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Abstract

Objective

Describe the co-design process and learnings related to developing the web-based Translating Research Evidence and Knowledge (TREK) ‘My Knee’ education and self-management toolkit for people with knee osteoarthritis.

Co-design process

Stage (i): Understand and define; systematically reviewed education interventions in published trials; appraised web-based information about knee osteoarthritis; and used concept mapping to identify education priorities of people with knee osteoarthritis and physiotherapists. Stage (ii): Prototype; created a theory-, guideline- and evidence-informed toolkit. Stage (iii): Test and iterate; completed three co-design workshops with end-users (i.e., people with knee osteoarthritis and health professionals); plus an expert review.

Results

The toolkit is available at myknee.trekeducation.org. Stage (i) identified the need for more accurate and co-designed resources to address broad education needs generated during concept mapping, including guidance on surgery, dispelling common misconceptions and facilitating engagement with exercise therapy and weight management. A theory- and research-informed prototype was created in Stage (ii) to address broad learning and education needs. Stage (iii) co-design workshops (n = 15 people with osteoarthritis and n = 9 health professionals) informed further content creation and refinement, alongside improvements to optimise usability. Expert opinion review (n = 8) further refined accuracy and usability.

Conclusions

The novel co-design methodology employed to create the TREK ‘My Knee’ toolkit facilitated the alignment of the content and usability to meet the broad education needs of people with knee osteoarthritis and health professionals. This toolkit aims to improve and facilitate engagement with guideline-recommended first-line care for people with knee osteoarthritis. Future work will determine its effectiveness in improving clinical outcomes in this population.

Keywords

co-development co-creation digital health blended-learning

Introduction

Knee osteoarthritis is a leading cause of disability, resulting in substantial personal and societal burdens worldwide.¹ All major clinical practice guidelines for knee osteoarthritis recommend patient education as first-line care, alongside exercise therapy and when appropriate, weight management.^2–6 Patient education is particularly important considering its potential to influence self-management and engagement with other first-line interventions^7,8 and willingness to undergo surgery.^9,10 However, a large proportion of people with knee osteoarthritis do not receive adequate patient education or engage in first-line care.^11–13 For example, only one-third of people with knee osteoarthritis feel informed about the condition, treatment options, and how to self-manage prior to an orthopaedic consultation.¹⁴

Barriers to people with knee osteoarthritis receiving patient education and engaging in first-line care are complex, spanning multiple levels when viewed from a socio-ecological perspective.¹⁵ For example, lack of knowledge, low self-efficacy, lack of peer support, length of consultation times, availability (or lack thereof) of resources and access to facilities or care pathways, represent individual, interpersonal, institutional and policy level barriers.^16–19 People with chronic health conditions such as osteoarthritis commonly present with misinformed beliefs, possibly influenced by increasing use of web-based resources²⁰ containing inaccurate information.²¹ Barriers also exist from a health professional's perspective, including insufficient knowledge, confidence and capability to provide accurate and patient-centred education.^8,17,18 Education provided by health professionals may not strongly align with the education priorities of people with knee osteoarthritis or clinical practice guidelines.^22,23 Additionally, the poor reporting of education interventions in clinical trials,²⁴ alongside the absence of clear recommendations in guidelines^2–6 for ‘what’ and ‘how’ to provide patient education, may impede its effective implementation.

Co-designing (i.e., collaborating with end-users to create, test and refine) interventions and resources can improve patient satisfaction and is considered best practice.^25,26 However, just 10% of education interventions for people with knee osteoarthritis in clinical trials,²³ and no websites about knee osteoarthritis included in a recent web-based evaluation²¹ were developed using co-design methods. The absence of co-design methods to create e-resources may partially explain why, to date, they have shown little potential for promoting behaviour change for people with osteoarthritis.²⁷ Comprehensive web-based resources, such as My Joint Pain,²⁸ do exist to support people to self-manage their knee osteoarthritis. However, there has been limited involvement of people with knee osteoarthritis in the design, development of content and usability testing of these resources to facilitate engagement in their use.^28,29 Co-designing web-based resources with greater involvement of stakeholders including people with knee osteoarthritis, health professionals supporting them, and expers are therefore warranted. Co-design methods may increase the appeal, use of and engagement with, web-based resources to support education and self-management of people with knee osteoarthritis, in both a self-directed and therapist-facilitated manner.

The aim of this study is to describe the co-design processes undertaken, and resultant learnings, to create the freely available web-based Translating Research Evidence and Knowledge (TREK) ‘My Knee’ education and self-management toolkit for people with knee osteoarthritis.

Methods

Reporting of this study has been guided by the CONSORT-EHEALTH checklist³⁰ (Supplementary Appendix A). The specific aims of the TREK ‘My Knee’ education and self-management toolkit were to:

Improve an individual's (living with knee osteoarthritis) knowledge about the condition to inform treatment decision-making and self-management;

Provide tools to facilitate self-efficacy for, and engagement in, guideline-recommended first-line care; and

Provide health professionals with resources that can be used clinically when educating and facilitating self-management for patients with knee osteoarthritis.

La Trobe Human Ethics Committee approved the co-design process (HEC 20188). The in-depth, engaging and iterative process applied to create the ‘My Knee’ education and self-management toolkit was informed by various accepted co-design methodologies,^31–33 but most closely aligned to the Good Things Foundation (www.goodthingsfoundation.org) pathfinder model for digital health inclusion (2019).³³ We further broke down the three stages from the Good Things Foundation pathfinder model³³: (i) understand and define, (ii) prototype and (iii) test and iterate, into six distinct steps (Figure 1). Steps 1–4 ran concurrently, with steps 5 and 6 occurring in successive order after the completion of the prototype.

