Infectious diseases represent a public health challenge worldwide, particularly in low- and middle-income countries where their impact is most severe [1]. Participatory education is key in preventing and controlling infectious diseases because it enhances knowledge, raises awareness, and empowers communities [2]. Co-design, understood as a collaborative approach where various stakeholders, including community members, contribute to the development of interventions tailored to local contexts, also plays a crucial role in health strategies by improving health care access, reducing costs, and promoting local ownership [3-5].

This study was conducted in Pueblo Rico, a municipality in the department of Risaralda, Colombia, situated in a vast rainforest area endemic to tropical diseases [6]. Despite ongoing efforts by health institutions, infectious diseases remain a significant public health challenge in Pueblo Rico [1]. In 2022, the number of malaria cases surged to 1971; tuberculosis cases reached their highest level in 15 years, with 24 cases and an incidence rate of 113.5 per 100,000 inhabitants; and the number of cases of cutaneous leishmaniasis rose to 48 [7].

The populations mainly affected by infectious diseases are those living in rural areas, of whom 31% are Indigenous people from the Embera community, and 15.1% are people of Afro-Colombian descent [8]. All face a multidimensional poverty index of 82% [8], which heightens their risk for infectious diseases. Factors related to poverty, such as inadequate water management, poor sanitation, and overcrowding, significantly contribute to the disease burden in these areas [9]. Furthermore, the enduring impact of the armed conflict has left 5699 affected individuals in Pueblo Rico, including Embera communities recognized as eligible for collective reparations [10]. In previous studies, we have identified significant barriers to health care accessibility, limited facilities, and administrative issues within the Colombian health system [11]. In addition, low schooling levels, communication challenges, cultural conflicts between traditional and western medicine, and community mistrust of health personnel hinder effective health literacy and health-related behaviors of Embera populations [12].

We considered the characteristics of the rural population when culturally adapting the participatory audiovisual methods used in this study. Cultural adaptation refers to modifying or developing interventions to better align with the sociocultural characteristics and needs of a target population, in this case, ensuring comprehensive health education and promoting behavioral change to improve uptake, acceptance, and ultimately health outcomes [12,13]. Techniques such as dramatizations, drawings, photographs, and videos not only capture participants’ knowledge, experiences, and perspectives but also transcend language and literacy barriers, simplifying complex health concepts such as infectious disease transmission and prevention [14].

By fostering discussion and community involvement in content creation, participatory methods enhance engagement, ownership, and practical application of knowledge, making them particularly valuable in rural and ethnic communities with limited formal education and structural barriers [14]. The World Health Organization has promoted participatory approaches such as ENGAGE-TB, which emphasizes the importance of community involvement and participatory methods to enhance the reach and sustainability of tuberculosis services [6].

This study aims to describe the co-design process and evaluate the capacity building of an education program for the prevention and control of infectious diseases using participatory audiovisual methods culturally adapted to ethnic communities and rural contexts in Colombia.

This paper presents the second phase of an implementation research project designed to enhance the prevention and control of malaria, tuberculosis, and leishmaniasis in Pueblo Rico through culturally adapted interventions. The first phase involved a participatory social diagnosis to identify barriers and facilitators to disease prevention and control. The second phase, explored in this paper, focuses on the co-design of a health education program, encompassing the training process and the cocreation of workshops and audiovisual materials (Table 1). The third and final phase will involve the program’s implementation.

A qualitative case study methodology was used for its exploratory and explanatory potential in open systems where context cannot be controlled [14,15]. Case studies are widely used in social innovation research to assess the effectiveness of social and cultural strategies [16].

The co-design process involved 15 community leaders hired by the project to contribute to the design, implementation, and evaluation of the program. Participants were selected through convenience sampling, with support from social organizations and local authorities. Eligibility criteria included being aged >18 years; residing in Pueblo Rico for at least 10 years; speaking Spanish; being literate; and having experience, interest, or knowledge in health.

