becomes a critical mechanism that taps into lived experiences, ensuring digital tools align with users' needs and capabilities. This iterative feedback loop allows for continuous refinement, enhancing usability and fostering a sense of ownership among older adults, which is crucial for long-term engagement and adherence to digital health interventions.

3. Execution Checklist: 5 Steps for Your First Co-Design Session

To ensure your co-design sessions with older adults are effective, inclusive, and contribute to reproducible outcomes, follow these actionable steps:

• Define Your Focus & Scope:

Clearly articulate the specific problem your digital tool aims to solve for older adults.

Identify the key features or aspects of the tool you want to co-design in this session.

Set realistic expectations for what can be achieved, focusing on specific feedback points rather than broad concepts.

• Recruit & Prepare Participants Thoughtfully:

Recruit a diverse group of older adults, considering varying levels of digital literacy, health conditions, and cultural backgrounds.

Conduct a Pre-Session Tech Check (Darley et al., 2022) with each participant a day or two before the session. Confirm their access to the necessary technology (internet, video conferencing software, microphone, camera) and troubleshoot any issues. This significantly reduces pre-session anxiety.

Plan and communicate fair compensation for participants' time and expertise. This is crucial for equitable recruitment and demonstrates respect for their contribution.

Send clear, simple instructions in advance, including a reminder of the session's purpose and what to expect.

• Facilitate for Inclusivity & Clarity:

Start with a warm welcome and clear introductions. Establish a safe, non-judgmental environment.

Use Anchoring Language (Darley et al., 2022) to explain digital concepts, relating them to physical-world analogies. Avoid jargon.

Employ visual aids and demonstrations. Show, don't just tell.

Actively encourage participation from all individuals. Use open-ended questions and allow ample time for responses. Be patient and listen attentively.

Incorporate 'literacy checks' by asking participants to rephrase instructions or concepts to ensure understanding.

• Document Systematically & Comprehensively:

Assign a dedicated note-taker or use recording (with consent) to capture all feedback, observations, and suggestions.

Document not just what was said, but also how participants interacted with the tool, their body language, and any points of confusion or delight.

Essential Elements for a Reproducible Co-Design Report:

Participant Demographics: Age range, digital literacy levels, relevant health conditions, prior experience with similar tools.

Session Context: Date, duration, location (physical/virtual), number of participants, facilitator details.

Co-Design Activities: Detailed description of tasks, prompts, and materials used.

Key Findings & Insights: Specific feedback, identified pain points, suggested improvements, and unexpected observations.

Methodological Adaptations: Any changes made to the session plan due to participant needs or technical issues.

Outcomes & Next Steps: How the feedback will inform design iterations, and plans for future co-design sessions.

Challenges & Limitations: Acknowledgment of any difficulties encountered during the session or limitations of the findings.

• Iterate & Communicate:

Analyze the collected data promptly. Identify common themes, critical issues, and innovative suggestions.

Translate findings into actionable design changes for your digital tool.

Communicate back to participants (if feasible) how their input has influenced the design. This fosters trust and encourages continued engagement in future iterations.

* Plan for subsequent co-design sessions to test revised prototypes, ensuring continuous refinement based on user feedback.

By moving beyond tokenistic inclusion and adopting a systematic, well-documented co-design process, developers can create digital health tools that are not only usable but truly empowering for older adults. This commitment to rigorous methodology and transparent reporting is the key to closing the digital divide and advancing the entire field.