Figure 1.

Three-stage, six-step co-design process used to create the TREK ‘My Knee’ education and self-management toolkit.

Stage (i): Understand and define

Step 1 involved a systematic review and meta-analysis evaluating the effectiveness of patient education as a stand-alone intervention, and in combination with other interventions.³⁴ Detailed evaluation of the content, development plus delivery method and mode of patient education interventions from the systematic review was also performed.²³ These assessments included appraising the comprehensiveness and accuracy of content based upon clinical practice guidelines, expert opinion and clinical research. Step 2 involved appraising commonly-accessed web-based resources for people with knee osteoarthritis in Australia, including evaluating their comprehensiveness, accuracy, credibility, readability and quality of information about treatment choices.²¹ Step 3 identified the education priorities of people with knee osteoarthritis²⁴ and physiotherapists²² using a mixed-methods concept mapping approach. Specifically, participants in both groups identified education priorities and rated them according to their perceived importance and either, confidence that they would receive the information (people with knee osteoarthritis) or, capability to provide education to address that priority (physiotherapists).

Stage (ii): Prototype

Step 4 involved developing a prototype of the TREK ‘My Knee’ toolkit using WordPress® (www.wordpress.org), hosted as a TREK subdomain (www.trekeducation.org). TREK is a not-for-profit initiative that aims to develop and share freely available web-based digital resources to support the education of health professionals and people managing musculoskeletal pain and other chronic diseases. Care was taken to ensure that content was aligned with the education priorities of people with knee osteoarthritis and health professionals,^22,24 clinical practice guideline recommendations,^2–6 and key research evidence that informed previous ancillary²³ and web content²¹ analyses. The Health on the Net Foundation Code of Conduct (HONcode)³⁵ and DISCERN³⁶ criteria were also considered during content development.

Stage (iii): Test and iterate

Step 5 involved three workshops to test, obtain feedback and refine the toolkit, including resources contained within it. Workshops 1 and 3 involved people with lived experience of knee osteoarthritis. Workshop 2 involved health professionals who commonly provide care for people with knee osteoarthritis. Participants were recruited via multiple channels, including the Good Life with osteoArthritis in Denmark® (GLA:D®) Australia (www.gladaustralia.com.au) and Musculoskeletal Australia (MSK Australia) (www.msk.org.au) email distribution lists, social media (Facebook and Twitter), contacts from related concept mapping projects^22,24 and the professional networks of the research team. To reduce feedback bias during workshop 3 (final workshop), people with lived experience of knee osteoarthritis were not eligible to participate if they were involved in creating any videos embedded within the toolkit.

Potential workshop participants followed an electronic link on the recruitment materials to a web-based platform where they provided consent, self-confirmed eligibility, answered baseline demographic questions and provided their email addresses for further communication. All participants were provided with a link to access the draft version of the toolkit at least one week before their workshop or individual session and were asked to explore the toolkit's contents. All workshops were 2 hours long and included an introduction presentation, breakout room activities and group discussions. Workshops were run by physiotherapists who have an interest in knee osteoarthritis research. The lead toolkit developer (AJG) led group discussions, with two other members of the research team experienced in qualitative and co-design methodology (AME and CJB) leading breakout room activities. Guides were created by four members of the research team (AJG, AME, CJB and DOS) to ensure consistency of breakout room activities (see Supplementary Appendix B). A fourth researcher (DOS) switched between rooms to ensure consistency. Interested participants who could not attend a workshop were invited to provide individual feedback via a recorded video meeting using Zoom^TM (with AJG, the lead toolkit developer) or via email. Individual meetings lasted approximately 30–40 min, covering the same topics as the workshops. All participants (people with knee osteoarthritis and health professionals) who provided feedback via any means received a supermarket voucher for their time (AUD 40). Revisions were made to the toolkit following each workshop, with participants in the subsequent workshops being provided with a link to the most updated version.

All workshop discussions were audio and video recorded, plus attending members of the research team took field notes. Two members of the research team (AJG and AME) independently reviewed audio and video recordings, plus researcher field notes to identify common themes and specific areas for improvement. Potential themes or areas for improvement were discussed by the research team during meetings following each workshop, with action plans agreed upon before making changes to the toolkit and resources.

To create lived experience video resources following workshop 1, participants from the first workshop and the concept mapping study completed during step 3²⁴ were emailed (by AJG) to ask for volunteers to share their stories. Videos were created by recording semi-structured interviews with a researcher (AJG) using Zoom^TM, guided by a topic guide (see Supplementary Appendix C). Responses were subsequently edited to create short engaging video clips. All participants gave consent and could view and provide feedback on the edited videos, including suggested changes, to ensure that their views and opinions were accurately represented. Each lived experience video participant received a supermarket voucher as compensation for their time (AUD 40). To create the expert/clinician videos, content experts (e.g., exercise therapy, medications, diet, etc.) from the research team's network were emailed (by AJG) to invite them to video record themselves via PowerPoint answering a series of pre-defined questions. Experts shared complete recordings, which were then formatted to create short engaging video clips.

