The co-design workshops were conducted in Gondar City, northwest Ethiopia, between February 2024 and July 2024. Gondar City has approximately 300 000 residents and is served by approximately 150 CHWs based in one of 30 government health facilities. Workshops were held in the meeting hall at the College of Medicine and Health Sciences, University of Gondar, Ethiopia.

Ethiopia has a three-tier healthcare delivery system comprising primary, secondary, and tertiary levels. The primary level includes primary hospitals, health centres, and health posts. Health centres provide preventive, promotive, and basic curative services and oversee several affiliated health posts within their catchment areas. Health posts function as the first point of contact for community-level services and are staffed by CHWs, locally known as health extension workers (HEWs). These facilities focus primarily on health promotion, disease prevention, and selected basic curative services. Secondary and tertiary levels consist of general and specialised hospitals that provide more advanced diagnostic and clinical care.²⁸

This study was conducted within the primary health care system and involved health posts and their supervising health centres. The communities served by the primary health care system include rural, urban and peri-urban populations largely dependent on agriculture, small-scale trade, and government service. Many households experience economic constraints, including low and unstable income and varying degrees of food insecurity.

Educational attainment differs across population groups, with lower levels of formal education more prevalent among older adults and rural residents. The majority of the population in Gondar City belongs to the Amhara ethnic group, and Amharic is the primary language spoken.²⁹

Administratively, Gondar City is organised into 6 sub-cities and 23 kebeles, which represent the smallest administrative units.²⁹ Community health workers in Ethiopia are government-employed HEWs who are recruited from the communities they serve. They are required to have completed at least secondary education and undergo formal pre-service training under the national Health Extension Program. Their responsibilities include delivering health promotion and disease prevention services, supporting maternal and child health programmes, promoting environmental sanitation, and implementing selected NCD prevention and control activities. Services are delivered primarily through health posts and community outreach, including household visits within designated catchment areas.¹⁴

A qualitative participatory action research design was employed using the Health CASCADE’s PRODUCES framework. The PRODUCES framework is a structural participatory approach that supports collaborative intervention co-design through iterative engagement with users and stakeholders. Developed by the Health CASCADE expert network, it provides a rigorous scientific methodology for co-creation research in public health. The framework provides a systematic process for identifying priority topics, generating contextually relevant solutions, and refining intervention components through participants’ feedback. This framework comprises seven components: Problem, Objective, Design, User, Co-creators, Evaluation, and Scalability, to frame the study’s aim (Table 1).^27,30,31 In this study, the framework guided the co-design process, and its application is summarised in Table 1.

The co-design process was conducted in three phases, consisting of seven steps each with specific aims, activities, and deliverables (Table 2).³¹

The planning phase consisted of two steps: establishing the research team and resource planning (Step 1), followed by participant recruitment (Step 2). The team undertook the literature review, drafted the rationale of the project, finalised the methodology and sought human research ethics approval. Several meetings among the research team established an understanding of the co-design process.

The study population in this co-design research is broader and includes all stakeholders actively engaged in the intervention development process. Although this study primarily aimed to develop an intervention to support CHWs, and CHWs therefore constituted the main study population, stakeholders within the community and health system were also included because of the participatory nature of the co-design approach. Therefore, the study population comprised key stakeholders directly involved in or affected by community-based NCD health promotion, who were engaged as active partners in the intervention’s co-design. A total of 16 co-design participants were recruited for the co-design workshop, consistent with the recommended 10–12 sample size for co-creation studies, which is in line with the recommended co-creator sample for participatory co-creation research.³⁰ We included currently working CHWs who were available to attend three workshops:

After potential participants expressed interest, they were provided with the Participant Information Sheet and allowed time for questions. We obtained written consent once a participant was satisfied with the information.

Three face-to-face workshops, separated by 1 week, were conducted in phase 2 and facilitated by the primary researcher. The same participants from workshop 1 were invited to participate in workshops 2 and 3. All co-design workshops were conducted in the local language (Amharic). Each workshop was organised into three main components: introduction, group activities, and consensus building. The activities undertaken during the co-design workshops are presented in Table 3.

