This study uses a convergent mixed methods design [40], with qualitative and quantitative data collected in parallel, to cocreate a digital health intervention for international students preparing for primary care consultations in Germany. The structure and methods of the cocreation workshops were specified in advance; building on a prior communication intervention (DiPPT) in obstetric care [41,42] and adapting it to the current target group.

Data integration occurred at the interpretation stage through narrative integration [43,44]. Quantitative survey data were used to descriptively characterize cocreators, summarize health care experiences, waiting room experiences, preparation behaviors, and evaluate ratings of existing DiPPT lessons. Qualitative data were used to explore and contextualize these experiences and behaviors in greater depth to identify needs and preferences for a redesigned digital intervention. See Table 1 for how qualitative and quantitative data were used to understand cocreators’ experiences and behaviors, and inform the adaptation of DiPPT for international students accessing primary care in Germany.

Ethical approval for the study was granted by the Ethics Committee at Constructor University (application number: 2022_01_B). All cocreators provided informed consent prior to taking part in each workshop and were informed about the purpose of the study, the types of data collected, and their rights as cocreators. Eleven out of 12 cocreators were employed as paid contributors and compensated equally based on the number of hours they contributed to the project (US $14.36/h). One cocreator was unable to receive payment due to visa-related employment restrictions and participated voluntarily. To protect cocreator privacy and confidentiality, audio recordings and workshop materials were anonymized with disclosure controls applied to names, health conditions, institutions, countries, and locations.

The original digital intervention (DiPPT) was developed to support communication between pregnant women and health care professionals in obstetric care [41,42,45,46]. The web-based tool delivered structured communication training through short lessons and exercises designed to help expectant mothers prepare for consultations and express concerns clearly. The intervention targeted safe communication behaviors during maternity care encounters and was informed by the Health Action Process Approach (HAPA) model, primarily using action planning (BCT 1.4) to encourage patients to plan for obstetric and midwife consultations ahead of time.

To ensure the intervention was grounded in real-world experiences, international students were engaged as cocreators. The following section outlines how they were selected and involved in a series of cocreation workshops designed to explore patient behaviors and collaboratively adapt a digital preparedness tool using the BCW [39]. Additional details are mentioned in Supplement 1 in Multimedia Appendix 1 that consists of a full list of tools used to collect data from cocreators.

Twelve international students participated in the cocreation workshops. Half reported living with a long-standing illness, including conditions related to mental health, musculoskeletal issues, and respiratory disorders. Despite this, most cocreators had visited a GP fewer than 5 times in the past year. Supplement 4 in Multimedia Appendix 2 provides detailed information about all data visualizations describing cocreators.

Cocreators described health care as an environment in which emotional uncertainty, system-level barriers, and communication breakdowns were common. Despite these challenges, many took active steps to prepare for appointments, suggesting that patient preparedness may be a promising target behavior. Insights from the workshops are presented below and summarized in Table 2. See Supplement 5 in Multimedia Appendix 5 for all data visualizations relating to cocreator experiences and behavior when receiving care.

Quantitative findings further showed that most cocreators viewed communication as a shared responsibility between physician and patient, although few felt that patients should take the lead role (Table 2 and Supplement 5 in Multimedia Appendix 5). Qualitative findings expanded on this pattern by demonstrating that cocreators generally expected physicians to assume primary responsibility for facilitating effective communication because of their duty of care or professional obligation.

Focus groups revealed differences in how patients prepared for their appointments. Cocreators frequently described taking notes, listing symptoms, or researching conditions the day before or on the way to the clinic. These actions were intended to structure the consultation, ensure efficiency, and psychologically prepare for the encounter. “Taking notes” was one of the most frequently coded behaviors in the dataset. Some cocreators used preparation as a way to prompt the physician, express concerns clearly, or guide the direction of the conversation.

Qualitative data revealed that while the concept of a DiPPT was welcomed, the design must prioritize usability and relevance. Rather than structured training, cocreators sought lightweight, responsive features that could flexibly support them before and during primary care consults. These insights are detailed below and summarized in Table 3. Supplement 6 in Multimedia Appendix 6 outlines all data visualizations relating to cocreator needs for the digital health intervention.