Step 6 involved an expert review of, and feedback about, the toolkit following the revisions facilitated by workshop 3. Three categories of experts were recruited from the research team's network:

Individuals experienced in the development of web-based toolkits

Osteoarthritis researchers

Specific intervention content experts (e.g., medications or weight management)

Each expert was provided with a list of feedback topics, including perceived accuracy, comprehensiveness, usability, engagement and miscellaneous comments. Experts could provide feedback via a web-based survey link (Qualtrics, Provo, UT) (Supplementary Appendix D), email, text file, Zoom^TM or pre-recorded audio. One research team member (AJG) reviewed all feedback to identify common themes and specific areas for improvement. Potential themes or areas for improvement were discussed by the research team, with action plans agreed upon before refinements were made to the toolkit and its resources.

Results

Stage (i): Understand and define

Step 1: Detailed systematic review³⁴ and ancillary analysis²³ findings are published elsewhere. Briefly, patient education as a stand-alone intervention improves pain and function compared to usual care, but improvements are small and may not be clinically important.³⁴ Combining patient education with exercise-therapy results in statistically significant and clinically important improvements in function compared to patient education alone.³⁴ Consequently, the ‘My Knee’ toolkit focused on supporting patient engagement and adherence to exercise therapy. We also identified that very few patient education interventions reported in published trials are theory-based or co-designed, especially when education is used as a control condition.²³

Step 2: Detailed web-based content evaluation findings are published elsewhere.²¹ Briefly, no website included in the analysis appeared to be co-designed, up to 40% of websites provided inaccurate information, and very few websites provided tools to facilitate user engagement and adherence to guideline-recommended treatments.^3–6 To address these gaps, content in the ‘My Knee’ toolkit was aligned to current evidence, aimed to dispel common misinformation from other web-based resources (i.e., about surgery and the pathophysiology of the condition) and provided tools to support implementation and adherence to patient-centered treatment (e.g., a personalised guide-maker).

Step 3: Concept mapping studies identifying the patient education priorities of people with knee osteoarthritis (n = 43)²⁴ and physiotherapists (n = 41)²² have been published elsewhere. Briefly, people with knee osteoarthritis prioritised education about surgical decision-making, including understanding the relationship between education and exercise therapy in the prevention of, or rehabilitation after, surgery. They also generally felt confident that health professionals would address their most important education needs but felt least confident that they would address education priorities about diet and supplements.²⁴ Physiotherapists prioritised providing information about exercise therapy and dispelling misconceptions about radiology, but felt least confident to provide weight management education despite believing it to be important.²² Therefore, while all education priorities identified in both concept mapping studies^22,24 were addressed in the toolkit, particular attention was paid to content to facilitate education about, and implementation of, weight management, diet and supplements.

Stage (ii): Prototype

Step 4: Table 1 provides an overview of the prototype development for the ‘My Knee' toolkit. It highlights how key findings from steps 1–3 informed the development of content and features in relation to the aims and guiding principles of the toolkit. Screenshot examples of the prototype toolkit can be found in Supplementary Appendix E.

Table 1.

Summary of the initial TREK ‘My Knee’ education and self management toolkit prototype development.

Item	Summary rationale and explanationi of how each item was addressed in prototype development
Aims of the toolkit
1. Improve an individual's (living with knee osteoarthritis) knowledge about the condition to inform treatment decision-making and self-management	- Most written content in the toolkit focused on enhancing self-efficacy through re-interpreting symptoms by providing information about modifiable risk factors, debunking myths about radiology and explaining symptoms from a biopsychosocial perspective. - Content was created to address the educational priorities of people with knee osteoarthritis and physiotherapists identified from the previous concept mapping studies in step 3.^23,25 - Content was created to be comprehensive and accurate in accordance with clinical practice guidelines and key research evidence (as per the rubric for the ancillary²³ and web-content²¹ analyses in steps 1 and 2 respectively). - Content was created to counter misinformation frequently found on the internet that was identified in step 2.²¹ - Content was created to align to DISCERN³⁶ principles for informed treatment decision-making and the HONcode³⁵ principles for information credibility. - An interactive quiz was created to test knowledge and challenge common misconceptions.
2. Provide tools to facilitate self-efficacy for, and engagement in, guideline-recommended first-line care	- Toolkit content and navigation explicitly stated what constitutes first-, second- and third-line care, and the reasons supporting the recommendations. - Content was created to assist with accurate interpretation of symptoms to improve self-efficacy for exercises. - A personalised guide-maker was created to supplement information in the toolkit and facilitate the performance mastery aspect of self-efficacy.⁴¹ - A lived experience case-study video, plus videos of an individual with knee osteoarthritis exercising, were included within the toolkit to facilitate the modelling aspect of self-efficacy.³⁸
3. Be used as a therapist-facilitated resource by health professionals providing care for patients with knee osteoarthritis	- The personalised guide-maker included sections to improve communication between a person with knee osteoarthritis and their health professional. - A ‘for clinicians’ tab was created containing an introductory video to the site and some quick-access links. - A resources section was provided for clinicians or people with knee osteoarthritis to be able to find and share infographics or resources.
Other principles guiding prototype development
Co-design¹⁰	- Toolkit content was created based upon the education priorities of people with knee osteoarthritis and physiotherapists identified in step 3
Patient-centred	- An interactive personalised guide-maker tool was created to allow users to tailor their learning and self-management. Those who engage with the tool are asked a series of questions about what topics they want to know about from the following options (1. Lifestyle and general health, 2. Exercise, 3. Weight management, 4. Medical management, 5. Surgical management and 6. Balance and falls). The personalised guide-maker tool then provides the user with an interactive PDF guide containing only information that the individual has selected. The guide provides information and tools to facilitate knowledge generation and self-management of the selected topics.
Theory-based	In the absence of clear guidance or evidence for theory-based interventions,^23,37 the prototype of the ‘My Knee’ toolkit was informed by motivational interviewing,³⁸ principles of andragogy³⁹ and theories related to enhancing self-efficacy.^40,41 - Motivational interviewing is based upon self-determination theory. An exercise therapy decision-making tool was created based upon key principles of motivational intervieweing (importance and confidence scales) to direct users to appropriate information. - For andragogy, interactive features were created involve learners in mutual planning, and decision-making in an attempt to trigger internal motivation. Users could identify their own learning needs through the personalised guide-maker and the exercises/tasks contained within it. - For self-efficacy, we targeted three aspects; (i) perfomance mastery, (ii) modelling and (iii) interpretation of symptoms.⁴¹ For performance mastery the personalised guide helps to facilitate mastery of various self-management skills. Videos were also created of exercises to support learning. For modelling we included a lived experience video from clinical research⁺ plus a video of an individual with knee osteoarthritis performing the NEMEX program⁺⁺ at varying degrees of difficulty. For Interpretation of symptomsan interactive quiz was cretaed to challenge common beliefs and other toolkit content was created to help facilitate accurate interpretation of symptoms.
Other features
Presentation	- For the prototype, content was primarily presented in written format using 'slides', infographics and links to external sites. The prototype was split into three sections: (i) making the most of this toolkit, (ii) understanding osteoarthritis and (iii) treatment options.
Engagement/interactivity	- Interactive features were developed, including (i) slide presentations (scrollable slideshow); (ii) quiz (slideshow with added interactivity); (iii) an exercise therapy decision-making tool (branching scenario); and (iv) a personalised guide-maker tool (branching scenario).