Participants were welcomed and briefed on the co-design process, the workshop’s goals and activities. Each workshop lasted approximately 2.5 h - 3.0 h, including a 20-min break. The co-design workshops were conducted using the ‘world café’ approach, a structured participatory method that facilitates collaborative dialogue through small-group, rotating discussions. In this format, participants engage in focused conversations around specific guiding questions at different tables in the same room, building on ideas generated in previous rounds and collectively refining priorities and solutions.³² A researcher was positioned at each table to take notes and record discussions. The workshops were designed using a world café co-design methodology, in which participants engaged in small-group discussions simultaneously within a shared space. Under these conditions, audio-recording was not feasible, as overlapping conversations would have rendered recordings difficult to attribute accurately to specific groups and challenging to transcribe meaningfully. Artefacts from the co-design workshops were generated on poster-sized sticky notes and organised using Miro software. After identifying and collecting all relevant materials, the artefacts, together with discussion notes, were thematically categorised using NVivo software (Version 14) (QSR International Pty Ltd, Massachusetts, United States [US]). A summary of workshops’ aims, guide questions and activities are presented in Table 3 and Online Appendix 1 Figure 1-OA1.

Data were collected through three participatory co-design workshops. The workshops were conducted as group-based qualitative discussions rather than individual interviews. This is in line with other co-design studies. An open-ended workshop facilitation guide, developed by the research team and informed by the PRODUCES framework, was used to structure discussions and participatory activities. Data sources included artefacts generated during the workshops, such as written responses on sticky notes, flipchart summaries, structured workshop tasks, and detailed discussion minutes from in-depth group discussions.

In this study, rigour was maintained through the application of the PRODUCES framework, developed by the Health CASCADE expert network, which provides systematic guidance for participatory co-creation research in public health. The framework outlines stages for identifying priorities, generating contextually relevant solutions, and refining intervention components through iterative participant engagement. We followed this approach to ensure the study’s transparency, credibility and trustworthiness. In addition, workshop discussions and artefacts were systematically documented and analysed to determine how participant contributions were generated, refined, and translated into intervention components.

A process evaluation was embedded within the co-design study. This co-design process was evaluated through a short survey adapted from the guide to co-creation,³³ to assess participants’ satisfaction with the co-design approach, the relevance of discussion topics, their level of engagement in the process, the value of their input, and the applicability of the proposed intervention for improving NCD health promotion in communities (Online Appendix 1 Table 1-OA1). The evaluation was conducted at the end of workshop 3 and lasted 15 min.

Data analysis was conducted using a qualitative thematic analysis.³⁴ We followed a five-step data analysis process. (1) We collected all relevant artefacts produced in each workshop; (2) Artefacts were then organised using Miro software (Online Appendix 1 Figure 2-OA1), and discussion notes were transcribed into English, and then exported to NVivo software for further analysis; (3) Using NVivo software, relevant information was extracted from notes; (4) The extracted information was analysed thematically. These themes were systematically organised into intervention outcomes and contents; (5) we reported a summary description that aligned with each workshop’s aims. Data on the experience of participants in the co-design process were analysed using descriptive frequencies.

Ethical clearance to conduct this study was obtained from the Human Research Ethics Committee of University of Southern Queensland (approval no.: ETH2023-0851) and University of Gondar (No. CMHSH R/C/TT/06/02/57/01/2016). Workshop participants were informed about the study, its nature and procedure. Written consent was taken and participants were informed that their involvement in the workshop was voluntary and will not have negative impact on their work or health service from the health system. We ensured the privacy and confidentiality of all participants throughout the study. As there were diverse participants, we recognised the potential for unequal power dynamics in our workshop. To address this, participants were informed that their perspectives are equally valued, and respected. Furthermore, the researcher created an inclusive space for all participants to ensure equal participation.

Participants’ number and characteristics are presented in Table 3. The same participants attended workshops 1, 2 and 3.

Participants acknowledged that CHWs were providing health education, promotion, screening, and referral services. However, participants indicated the irregular delivery of these services and highlighted the need to empower CHWs to undertake these roles effectively via capacity-building intervention.

