During 2017, Australia became home to 16,757 refugees [1]. Women and children, who comprised 87% [1, 2] of these new arrivals, face significant health challenges, including limited access to quality sexual and reproductive health (SRH) services [3, 4]. Poor SRH care has intergenerational consequences, affecting health and psychosocial outcomes for both mothers and their children [5]. Conversely, access to quality SRH services improves a number of health outcomes in women including prevention and management of high-risk pregnancies, reduction in unplanned pregnancies and abortions, reduction in obstetric complications, decreased anaemia and improved nutrition for both mother and baby [6, 7]. Despite these benefits, within Australia, women from migrant and refugee communities report less SRH awareness and experience reduced access to SRH-specific care as well as culturally-relevant support that could assist them to make evidence-based decisions about their own health and service utilisation [2]. A new approach to improve access to healthcare for underserved communities, particularly for women from refugee and migrant backgrounds, is needed, one that centres these women in the process of finding, developing and disseminating the solutions themselves.
Addressing public health problems through human-centred design (HCD) can be a more ethical and effective approach to developing solutions with underserved populations that are more likely to experience significant disadvantage or social marginalisation [8, 9]. HCD utilises multidisciplinary teams to approach the problem-solving process through three distinct phases: Inspiration, Ideation and Implementation [10]. HCD utilises “techniques which communicate, interact, empathise, and stimulate the people involved, obtaining an understanding of their needs, desires, and experiences, which often transcends that which the people themselves actually realised” [11]. Human-centred design, design thinking, co-design, co-production and co-creation are all terms that are often used interchangeably despite having nuanced differences in application and outcome. Each of these approaches focus on addressing complex problems and designing solutions with the end user communities (i.e. beneficiaries) [12, 13]. Design thinking is a specific set of stages within the HCD approach which help to guide problem solving teams through the whole experience as it diverges and converges the Inspiration, Ideation and Implementation phases in an iterative manner. Co-design, short for collaborative design is the process of design thinking steps that includes generative research (i.e. learning from end users) and development design (i.e. creating solutions with end users) [14]. This second, development design stage, is often termed co-production and together with co-design, these two stages form co-creation.
Studies have demonstrated promise that using HCD when developing health interventions can improve health outcomes for diverse populations [15,16,17] and that solutions developed using this approach result in increased uptake of services [18]; produce higher quality products and interventions; and that these products and interventions increased beneficiary satisfaction [19]. Importantly, this approach allows for the development of locally-driven, contextually-appropriate information that is crucial for meeting the health literacy needs of this population. However, a scoping review analysing 21 different studies for use of HCD in global health across various geographies and populations was unable to draw definitive conclusions about the effectiveness, because of the heterogeneity of implementation, application areas and contexts [20]. There remains a lack of understanding regarding how best to achieve and evaluate a successful HCD-driven solution [20] and how to destabilise power structures inherent to the HCD process itself. Maya Goodwill (2020) argues five different yet interrelated forms of power exist within the design process. These include privilege, access power, goal power, role power and rule power” [21]. These power differentials are present no matter how well-intentioned the design process is and there is a growing need to evaluate the implementation of programs that apply HCD principles, particularly when working with communities affected by the legacy of colonisation and systemic bias. Implementation evaluations not only assess a program’s deliverables against intended goals but also identify the strengths and weaknesses of a the implementation process, informing replication and efforts to scale [22]. To date, there are limited studies or reports detailing an implementation evaluation of an entire HCD project. Most studies address only one aspect of the design process such as planning [18, 23], prototyping [24] or assessing stakeholder engagement [25] but do not evaluate the entire approach. This study aimed to evaluate the HCD approach that Shifra, a small Melbourne-based not-for-profit focused on improving access to healthcare for refugees and new migrants, undertook in developing a web-based application to deliver local, evidence-based and culturally relevant SRH information to its users. Future papers will assess the relative success of the Shifra app in achieving its intended outcomes related to improving SRH literacy within non-English speaking refugee communities.