⁺

Bell, E.C., Wallis, J.A., Crossley, K.M., Trivett, A and Barton, C.J. (2021). Patient Forgoes Knee Replacement Surgery by at Least 2 Years After Appropriate Nonsurgical Care Following Cardiac Rehabilitation: A Case Report. JOSPT cases. 1(1):21-26.

⁺⁺

Ageberg, E. Link, A and Room, E.M (2010). Feasibility of neuromuscular training in patients with severe hip or knee OA: The individualized goal-based NEMEX-TJR training program. BMC Musculoskeletal Disorders. 11 (126):1–7.

HONcode: Health on the Net Foundation code of conduct; NEMEX: Neuromuscular exercise program.

Stage (iii): Test and iterate

Step 5: Demographics of all participants attending workshops or providing individual feedback are provided in Table 2.

Table 2.

Co-design participant demographics.

Workshop 1 & individual feedback (lived experience)
Total participantsFemale/Male	95/4
Age*	68 (63–78)
Workshop 2 & individual feedback (health professionals)
Total ParticipantsFemale/Male	98/1
Age*	39 (28–59)
Years of experience*	17 (5–24)
Profession - Physiotherapist - Exercise physiologist - Nurse practitioner	711
Workshop 3 (lived experience)
Total participantsFemale/Male	61/5
Age*	73 (58–75)
Years living with knee osteoarthritis*	10 (3–20)

* Median (range).

Workshop 1, held in June 2021, involved seven people with knee osteoarthritis, with a further two people providing feedback via individual web-based meetings (Table 2). Major feedback suggestions from workshop 1 and the subsequent toolkit revisions are presented in Table 3. Overarching feedback indicated that the content was appropriate, and the personalised guide-maker was novel. However, the toolkit was considered complicated, lacked inspiration for engagement, and was perceived to be too similar to other web-based sources of information. Numerous suggestions to improve usability and engagement were provided and addressed (Table 3). Screenshot examples of the revisions are presented in Supplementary Appendix F.

Table 3.

Summary of major feedback from workshop 1 leading to revisions in the TREK ‘My Knee’ toolkit.

Feedback	Supporting data	Actions implemented into toolkit
Content was good, but too much and difficult to navigate	‘this needs to be simplified’ (P1); ‘slides were difficult to use’ (P6);‘it was a lot of information to take in all at once’ (P3); ‘I like the fact that there was detail…it's just a question of where it's placed’(P7); ‘It's all there, it's just a case of presenting it in a better manner…I want more of a choice what I select to click on’ (P2); ‘keep it simple initially and then give a choice’ (P5); ‘I want a list of things’ (P3); ‘Maybe a frequently asked questions kind of section’ (P2).	Written information was simplified and reorganised from being slide-based to FAQs using accordion functionality
More quizzes as these were reported to be ‘engaging and fun’.	‘there was a test your knowledge section, I like that sort of thing. A similar quiz at the end of exercise, or surgery would focus my mind a little bit’(P2);’I did the quiz and got 11/14 right and I thought how dare I get 3 wrong so it made me look into the content more’ (P1); ‘I like the quizzes and I was very pleased that I got them all right’(P7); ‘I thought the test was really good, I thought I knew a lot but I got 3 or 4 questions wrong. Some obvious things I didn't know so that was really good’(P3); ‘(the quiz) was straight forward, it worked’(P8).	Split the quiz into two; one quiz about the condition and its symptoms, and one quiz about treatments. New questions were generated as necessary
A single ‘work-along’ video for the suggested exercises rather than sorting through multiple videos	‘I’d love to have within something like this a little program that I could follow’ (P8); ‘I don't want to have to think about exercises, I want to just put something on and watch it’ (P9); ‘I would like to click on a link that takes me to exercises just for knees, backs or whatever’ (P5); ‘maybe even some workout videos where people can work out along’ (P7); ‘that exercise ‘buddy’ works for me’ (P6).	Creation of a work-along exercise video
More lived experience videos to make the site more engaging, motivating and relatable	‘(I want to see) this is the result of doing that sort of thing’ (P2); ‘people love testimonials’ (P3).	Addition of lived experience videos throughout to provide insights and tips for living with the condition. Videos created: - What advice would you give? - Understanding symptoms - What to do in a flare up - Exercise therapy - Diet - Supplements - Assistive devices
Written information to be presented in video format from content experts	‘I just think it would be nice to have one of you introduce the material… make it like a webinar’ (P4); ‘I agree (to the previous comment)’ (P2 and P5).	Addition of clinician/expert videos discussing common misconceptions and addressing FAQs. Videos created: - Exercise and physical activity - Weight management - Medications - Assistive devices - Hot or cold - Injections - Surgery - Footwear and orthoses
An engaging and inspiring introductory video to help navigate the site.	‘When I look at the content it has no appeal’ (P1); ‘introductions from you as researchers about what the site has to offer, and what it aims to do’ (P7); ‘I found it difficult to use’ (P5); ‘I found it frustrating that I couldn't find things’ (P6).	Creation of an introductory video
More information on weight management	‘Diet is not attended to as much as it should be… with the sub bracket of alcohol consumption’ (P3); ‘Yes I thought that (in relation to the previous comment)’ (P1).	Addition of lived experience and expert video, more information about weight management in general
More information on medications and supplements	‘I think most people in Australia would pick up on Panadol rather than Tylenol’(P1); ‘I think glucosamine gets a page on its own that says it may or may not be effective but give it a go. I wanted more information on other things like turmeric, capsicum etc.’ (P2).	Addition of lived experience and expert video plus additional content on supplements and changed wording to paracetamol