For the training plan, workshops, and cocreated audiovisual materials, technical consultations with experts in malaria, leishmaniasis, and tuberculosis were conducted using nominal group exercises to identify key workshop topics. Simultaneously, a participatory social diagnosis was carried out to identify unhealthy practices, knowledge gaps, and negative attitudes, shaping the workshop objectives. Both techniques were led by the research team, after which an ethnoeducator developed the pedagogical design for the cocreation sessions.

The cocreation of workshops and audiovisual materials occurred through theoretical-practical sessions using participatory audiovisual methods. This process was made possible by the collaboration of multiple stakeholders: the research team, which guided content and methodology; the community leaders, who designed the workshops and contributed to audiovisual creation; and the audiovisual production team, which provided technical support. A total of 40 six-hour sessions were conducted (20 for workshop design and 20 for audiovisual production).

The evaluation focused on community leaders’ perspectives to understand their experiences and learning during cocreation. Qualitative data were collected through 2 focus groups, each lasting approximately two-and-a-half hours and conducted by the first author (MMB-G). The first focus group took place at the end of the training phase, after participants were introduced to theoretical concepts, while the second was held at the conclusion of the co-design process, emphasizing practical application. Both assessments examined perception, pedagogy, learning, skills, and critical thinking (Multimedia Appendix 1).

In addition, a quantitative evaluation of knowledge acquisition was conducted at the beginning and end of the co-design process by the research team. Individual initial and final assessments measured theoretical knowledge through 6 multiple-choice questions with images to aid comprehension, along with 2 open-ended questions for further exploration. The final evaluation also included a group exercise to assess participants’ acquired competencies and their ability to apply theoretical knowledge in practice. For the 3 infectious diseases under study, the evaluation covered disease overview, transmission cycles, diagnosis and treatment, and preventive behaviors. Leadership assessment focused on negotiation skills, teamwork, and communication, while pedagogy evaluation considered learning objectives, content structuring, practical application, and assessment criteria.

Focus groups were audio recorded, transcribed verbatim, and coded using ATLAS.ti software (Lumivero, LLC) by the second author (LSZ). Content analysis was conducted by MMB-G, considering both the learning process and participants’ perceptions of methodology. Quantitative data from multiple-choice questionnaires were manually coded, with scores weighted on a 5-point scale for individual evaluations. Final individual and group evaluation scores were averaged. Open-ended responses were scored based on their alignment with the correct answer. Evaluation data were categorized into 3 performance levels (low, medium, and high), with percentage values assigned to each. A comparative analysis was then performed to assess changes in knowledge by comparing the percentage distribution of scores from the initial and final evaluations.

The research was approved by the research ethics committee of Centro Internacional de Entrenamiento e Investigaciones Médicas (International Center for Training and Medical Research; 1272). To conduct this study, written informed consent was obtained from all participants involved. They are preserved in the physical and digital records of the project, which are for the exclusive use of the research team.

Of the 15 participants, 9 (60%) were Indigenous people from the Embera community, and 6 (40%) were people of Afro-Colombian descent; moreover, 11 (73%) were women, and 4 (27%) were men. The participants were aged between 19 and 50 years. Of the 15 participants, 4 (27%) were nursing assistants, 4 (27%) were education technicians, 3 (20%) were high school graduates, 3 (20%) studied public health, and 1 (7%) was a psychologist.

The cocreation process yielded 2 main outcomes (Figure 1). The first was the development of 12 workshops co-designed with the community leaders, with 4 workshops dedicated to each of the 3 diseases under study: leishmaniasis, malaria, and tuberculosis. Each workshop focused on a general theme: awareness and motivation, promotion of preventive practices, promotion of early diagnosis and timely treatment, and mitigation of risk factors. The community leaders were divided into 4 subteams, each responsible for designing 1 workshop for each disease.

The methodology for designing each workshop included 4 main steps. The first was preparation, which involved the presentation of the findings of the participatory diagnosis by the social research team, highlighting the strengths and weaknesses of the community regarding disease-related knowledge and behaviors. Basic information regarding the diseases was then reviewed with a health expert. In the second step, the social research and pedagogy teams collaborated with the community leaders to define a clear objective and message for each workshop. In the third step, playful activities for the workshops were designed by community leaders with the support of the social research and pedagogy teams: one to promote reflection, one to demonstrate learning, and one to promote action. Finally, in the fourth step, the community leaders reviewed and assembled the workshops they had designed and conducted a pedagogical practice where they shared the complete workshop with their peers.