This study adopted a convergent mixed methods design to cocreate a DiPPT with students from an international university in Germany. To our knowledge, this study is the first to explore the health care needs and experiences of international students accessing primary care in Germany and to use these insights to cocreate a DiPPT. Quantitative and qualitative data together captured international students’ health care experiences, preparation behaviors, and perceptions of a digital preparedness intervention. Integrating quantitative and qualitative findings enabled interpretation of both the prevalence and context of cocreators’ experiences. Survey findings provided descriptive insight into communication perceptions, health care experiences, and waiting room conditions, while qualitative findings contextualized these patterns by exploring emotional vulnerability, preparation behaviors, and intervention preferences in greater depth. Cocreators’ needs explored in the qualitative data included both interpersonal communication needs and challenges as well as broader system-level barriers related to navigating the health care system and accessing services. Importantly, these findings suggest that the health care experiences of international students may reflect the more general experience of young adults navigating an unfamiliar health care system independently for the first time. Collectively, the data informed a design specification for a digital intervention tailored to international students in Germany while demonstrating a replicable approach for integrating cocreation methods and the BCW in digital health intervention development.

In the survey data, most cocreators agreed that communication should be a shared responsibility between physician and patient, and the majority disagreed that patients should carry the lead role. Qualitative findings indicated that despite the shared responsibility, physicians were expected to take the lead due to professional responsibility. The expectation that both parties should contribute to communication is consistent with evidence that younger people increasingly wish to participate actively in health care decisions rather than adopt a purely passive role [55,56]. Similarly, recent work on Generation Z has found that young adults value collaborative relationships with health care providers, leveraging digital fluency to become more health literate and actively taking part in decision-making [57]. However, expectations regarding who should lead the consultation may also reflect previous health care experiences in cocreators’ countries of origin. Most cocreators in the present study originated from Asia and Africa, where shared decision-making often differs from the Western European and North American model. Across many South Asian settings, patients commonly value involvement while expecting physicians to provide recommendations and assume greater responsibility for directing consultations [58-60]. Evidence from African settings is more heterogeneous, but similarly suggests that clinician authority remains influential in many contexts, while patients continue to value involvement in decisions [61,62]. Taken together, these findings suggest that the pattern observed in this study may reflect the combined influence of being a young adult seeking active involvement in health care while drawing on previous experiences of health care systems in which physicians are expected to take greater responsibility for guiding clinical discussions.

Findings from the survey data further showed how many cocreators felt misunderstood or not listened to, while qualitative findings provided insight into the perceived causes of these experiences, including language barriers, insufficient explanations, lack of empathy, and dismissive behavior. Across the focus groups, cocreators reported feeling emotionally vulnerable during primary care interactions. For international students, these experiences may be compounded by the transition to a new health care environment.

Cocreators described not only communication difficulties during consultations but also uncertainty about how health care services operate in Germany. This suggests that experiences of care are influenced by both being recent migrants and navigating an unfamiliar health care system independently for the first time. Emerging adulthood is characterized by increasing responsibility for managing one’s own health care, including recognizing when to seek care, arranging appointments, selecting providers, communicating symptoms, and making health care decisions without parental support [63]. Previous research has shown that young adults commonly experience uncertainty about how health care systems operate, question whether their symptoms warrant seeking care, worry about whether their concerns will be taken seriously, and often lack the health care knowledge and confidence developed through prior experience [64,65]. These challenges may be further amplified when young adults are simultaneously adapting to a new health care system with unfamiliar organizational structures, administrative processes, and communication norms. Previous studies in Hungary, Turkey, and the United States have reported similar findings: international students experienced language barriers, difficulties with appointment and insurance processes, perceived lack of dignity or insufficient care, and challenges navigating health care services [66-68]. These findings echo broader research documenting negative health care experiences among migrant groups in Germany, particularly concerning unclear communication, perceived indifference, cultural barriers and lack of dignity in care [69-72]. Complaints of dismissiveness and language barriers were among the most frequently coded responses, aligning with broader literature on migrant health care experiences in Germany [73,74].