Context
The Shifra web-app (herein simply referred to as an “app”), provides high quality, rights-based information on family planning, pregnancy and newborn health, sexuality and sexual health, as well as mental health, family violence and adolescent health. Written and video resources provide information on accessing health services in Australia and cover topics such as healthcare rights and responsibilities, accessing translating and interpreting services, public and private insurance, as well as clinic locations [26]. The app was originally designed for English and Arabic-speaking communities living in Melbourne and is in the process of being translated into other languages. As Shifra is committed to working in partnership with refugee and migrant communities to create products that are both ethical and sustainable [26], the team chose to apply a HCD approach, using design thinking methods to prototype and eventually develop its digital health intervention. Co-designers for the app included refugee end users, subject matter experts (SMEs) from different, partner organisations that focus on health for multicultural communities, user experience (UX) students, and computer programmers. Given the sensitive nature of the content for this app, SMEs were used to support and reinforce the refugees’ opinions when designs may be seen by some in the community as confronting. This happened in one instance, where a refugee end user noted that icons used to reference herpes were inappropriate. The designers questioned this, an SME was independently consulted in the same session and supported the initial opinion that the image was inappropriate and should not be used. Following this session, the designer’s supervisor was notified of the issue and the refugee who made the initial observation was debriefed and reassured that her opinion was valid and paramount to the development of a sensitive and quality app.
Local partnerships were integral to completing many of the design steps. In 2017, Shifra collaborated with an undergraduate UX class from Monash University’s School of Art Design and Architecture. A semester-long process to design a digital health solution to bridge the gap in refugees’ access to SRH services resulted in five prototypes. Shifra’s founder (RB) then selected two designs to combine and develop further in conjunction with the co-designers to incorporate end users’ values and cultural beliefs [27]. The Shifra team used a combination of design thinking approaches developed by IDEO, Stanford’s d-School and Mummah et al. (2016) [10, 24].
IDEO’s Field Guide to Human Centred Design [10] and the Stanford d-School’s Process Guide influenced the development of the Empathise, Define, Ideate, Prototype and Test steps [28] however the external assessor renamed the Test step “Launch and Share”, to ensure appropriate dissemination of any product or early research findings as per Fig. 1 [24]. Given the importance of evaluating public health interventions yet the lack of robust methodology surrounding those that are co-designed, the Shifra team planned for process evaluation to be undertaken regularly and as objectively as possible.
Shifra’s human-centred design process
Empathise & define
Empathy sessions between Arabic-speaking refugees, refugee advocates and healthcare workers took place with final year UX students from Monash University throughout the first half of 2017. Researchers undertook CBPR activities and group surveys to better understand barriers and enablers to accessing healthcare for women from these refugee backgrounds. Partner organisation, Multicultural Centre for Women’s Health (MCWH), referred four refugee end users and two others were recruited using snowball-sampling techniques. MCWH also assisted in connecting the CBPR researchers to women interested in helping the Shifra team improve their understanding of the healthcare journey of different women from within these communities in Melbourne.
Ideate & design
UX students designed a solution based upon the insights gained during these empathy sessions. These designs were ideated then iterated with end users and other key stakeholders over several sessions throughout Monash University’s first semester in 2017. After selecting the winning design, Shifra’s founder participated in a hackathon hosted by Random Hacks of Kindness, a not-for-profit company that connects business analysts, programmers and UX designers with social impact organisations for weekend long prototyping meetups. Several computer programmers worked on Shifra at the event and continued to develop the technological component of the app until the next hackathon five months later. The beta version of this app was developed, tested and iterated with Arabic-speaking refugees over the next five months.
SMEs vetted health information and simplified content into plain language for accuracy and accessibility. After development of the initial prototype, a more advanced version was user tested with two different groups of co-designers. First, Arabic-speaking women tested the beta version of the app through a partnership with a local adult education program and neighbourhood house, located in Melbourne’s inner-city suburbs where one in four people are from migrant or refugee backgrounds. Again, the app’s content was user tested with SMEs for accuracy and accessibility. Online SMEs from around the world completed functionality and basic content testing via a Qualtrics online survey software and a group of local SMEs then met in person to review and edit the health content, ensuring it was evidence-based before simplifying the information further into plain English prior to Arabic translation. The six people who attended user testing sessions and the all SMEs were recruited using snowball-sampling techniques.
Launch & share
Shifra launched the beta version of the app in August 2017 with an event attended by co-designers, supporters, and funders.