The overarching goal of this project is to explore ways in which design can empower and engage the public and the healthcare system in the social determinants of health and their detrimental effects.

Desk Research and Expert Interviews

Given there is a significant body of existing research in this area, I first conducted a review of available literature and used the outputs to create a discussion guide for interviews with experts in public health, epidemiology, digital health and health communication. While these sessions gave me direction as to potentially viable routes for product development and ideas for eventual use cases, they also raised questions about whether efforts to engage the public could themselves be disempowering.

Online Participatory Action Research

Due to the COVID-19 pandemic I had to find new ways to interact with and design for the general public. Over the last 12 months I have been running a series of advertising campaigns on social media.

Facebook adverts using simple images and statistics (including those shown in the attached images) were used as a means of prompting members of the general public to complete an online questionnaire and comment or interact with the advert itself. The responses to these adverts have ranged from helpful and expected, to dangerous and bizarre. As public interest in health and the disproportionate risks experienced by BAME groups skyrocketed during the COVID pandemic so did interaction with the adverts, with comments often mirroring public dialogue in the UK.

Responses received via the questionnaire and comments/interactions on Facebook have been used to create a number of ‘target user’ personas. In turn, these personas have been used to inform iteration of the advertising campaign and messaging, alongside the creation of a rapidly prototyped online calculator. Discussion with a sociologist highlighted that using the personas within any eventual digital product could be a valuable means of building empathy and understanding amongst users. Additionally passive analytics on the web-based prototype and discussion with a select number of users has been used to refine the prototype user journey.

The use of promoted advertising through social media is intended to be a response to the use of memes/viral images as a means of spreading misinformation and 'fake news' about coronavirus and public health more broadly. This technique itself is evolving over the course of the project.

Speculative Design

Inequality and its impacts are an institutionalised aspect of modern life, and can feel like an insurmountable problem to tackle. The daunting scale of the challenge led me to set ‘speculative design’ as an appropriate means of bypassing the often limited ‘how could a quantification be created?’ questions and focus on implications and opportunities presented by solutions. One means of generating ideas which can aid critical thought is ‘Morphological Analysis’ as popularised by Victor Papenek in his book ‘Design for the Real World’ (Panapek, 1972). By utilising a three dimensional matrix, I have been able to rapidly generate potential applications and ecosystems which the underlying ‘health inequality metric’ could exist within. The ideas will first be ‘triaged’ based on predetermined criteria, with several selected for further use as design probes during interviews with relevant experts. While the application concepts used as ‘probes’ will be purely speculative, the eventual proposals outlined in my thesis will be assessed for economic, clinical, regulatory and ethical viability to ensure that anything created is usable in the real world.

A large proportion of global morbidity and mortality is preventable. A group of conditions often referred to as preventable or lifestyle-related diseases (such as Type II Diabetes, Stroke and even Depression) are associated with a set of known, measurable risk factors which evidence has shown can be targeted and reduced. Existing interventions and policies have primarily promoted and facilitated behaviour change on an ‘individual’ level as a means of reducing exposure to preventable risk factors, such as initiatives to reduce the incidence of smoking, increase physical exercise or improve diet quality. These programs often involve tools which allow the impact of behaviour (e.g. smoking) or risk factor on an individual’s health be estimated.

The social determinants of health are a similar set of established risk factors known to strongly influence our health and life in many ways, however outside of scientific research little effort has been applied allowing the public to understand their impact and engage in their reduction. I became interested in whether these additional risk factors for preventable disease which we have little control over could be quantified using digital tools to awaken activism, empower education and awareness, augment primary and secondary healthcare and ultimately reduce the health repercussions of SODH.

After initial desk research into the most impactful determinants, and some discussion with relevant experts I decided to break my project into two work streams: ‘concept’ and campaign’. The concept work stream has explored the quantifying tool, it’s inputs, underlying calculations, suitable evidence and speculated on whether novel technologies (such as machine learning) could be used to augment the eventual product. While these sessions were highly useful they also raised questions about whether efforts to engage the public could themselves be disempowering. At this point I decided to test my assumption that health inequality reducing solutions would be of interest and value to the public, by directly asking them through participatory action research.

The campaign work stream has used participatory action research methods through the application of social-media advertising. Facebook adverts using simple images and statistics (including those shown in the attached images) were used as a means of prompting members of the general public to complete an online questionnaire and comment or interact with the advert itself. The responses to these adverts have ranged from helpful and expected, to dangerous and bizarre. As public interest in health and the disproportionate risks experienced by BAME groups skyrocketed during the COVID pandemic so did interaction with the adverts, with comments often mirroring public dialogue in the UK.

During participatory action research on Facebook, my advertising campaign was unexpectedly restricted and my ability to create promoted posts was temporarily blocked. I have since discovered this was a result of the advertisement content being deemed ‘political or special interest’. While ‘health inequality’, here meaning here avoidable, unfair or systematic differences in health between different groups of people, is a well documented global phenomena which is not inherently political it would appear that proactive initiatives to reduce it are as they are based on the assumption that all people deserve the right to the highest attainable standard of health. After drafting a political statement I have since regained my ability to post adverts.

Responses received via the questionnaire and comments/interactions on Facebook have been used to create a number of ‘target user’ personas. In turn, these personas have been used to inform iteration of the advertising campaign and messaging, alongside the creation of a rapidly prototyped online calculator. Additionally passive analytics on the web-based prototype and discussion with a select number of users has been used to refine the prototype user journey.

I plan to put the next version of calculator live and continue to iterate whilst drafting speculative concepts on potential applications of a health inequality metric. These speculative outputs will be assessed for economic, clinical, regulatory and ethical viability to ensure that anything created is usable in the real world.

Many factors influence our health. From things we can control (e.g. level of physical activity and diet), to those which are predetermined at birth (genetic factors) and aspects of our lives which we have little ability to change (location and social factors) all act to together to impact our risk of disease, life expectancy, mental health, and even our sleep.

In addition, the way we learn about and engage with our health is changing. New technology has facilitated intuitive and low-cost health measurement and education through smartphone applications, websites and new and engaging forms of media (e.g. podcasts, web series). These new tools have been used for conventional means of preventative healthcare and reduction of lifestyle-factor related risks, i.e. smoking cessation, exercise tracking and chronic disease management.

We now know much of an individual's risk of preventable disease is determined by factors which are outside their control, for example their sexual orientation or immigration status. These factors, otherwise known as the social determinants of health (SODH), dictate much of our mental and physical health and cover for example housing, education, exposure to pollution, gender, and ethnicity. Social determinants act through causal chains to alter our risk of disease, for example ethnicity can impact access to healthcare resources or health literacy which can in turn increase risk factors for a number of preventable diseases. These differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work and age are referred to as ‘Health Inequalities’ and are often ignored by the Healthcare Systems of the 21st century. This neglect is in part due to their complexity, difficulty to articulate and recent emergence as an element of public health. Health inequality is fundamentally wrong and should be incorporated into the healthcare and preventative health systems of the future.