The second main outcome of the cocreation process was the creation of 3 audiovisual products (refer to Multimedia Appendices 2-4): an animation about malaria [17], a comic book about leishmaniasis [18], and a puppet show about tuberculosis [19]. Each audiovisual product consisted of 4 episodes. The cocreation process involved the community leaders, audiovisual producers, the social research team, and a health expert who helped define themes and content. This process included 5 steps. The first step was an introduction to audiovisual expression, which included exercises such as dance to engage the creative side of the community leaders, as well as basic training in artistic techniques. The second step was defining the story and script, incorporating key and precise knowledge about the diseases under study. Next came the elaboration of characters, scenography, and other elements through drawing, painting, and other crafts. The fourth step involved assembly for the puppet show and recording for the animation. Finally, the audiovisual producers made technical adjustments and improvements to the products cocreated with the community leaders.

Once the audiovisual products were incorporated into the workshops, the final outcome was 12 workshops, each with five sections: (1) introduction of the workshop facilitators and main theme and a playful activity to determine preexisting knowledge about the theme; (2) content presentation, featuring 1 episode of the cocreated audiovisual material to explain the theme of the workshop and a presentation by the community leaders to elaborate on the theme; (3) a playful activity to practice what was learned; (4) a motivational activity to promote application in participants’ day-to-day lives; and (5) an evaluation of what participants learned and their perceptions of the workshop.

The quantitative evaluation (Figure 2) yielded positive outcomes for knowledge acquisition and significant improvement in leadership and pedagogy. In the initial evaluation, of the 15 participants, 7 (47%) demonstrated low leadership performance, and 6 (40%) showed low pedagogical performance; however, by the final evaluation, no participant scored low in either domain. For leadership, the proportion of participants with good results increased from 40% (6/15) to 73% (11/15), and the proportion of those with excellent results increased from 13% (2/15) to 27% (4/15). For pedagogy, the majority of the participants made substantial progress, with 93% (14/15) attaining excellent scores in the final evaluation.

Concerning health knowledge, specifically regarding leishmaniasis, the proportion of participants achieving excellent scores doubled, increasing from 40% (6/15) in the initial evaluation to 80% (12/15) in the final evaluation. Moreover, the elimination of low scores in the final evaluation represented notable progress. For malaria, participants already performed well in the initial evaluation, with no low scores and 60% (9/15) achieving excellent scores. By the final evaluation, the proportion with excellent scores increased to 12 (80%), reflecting a positive results. In contrast to malaria, tuberculosis presented the poorest initial scores, with 60% (9/15) of the participants attaining low scores and only 13% (2/15) achieving excellent scores. However, tuberculosis demonstrated the most significant improvement, with low scores being completely eliminated by the final evaluation. The proportion of participants with excellent scores surged to 80% (12/15), showcasing a substantial increase.

In the qualitative evaluation, one of the sections discussed participants’ perceptions of the methodology (Textbox 1), which were positive overall.

Participants emphasized pedagogical strategies that served as learning facilitators. These included the use of playful activities and humor in addressing pedagogy topics, as well as clarity, precision, and constant reiteration when discussing health-related topics. In addition, drawing on community health work experiences in similar contexts from different parts of the world as inspirational examples was recognized as a valuable strategy to motivate participants. Both Embera and Afro-Colombian participants emphasized the value of having a mixed group with members of both communities because through the cultural exchange, they learned about each other’s cultural practices, and it allowed the Embera participants to develop new language skills. Finally, the community leaders discussed the evaluation, noting that performing group evaluations allowed each participant to contribute what they knew and that including traditional elements from their culture in the evaluation was a novel approach. However, they also identified challenges in terms of time management and understanding the evaluations:

The second section of the qualitative evaluation (Table 2) centered on the learning process, assessing participants’ performance in 6 focus areas (the 3 diseases under study and the domains of leadership, pedagogy, and audiovisual creation). For the diseases, the initial evaluation revealed new learning identified by participants, which increased by the final evaluation. This improvement was evidenced in the greater quantity, specificity, and detail of the responses and topics mentioned.