FAQ: Frequently asked question.

(Note: participants 1–7 = workshop, participants 8 and 9 = individual feedback).

Workshop 2, held in October 2021, involved seven health professionals, with a further two providing feedback via email (Table 2). The major feedback suggestions, including subsequent toolkit revisions, from workshop 2 are presented in Table 4. Overarching feedback indicated that the health professionals liked the personalised guide-maker, valued the lived experience resources, and were likely to use the toolkit in a therapist-facilitated learning format with patients. Possible improvements identified included navigation optimisation and content adaptation for diverse groups of people with knee osteoarthritis, particularly in relation to exercise therapy. Screenshot examples of revisions are presented in Supplementary Appendix G.

Table 4.

Summary of major feedback from workshop 2 leading to revisions in the TREK ‘My Knee’ education and self-management toolkit.

Feedback	Supporting data	Actions
Re-design the home page based upon where an individual is in the patient journey	‘Having some headings focused on where the person is in their journey (will help navigation)’ (P1); ‘just thinking about the front page and navigation… when we’ve tried to design websites in the public health context we think of the three click rule’ (P1).	Home page re-designed to be more user friendly relating to where the user is in the patient journey. Use of icons also improved navigation
Desire for downloadable ‘factsheets’ that summarise key information	‘Sections that could be maybe printed off and like specific maybe summary sections’ (P5); ‘printable resources are definitely something that's key, maybe just summarises some of the key points for the videos’ (P6).	Three downloadable fact sheets were created – i. facts and myths about knee osteoarthritis, ii. osteoarthritis treatments and iii. what to do in a flare up. The facts and myths about knee osteoarthritis factsheet was also added to the downloadable personalised guide.
NEMEX* exercises may be too hard or unsafe for some people with knee osteoarthritis. More screening information and alternate options needed	‘I see a population that have a high degree of multi-morbidity and high risk of falls, and so, most of the exercises, they are probably too hard for my clients’ (P2); ‘having a disclaimer out if you've had a fall, maybe consult with someone before you start’(P3); ‘there's a massive falls risk with some of the exercises’(P1); ‘the exercise program looks suitable for people with mild to moderate issues; however, the vast majority of the patients that we see are unable to do most of those exercises’ (P8).	This prompted overall reflection on the ‘exercise therapy decision-making’ tool. Consequently, it was split to create two distinct tools – ‘exercise checker’ for people who already have an exercise program and ‘exercise selector’ for people who don't yet have an exercise program.In the exercise checker, physical activity components were added as the initial tool was very focused on resistance exercises.In the exercise selector, new branches and screening questions were added, and two new exercise program end points were created to make exercise selection more personalised and safer.Additionally, changes were made to the content within the personalised guide – the full NEMEX exercise program was removed from the guide. It was replaced with generic information about the importance of exercise, a pain monitoring tool, an adherence log and a hyperlink to the decision-making tool for users to find the most suitable exercises for their level.
Add content to help people with knee osteoarthritis navigate health resources or access funding	‘Maybe having some information about how public health funding could be accessed’ (P3).	Added basic information to the toolkit to help people navigate health resources and access funding
Create more visual animations so that not all are ‘talking head’ type videos	‘There are a lot of talking head videos and they don't deliver the message very well, especially if they aren't subtitled. Consider use of visuals to make it more accessible’ (P1); ‘(adding animations) its not cheap and its not easy… it just adds so much more emphasis’ (P1).	Created an animated video explaining the condition of knee osteoarthritis to facilitate testing the usefulness of this type of resource for people with knee osteoarthritis in workshop 3
Desire for more information on balance and falls	‘I think it would be a good idea to include it (balance and falls) in the guide’ (P4).	A researcher with experience in balance and falls was consulted to help create content and activities for the personalised guide

NEMEX: Neuromuscular exercise program.

(Note: participants 1–7 = workshop, participants 8 and 9 = individual feedback).