This study confirms that in addition to provider demeanor, system-level needs and challenges also shape health care experiences of international students. While the surveys primarily characterized communication experiences and waiting room conditions, qualitative findings additionally identified broader system-level challenges, including difficulties arranging appointments, identifying suitable providers, and accessing digital infrastructure. These findings align with recent research showing that migrant groups in Germany often face structural barriers when navigating health care systems, including limited information about available services and administrative complexity [22]. While these challenges are common among migrant populations, they may have particular implications for international students, who must navigate unfamiliar health care processes independently for the first time. These findings highlight the importance of accessible, efficient, and supportive health care encounters for individuals who are unfamiliar with the health care system. Studies of digital health systems also suggest that insufficient integration of digital services and patient-facing tools within existing health care infrastructures can further limit accessibility and usability [14,75].

Cocreating an intervention with international students provided insight into how health care support may need to be tailored to this population. Cocreators preferred concise, practical, and multifunctional digital tools that could support both consultation preparation and broader health care needs.

Qualitative data also indicated that most cocreators actively prepared for consultations by taking notes and researching symptoms, with a motivation to improve communication efficiency and manage emotional stress. Preparation strategies were implemented just prior to appointments and were often used to prompt physicians during the consultation. This mirrors findings from previous studies highlighting that patients who prepare in advance are more likely to participate actively in clinical conversations [45,76]. While cocreators accepted shared responsibility for communication, they generally expected more engagement and empathy from providers, reinforcing the need for bidirectional communication efforts [77,78].

Feedback on the current DiPPT was mixed. Integrated qualitative and quantitative data suggested that perceptions of the intervention were influenced by both the content and delivery format of the lessons. The highest-rated lessons addressed challenges frequently identified by cocreators throughout the workshops, including obtaining clear information, communicating concerns, and preparing for consultations. In contrast, lower-rated lessons were perceived as more burdensome, less relevant to cocreators’ immediate needs, or as placing additional responsibility on patients rather than health care providers. This latter finding converges with cocreators’ views regarding communication responsibility, with cocreators generally expecting physicians to take the lead role in facilitating effective health care communication. Qualitative data further indicated dissatisfaction with lengthy lessons, quizzes, and open-ended exercises, while quantitative findings showed that the highest-rated lessons were among the shortest and least demanding components of the intervention.

Together, the data suggest that intervention acceptability may depend not only on addressing communication challenges experienced by patients, but also on presenting support in a concise, practical, and low-burden format that aligns with cocreators’ expectations of the doctor–patient relationship. Similar to findings in the literature [11,45], digital interventions that incorporate personalized feedback and patient-centered support are more likely to be adopted. However, many cocreators expressed skepticism about routine tool use, emphasizing that added features were necessary to drive engagement [79,80].

The BCW was used to derive design specifications for a DiPPT tailored to international students [81]. Cocreation insights were mapped onto COM-B determinants (Capability, Opportunity, and Motivation) to identify key behavioral drivers of patient preparedness (the target behavior) among international students (the target audience). Capability-related needs included structured communication support (eg, checklists), opportunity-related factors reflected physician encouragement and system integration, and motivation-related factors emphasized interactive and multifunctional features (eg, chatbots). The relationship between these determinants and resulting intervention features is summarized in Supplement 7 in Multimedia Appendix 7.

As a potential implementation pathway, the intervention may be embedded into university orientation programs and distributed via clinic-based pamphlets, thereby normalizing the practice of patient preparation among students. Moreover, orientation programs may benefit from providing international students with clearer information about how the German health care system functions. This approach is echoed by Abdulai and colleagues [82], who emphasize the importance of considering contextual factors and leveraging existing university support structures when supporting international students. Informing students about available health care services, as well as existing tools and resources for finding clinics, booking appointments, and accessing digital health services, may help alleviate some of the navigation challenges reported by cocreators in the workshops. Taken together, these findings offer a behaviorally grounded and contextually responsive foundation for intervention development.