Concerning leishmaniasis, the initial evaluation showed that participants primarily learned about vector characteristics and the transmission cycle. In the final evaluation, there was a notable improvement, with the participants demonstrating knowledge not only about vector characteristics but also about prevention strategies, the importance of treatment adherence and timely diagnosis, the types of leishmaniasis, and the importance of a balanced diet. An example of the knowledge acquired about leishmaniasis is illustrated in the following quote:

In the case of malaria, the initial evaluation had the highest number of responses and topics mentioned, covering vector characteristics, prevention strategies, transmission cycle, and treatment. However, as with the other diseases, there was an increase in the specificity of the responses in the final evaluation, with participants additionally mentioning timely diagnosis, treatment adherence, the importance of seeking medical attention and not self-medicating, and the importance of a balanced diet. A participant stated as follows:

Regarding tuberculosis, in the initial evaluation, participants mainly mentioned learning about prevention strategies, symptoms, and treatment. There was an improvement in the final evaluation, in which they reiterated learning about prevention strategies and symptoms while adding learning about transmission, timely diagnosis, and the importance of a balanced diet:

With regard to the domain of leadership, in the initial evaluation, participants noted their acquisition of theoretical knowledge, such as the characteristics of a leader, as well as insight into the experiences of renowned world leaders. At the same time, they recognized that it was a difficult subject because it was new to them. However, in the final evaluation, participants highlighted the development of practical public speaking skills:

Regarding the pedagogy domain, in the initial evaluation, participants highlighted learning about the importance of using the appropriate methodology to reach their communities, including the use of audiovisual tools and playful activities. However, they encountered difficulties in grasping more practical aspects, such as planning and crafting objectives for the workshops. These challenges persisted in the final evaluation; for instance, they mentioned the challenges in describing activities step by step. Nonetheless, they recognized the importance of planning to better address community needs, establishing clear objectives to guide workshops, and creating clear messages without using technical terms to facilitate the community’s comprehension of the topics:

The last domain evaluated was audiovisual creation. In the initial evaluation, participants had only engaged in the creation of basic audiovisual products during the workshops. Despite their limited experience, they expressed their enjoyment in developing this type of product, particularly highlighting TikTok videos and radio dramas, with a participant noting the usefulness of audiovisual products for community education.

By contrast, in the final evaluation, they emphasized the value they found in learning to create diverse types of audiovisual products, especially animations. However, they reported facing several challenges during the creation process, such as experiencing frustration with the time-consuming nature of stop motion or the physical demands of assembling a puppet show. These challenges, common when working with artistic or physical skills, did not hinder the process. Instead, they were acknowledged and mitigated by balancing activities during implementation.

Another aspect participants emphasized was the enjoyment they found in crafting visual elements for the audiovisual products, such as creating drawings for comics and crafting puppets for shows. They also noted improvement in their artistic skills. Furthermore, they found the use of apps to be an interesting aspect of the process; however, they encountered technological barriers. Regarding the utility of the products, participants emphasized their potential to amplify the impact of the workshops by reaching more people due to their participatory nature, which facilitates engagement and learning, as expressed by a participant:

The co-design process showed that participatory methods, knowledge exchange, and culturally adapted tools enhanced ownership, engagement, and knowledge acquisition, leading to significant improvements and positive feedback.

As a case study, this research prioritized depth over representation; accordingly, a purposive sample was selected. In future studies, the development of other case studies will be useful for comparing and generalizing the findings of this study.

The co-design process was driven by three key factors: (1) active community participation at every stage; (2) knowledge exchange between multidisciplinary technical expertise and practical local knowledge; and (3) the use of innovative, culturally adapted pedagogical tools tailored to the rural context and population. This co-design process proved to be an effective method for meaningful capacity building among populations experiencing vulnerability in complex settings and has the potential to contribute significantly to the improvement of infectious disease prevention and control.