Workshop 3, held in November 2021, involved six people with knee osteoarthritis (Table 2). Only one of the six participants was also involved in workshop 1. The major feedback suggestions, including subsequent toolkit revisions, from workshop 3 are presented in Table 5. Overarching feedback indicated that they liked the content within the toolkit, but navigation could be further improved. There were also suggestions about the name of the toolkit and how to best present video content. Screenshot examples of revisions are presented in Supplementary Appendix H.

Table 5.

Summary of major feedback from workshop 3 leading to revisions in the TREK ‘My Knee’ education and self-management toolkit.

Feedback	Supporting data	Actions
People with knee osteoarthritis generally liked the term ‘toolkit’ but provided refined suggestions	‘I like (the term) toolkit, but toolkit about what?’ (P3); ‘what about osteoarthritis toolkit or knee arthritis toolkit’ (P5); ‘I think the term toolkit is much better than website’ (P2); ‘online workbook, online guide, online discovery (are alternate options)’ (P1).	The name TREK ‘My Knee’ education and self-management toolkit was agreed upon.
People with knee osteoarthritis preferred talking head videos compared to animated	‘The real person makes it more legitimate and credible’ (P1).	Videos remained as talking heads.
Navigation remained difficult, especially for the exercise resources	‘(Navigation was) a bit difficult, you could miss that the top menu was actually a drop down, the red boxes are giant in comparison’ (P3); ‘I found things that I couldn't find again’ (P5); ‘I didn't know where I was on the site as all the videos had the same image of a leg (the thumbnail)’ (P4); ‘need to make the exercises easy to find/accessible’ (P1).	Added drop down arrows to the top menu.Changed thumbnails to the videos so that it was easier for those using the toolkit to identify where they were/what they had already seen.Exercise resources had a dedicated page.Other layout/navigation edits included generic changes to site layout and increased use of images/tiles to select content to view.
Language and presentation of content	‘What is meant by strength exercises? Do you mean with the bands’ (P3); ‘I did notice a few typos’ (P5).	Additional explanation of strength exercises was provided when appropriate.The toolkit was proof-read by a research assistant.

TREK: Translating Research Evidence Knowledge.

Step 6: Emails were sent to 12 experts in December 2021, with eight providing feedback (one general practitioner, one rheumatologist, three physiotherapists, one dietitian, one orthopaedic surgeon trainee and one toolkit development expert). The major feedback suggestions, including subsequent toolkit revisions, are presented in Table 6. In addition to simple edits to ensure accuracy, notable revisions included greater use of the ‘grid’ function to improve layout and navigation, placing injections into second-line instead of third-line care, and significant edits to the healthcare resources and referrals section. Screenshot examples of the revisions are presented in Supplementary Appendix I.

Table 6.

Summary of major feedback from our expert opinion panel leading to revisions in the ‘My Knee’ education and self-management toolkit.

Section	Feedback data from	Actions
Homepage	‘I think only have the tiles. The second lot of subtitles seem redundant as they are at the top of the page. The different pictures are distracting.’	Homepage simplified to have tiles with picture only. Also the video was shrunk and provided in a grid format.
How do I know if I have knee osteoarthritis	‘The NICE criteria is not the most accurate, but is the most commonly used and has highest sensitivity. Amend wording accordingly’	Wording amended
Treatment options	‘Recommend placing injections as second-line treatment’; ‘What advice can those living with knee osteoarthritis give you about the management of their condition?’ seems in a weird banner on its own just make a drop down box with videos included’	Injections section moved to second-line treatmentsPresentation of lived experience videos was changed from accordion to grid function throughout
Exercise and Physical activity	‘Provide clearer recommendations regarding intensity and examples’; ‘The exercise and physical activity log is biased towards strengthening – be more explicit’; ‘Make navigation to exercise resources easier’; ‘Consumer videos about exercise feel hidden as they are all the way down page. Can they almost be in a separate section with a hyperlink to them from here?’	Provided guidelines for intensity and examplesImproved wording and updated workbook to clarify that the log was specifically for resistance trainingExercise resource page was made more explicit on the toolkitThe presentation of the lived experience videos from accordion to grid addressed this
Healthcare resources and referrals	‘I think that this section needs a clean up….kind of reads like someone was making notes rather than a nice summary’	Significant edits to improve presentation of information. Each option given a dedicated page
Medications	‘Remove the recommendation about paracetamol’	Improved the accuracy of information about paracetamol, including that some guidelines recommend against.
Weight management	‘Avoid the use of BMI, waist circumference and waist:hip ratio are much better’; ‘Suggested alternate goals for the workbook to be more instructive’; ‘Add in processed foods with added salt, sugar and fat to the ‘what to avoid’ sub section’; ‘Add in a section to encourage individuals to check with a dietician about potential nutrition deficits’; ‘Link to healthy weight for life or CSRIO’	BMI was removed, with waist circumference and hip:waist ratio prioritised.Edited wording in the personalised guideAdded other suggestions to the toolkit
Surgery	‘The strength of the decision-making tool recommendation could be reduced, especially as some of the information contained within it conflicts information on the toolkit’; ‘May be worth including more about osteotomy’	Edited wording to reduce the strength of recommendation and added a disclaimerIncluded information about tibial osteotomy
For clinicians	‘I kind of expected to have some links to guidelines for management in the clinician section – it was a bit strange not to have anything’; ‘Add quick links to this section’; ‘I was expecting to see more about guidelines – include this’	Added information from guidelines throughoutIncluded quick links to this sectionGreater detail in the ‘for clinicians’ section to align to guidelines
Video content	‘Consider having a surgeon doing the surgery video’; ‘Could videos be made that match other populations who have osteoarthritis in Australia (e.g., age, race, background etc.)’	Invited a surgeon to film video for future uploadThis is to be addressed in future iterations
Quiz	‘Recommend not having the question about which structure osteoarthritis affects the most’; ‘I like the knowledge quiz and video. The picture icon though is lower res and again could be simpler’	This corresponding question was removed from the quiz and all images were reviewed for quality

NICE: National Institute for Health and Care Excellence; BMI: body mass index.