This study illustrates the value of combining behavioral science frameworks such as the BCW and COM-B model with systematic cocreation methodologies, including the Health CASCADE guidelines [83] and the PRODUCES framework [38]. The PRODUCES framework helped in conceptualizing the problem, communicating the objective and design of, as well as identifying the cocreators to recruit as part of the workshops, and in determining the scaling strategy to use. The BCW played a key role in shaping the sequence and focus of the workshops, facilitating the identification of end-user needs and behavior change determinants. The design of the workshops was also guided by the work of Health CASCADE, who have developed cocreation guidelines [83], to create an inclusive and transparent process and ensure that cocreators’ voices were meaningfully integrated into the intervention’s design. By combining these methodologies with the BCW and COM-B, the study provides a replicable and scalable roadmap for developing digital health interventions that are grounded in theory and shaped by the lived experiences of users by means of acting as a role model. Together, these frameworks support the creation of interventions that are sensitive to real-world user needs, anchored in validated behavior change methods, and designed with sustainability in mind through participatory development practices.

While the previous section outlines the behavioral determinants and design specifications of the intervention, questions remain regarding its feasibility and potential adoption in real-world settings. Although cocreators expressed preferences for an intervention that would support doctor-patient communication, several indicated that they would likely use such a tool only once or before particularly important medical appointments.

The data also highlighted challenges relating to the digital medium. Together, the limited connectivity and skepticism towards a standalone communication app suggest that the intervention may function primarily as a situational preparation aid rather than a tool intended for continuous engagement. This pattern aligns with broader findings in digital health research showing that initial interest in digital tools often does not necessarily translate into sustained use [84,85]. Many digital health interventions experience rapid declines in engagement following early exposure, even when users report positive perceptions of their usefulness [86,87].

Adoption of digital health tools is also influenced by the broader environment in which they are deployed. Cocreators highlighted that the perceived value of a preparedness tool would increase if it addressed system-level challenges, such as appointment scheduling, clinic navigation, or access to medical documentation. Prior research has shown that digital health interventions are more likely to be adopted when integrated into existing care infrastructures rather than functioning as standalone behavior change tools [88,89].

If the intervention is primarily used as a one-off preparation tool, its effectiveness may therefore depend on where it is embedded within existing systems, such as appointment booking platforms, university health services, or patient portals. Future work should therefore explore which digital tools and communication channels international students currently rely on when navigating health services in Germany, as this may reveal more feasible points of integration. In some contexts, a lightweight intervention embedded within existing platforms or informational resources may be more appropriate than a standalone application.

To enhance cocreation and better understand the mutual communication between physicians and patients, future studies should consider involving physicians and clinic administrators as cocreators in the process. Additionally, the coding frame used for qualitative content analysis was limited in distinguishing between specific content, design, and functional preferences for digital tools. Future iterations should further refine coding categories with respect to specific aspects of the DiPPT that should be retained or excluded, and further delineating the miscellaneous categories for cocreator needs of a digital health intervention.

Furthermore, quantitative data were collected anonymously, preventing direct linkage with qualitative insights by person. Future designs should link cocreator data to deepen the understanding of tool acceptability among distinct user profiles. Finally, cocreation prioritizes depth of insight over statistical representativeness, so the study involved a small sample of international students (n=12), homogeneous with respect to age (19‐22 y), enrolled at a single English-speaking international university in Germany, limiting generalizability. Therefore, the findings presented here should not be interpreted as reflecting the needs of the broader migrant population in Germany. Moreover, the extent to which the findings are specific to international students, reflect broader migrant experiences, or arise from the intersection of student and migrant identities remains unclear. Further research is needed to disentangle these influences and examine the transferability of the findings to other populations. However, the methodological approach may be transferable to other contexts, and future research should extend this approach to diverse academic institutions, age groups, and include a wider range of cultural backgrounds.

The detailed reporting of the cocreation procedures and the transparent presentation of the coding frame provide a foundation that future researchers can use to inform the design of workshops with other migrant subgroups and settings.

In conclusion, this study identified key communication and system navigation challenges faced by international students in German primary care and translated these into design specifications for a tailored DiPPT. By integrating cocreation methods with the BCW and COM-B model, the study offers a foundation for future intervention development.