Participants identified five primary roles for CHWs in promoting NCD health within their communities: (1) raising NCDs and healthy lifestyle awareness (health education and promotion); (2) conducting community-based NCD screening; (3) referring individuals for diagnosis and follow-up, when necessary; (4) supporting medication adherence for community dwellers with NCD diagnoses; and (5) reporting health outcomes and performance.

Four main desired outcome measures were identified for the capacity-building intervention: (1) improving CHWs’ knowledge of NCDs and healthy living; (2) developing their practical skills in meal planning and preparation, physical activity, and communication; (3) capacity for facilitating behaviour change to increase duration of physical activity and consumption of a healthy diet; and (4) application of knowledge and skill within communities. In addition, participants also indicated that CHWs could serve as role models for healthy diet and physical activity and should be included in outcome measures.

The final intervention programme, ‘Empower Community Health Program’, was drafted, which includes multifaceted intervention components. Participants prioritised the following intervention topics: (1) learning about NCDs, nutrition, and physical activity; (2) skill development in healthy meal preparation and motivational interviewing; (3) behaviour change for a healthy diet and physical activity; and (4) community application of knowledge and skills (Online Appendix 1 Table 2-OA1). For the delivery of the intervention, participants generally agreed that it should include both theoretical and practical components. Participants discussed the application of training within communities and finally agreed that CHWs should be first trained to deliver the programme. Participants named the intervention ‘የማህበረሰብ ጤና ማሻሻያ ስልጠና’ in the local language, translated by the research team as ‘Empower Community Health’.

A blended learning approach that combines in-person interactive sessions with practical demonstrations was preferred. In addition, interactive training sessions with case scenarios were highlighted as an effective method to encourage engagement. Participants suggested using social media platforms, such as Telegram, to enhance accessibility. Some argued that potential internet connectivity issues could challenge its implementation. Regarding the delivery language, all groups unanimously agreed to deliver the intervention in English and Amharic (the local language). The preferred intervention duration and frequency varied among groups, ranging from 4 weeks to 6 weeks. The programme was designed to be delivered over 6 weeks, with one session planned for each week (Table 4).

Each week, the programme covers a range of topics from understanding NCDs and healthy lifestyles to practical skills such as meal planning, physical activity, and behaviour change strategies.

Overall, participants were satisfied with the co-design process. Engagement levels were generally positive, and the workshop enhanced their understanding of the co-design. Most participants felt their contributions were valued; six felt their input was appreciated, while two were neutral (Figure 2).

The study utilised the PRODUCES framework using the Health CASCADE network to guide the development of the capacity-building programme for CHWs. The framework is a structured participatory guideline that emphasises stakeholder engagement and is a useful tool for co-designing health interventions. We included diverse participants, collaborated to identify their intervention needs and content, and shaped the intervention programme. Although the study involved end-users, consumers, and key stakeholders, the study cannot be generalised to other countries. The intervention developed in this study may not be globally applicable; however, the process provides a framework for future low- and middle-income countries research that seeks to co-design interventions for CHWs. Furthermore, including diverse participants in our co-design process allows a wide range of views in the process.

This study demonstrated the methodological value of using a co-design approach in developing interventions for CHWs. By actively involving intervention users, community members with and without NCDs, and health system stakeholders, the co-design process ensured that the intervention was tailored to local needs, preferences, and context. Previously, interventions for CHWs were primarily developed by researchers with limited involvement from intervention users, consumers and stakeholders. The co-designed intervention, ‘Empower Community Health’, was developed collaboratively with users, consumers and health system stakeholders to build both theoretical knowledge and practical skills for promoting healthy lifestyles and preventing and managing NCDs within Ethiopian communities. This programme has the potential to strengthen CHWs’ capacity to deliver community-based NCD health promotion and aligns with the WHO’s task-shifting strategy, which promotes the delegation of selected NCD services to CHWs. Methodologically, the study shows that co-design is a feasible and rigorous approach for creating CHW-focused interventions, offering a model for future public health research seeking to integrate experiential knowledge with evidence-based practice. Furthermore, this study provides practical guidance for researchers and practitioners seeking to co-design similar health promotion programmes tailored to local context and health system.