Discussion

The TREK ‘My Knee’ toolkit was uniquely developed through comprehensive co-designed methods involving people with lived experience, health professionals and experts. This process led to a highly engaging multimedia platform, novel personalisation functions and specific content to help health professionals facilitate patient education. Stage (i) identified the need to create content and resources to dispel common misconceptions about osteoarthritis and to facilitate engagement with exercise therapy and weight management. The theory- and research-informed prototype created in Stage (ii) aims to promote active learning and enhance self-efficacy for, and engagement with, guideline-recommended first-line care. Co-design workshops and expert opinion review in Stage (iii) facilitated improvements in clarity, accuracy and usability. The ‘My Knee’ toolkit offers great potential to improve outcomes for people with knee osteoarthritis; however, further research is now needed to determine the feasibility and effectiveness in real-world settings.

Although Step 1 of our co-design process was unable to determine ‘what’ education content is most effective for people with knee osteoarthritis,²³ we did identify that education is more effective when provided alongside exercise therapy.³⁴ This evidence aligns with current guideline recommendations for first-line care^3–6 and supports priorities identified by people with knee osteoarthritis²⁴ and physiotherapists²² about receiving/providing education about exercise therapy in Step 3. Consequently, much of the toolkit's content addresses the importance of exercise therapy, and tools and resources to facilitate its implementation are provided. Workshop feedback in Step 5 further emphasised the desire for information and resources to facilitate exercise therapy, and informed subsequent toolkit edits. Feedback led to the creation of a ‘work-along’ exercise video and expansion of the exercise therapy decision-making tool to incorporate important exercise safety considerations. The information and resources available in the ‘My Knee’ toolkit may help to address the lack of accurate and clear information about, and tools to help implement, exercise therapy from other web-based resources.²¹

People with knee osteoarthritis desire information about surgery,²⁴ yet online information about surgery is often inaccurate and misleading.²¹ Content within the ‘My Knee’ toolkit aims to reinforce that surgery is considered third-line care and not required by most people with knee osteoarthritis.⁴² Lived experience videos were developed to counter common misconceptions and to highlight that surgery may be avoided by engaging with first-line care including exercise therapy. A potential barrier to health professionals supporting implementation of first-line care is the lack of clarity about their role and perceived capability to provide weight-management advice.^17,22,43,44 Content within the My Knee toolkit, including the personalised guide-maker feature, was co-created with an academic dietitian. This ensured the inclusion of evidence-informed resources to support health professionals who may lack the confidence to discuss weight management.²² Considering the projected future global burden of obesity,⁴⁵ and the association of weight loss with improved knee osteoarthritis symptoms,⁴⁶ it is hoped the toolkit will promote the better provision of, and engagement with, interventions to support weight management.

Our co-design workshops highlighted the importance of avoiding information overload (i.e., too much), with failure to do so being a known limitation for similar web-based resources.^28,29 Examples to guard against information overload that this feedback informed included increased use of videos and icon-based hyperlinks to convey content rather than text, creating frequently asked question sections to guide users to find relevant information, a dedicated exercise therapy resource page and an improved navigation bar. The ability of users to tailor their own personalised learning guide may also help to prevent information overload, with this feature being reported as strength of the ‘My Knee’ toolkit by workshop participants in Step 5. The diversity of resource formats (i.e., written materials, infographics and video resources) was also reported as a strength of the toolkit compared to similar resources^28,29 and will help the toolkit to appeal to varied learning preferences.⁴⁷ Future revisions are likely to further improve the user experience and will be informed by similar co-designed research methods with other populations including rural populations, people with lower digital and health literacy and culturally and linguistically diverse (CALD) communities.

It is unclear if theory-based education interventions and websites result in better outcomes compared to those that are not theory-based.²³ However, considering the potential importance of theory in learning outcomes⁴¹ and facilitating behaviour change,⁴⁸ we ensured theoretical principles of andragogy,³⁹ motivational interviewing³⁸ and self-efficacy⁴⁰ were considered and integrated where possible when developing the ‘My Knee’ toolkit. Creating a theory-informed web-based resource is challenging, as theoretical principles are most applicable to synchronous, in-person scenarios.^38–40 Nonetheless, theoretical principles were used to inform content and refine tools to optimise the quality, engagement and personalisation of the learning experience (i.e., personalised guide-maker, quizzes and lived experience videos for modelling). Workshop feedback from people with knee osteoarthritis and from health professionals during Step 5 supported the value of this approach and the resulting resources.

Implications and future directions

The ‘My Knee’ toolkit and its resources create opportunities to enhance engagement with first-line care and self-management, which may ultimately improve clinical outcomes for people with knee osteoarthritis. However, research is needed to determine whether the ‘My Knee’ toolkit can improve the knowledge or self-efficacy of those using it. Additionally, feasibility and effectiveness testing of the ‘My Knee’ toolkit as both self-directed and therapist-facilitated resource are required and planned by our research team. Other research groups are also encouraged to consider using the ‘My Knee’ toolkit in trials providing patient education to people with knee osteoarthritis. In particular, the ‘My Knee’ toolkit offers opportunities to improve the implementation of theory-based education interventions in clinical trials, especially when being provided as a control condition.²³ A comparison of the ‘My Knee’ toolkit against other more passive or non-theory-based information or education interventions used in previous patient education clinical trials is also encouraged.

The ‘My Knee’ toolkit was not created with the intention of replacing health professional consultation. Rather, we hope that the ‘My Knee’ toolkit; (i) promotes guideline-recommended care and provides those using it as a self-directed resource with the information they need to make informed decisions about whether professional input is warranted and; (ii) can be used as a supplementary resource to enhance the education that health professionals provide. Further research to understand ‘how’ the ‘My Knee’ toolkit is best used to support care is warranted. This includes determining whether health professionals feel confident or capable of incorporating the toolkit into patient care, or whether people with knee osteoarthritis value an initial consultation with a health professional to co-navigate resources. Research to identify the content, resources or features most frequently used or valued by people with knee osteoarthritis and health professionals is also planned by our research team to facilitate future iterations and improvements. We also hope that respected evidence-based programmes for people with knee osteoarthritis such as GLA:D®⁹ or Enabling Self-management and Coping with Arthritic Pain Using Exercise (ESCAPE-pain^TM)⁴⁹ consider signposting participants to the ‘My Knee’ toolkit for further reading and learning. To facilitate awareness and use of the ‘My Knee’ toolkit, we have drafted a dissemination and continual improvement plan (Supplementary Appendix J). The dissemination plan leverages upon co-design participants and their networks to help reach a broad audience of both people with knee osteoarthritis and health professionals.

Limitations related to how the ‘My Knee’ toolkit was developed should be considered. Although participants were recruited from a wide range of sources, the recruitment methods and samples were biased towards English-speaking people. Further, we did not measure digital literacy of our cohort, but our sample was all competent with using the internet, videoconferencing and email, meaning they may not represent all people with knee osteoarthritis consulting with physiotherapists. Notably, future research should consider involving CALD communities and people with varying health literacy levels to improve accessibility, as this is a known barrier to the use of such interventions.²⁹ This may include making content within the ‘My Knee’ toolkit accessible to non-English speaking populations, considering that knee osteoarthritis is a leading cause of disability worldwide.⁵⁰ Involving a greater diversity of health professionals within Step 3 may have also identified differing education priorities and potentially increased the comprehensiveness and usability of the resource. For example, the volume of information about interventions such as medications and supplements may have been increased if education priorities were investigated with General Practitioners, pharmacists or dietitians. Our expert opinion review was also biased towards those known by the research team. Additional peer review of our content by other experts, health professionals and people living with knee osteoarthritis is encouraged, alongside the planned periodical review of content to facilitate regular updates to align the toolkit to the latest evidence and user needs.

Conclusion

We have outlined the three-stage, six-step process used to co-design the novel theory-informed TREK ‘My Knee’ education and self-management toolkit. This web-based toolkit creates potential opportunities to enhance patient engagement with first-line care and self-management, which may improve clinical outcomes. It can be used independently by people with knee osteoarthritis, or in collaboration with a health professional. Future research will determine feasibility and effectiveness of the toolkit and inform its continual improvement.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076231163810 - Supplemental material for Co-design of the web-based ‘My Knee’ education and self-management toolkit for people with knee osteoarthritis

Supplemental material, sj-docx-1-dhj-10.1177_20552076231163810 for Co-design of the web-based ‘My Knee’ education and self-management toolkit for people with knee osteoarthritis by Anthony J Goff, Danilo De Oliveira Silva, Allison M Ezzat, Kay M Crossley, Marcella F Pazzinatto, Christian J Barton and in Digital Health

Footnotes

Authors’ Note

Lived experience group : Shirley Allott,Phillip Goode,Barbara Griffiths,John Heath,Lawrence Jacks,Ray Pereira,Fiona Seymour,Ernst Willheim,Maureen Young. Health professional group: Dawn Aitkin,Susy Baezinger,Emily C Bell,Jocelyn Cefai,Amy Dennett,Lachlan Dewar,Alex Donaldson,Adrienne Forsyth,Ali Gibbs,David Hunter,Jo-Anne Manski-Nankervis,Marie March,Mark Merolli,Paul O’Halloran,Clare Patterson,Soren Skou,Sze-Ee Soh,Monique Strelnikow,Jade Tan,Clodagh Toomey and Jason Wallis.

Contributorship

AJG,CJB and DOS conceived the co-design process. AJG,CJB,DOS,AME,MFP and KMC were involved with co-design processes,analysis and creation of the online toolkit. AJG,CJB and DOS wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Declaration of Conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research,authorship,and/or publication of this article: CJB is the Founder of the not-for-profit Translating Research,Evidence and Knowledge (TREK) initiative. DOS is the Co-Founder of the not-for-profit Translating Research,Evidence and Knowledge (TREK) initiative.

Ethical approval

The human ethics committee of La Trobe University approved the co-design process used in this study (HEC 20188),plus the concept mapping methodology outlined in Stage (i) (HEC 19211).

Funding

The author(s) disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: The author AJG held a sponsorship from Singapore Institute of Technology for the completion of his PhD at La Trobe. The financial sponsor played no role in the design,execution,analysis and interpretation of data,or writing of the study.

Guarantor

AG.

Supplemental material

Supplemental material for this article is available online.

ORCID iD

Anthony J Goff

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