human centered design research paper

Bridging Implementation Science and Human-Centered Design: Developing Tailored Interventions for Healthier Eating in Restaurants

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• Published: 09 September 2024

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• Melissa Fuster   ORCID: orcid.org/0000-0001-6357-9986 1 ,
• Shelby Hipol 2 ,
• Terry TK Huang 3 ,
• Uriyoán Colón-Ramos 4 ,
• Cara Conaboy 1 ,
• Rosa Abreu 5 ,
• Lourdes Castro Mortillaro 2 &
• Margaret A. Handley 6  

Restaurants are important institutions in the communities’ economy with the potential to promote healthier foods but have been under-engaged in public health nutrition efforts. In particular, independently owned, minority-serving and minority-owned restaurants, remain under-represented in nutrition promotion efforts despite disproportionate burdens of diet-related health outcomes among minority populations. Addressing this gap in engagement, we undertook a process of co-designing and implementing healthy eating-focused interventions in two Latin American restaurants in New York City, combining the Behavior Change Wheel intervention development framework with a Human-Centered Design approach. Restaurant owners and chefs were involved in the research synthesis and solution development processes, resulting in two tailored interventions. This paper describes this co-development process and offers reflections and lessons regarding: (1) implementation research in community settings, (2) the application of Human-Centered Design to promote the uptake of community-based interventions on food and health equity, and (3) the combined use of Human-Centered Design and Implementation science in these complex community settings.

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Diet-related non-communicable diseases, such as heart disease and diabetes, are among the leading causes of death globally. In the United States, ethnic and racial minority populations, including Hispanics, are disproportionately affected by these conditions (Daviglus et al., 2014 ). The pressing nature of this problem requires new ways of promoting healthier eating habits, moving beyond individual-focused interventions to those that address the social and physical environments influencing food choices. Moreover, in line with recommendations from the World Health Organization, health promotion must include collaboration with stakeholders to focus on their needs and strengths, developing interventions via participatory, context-specific, multi-level, approaches (WHO, 2017 ).

Foods away from home are increasingly important and have been associated with poor dietary outcomes (Kityo & Park, 2022 ; Liu et al., 2020 ; Meza-Hernández et al., 2023 ; Polsky & Garriguet, 2021 ; Salleh et al., 2021 ; Wellard-Cole et al., 2022 ). These foods can be acquired through a variety of restaurants, yet, most research has focused on fast foods, with restaurants serving ethnic foods remaining an under-studied and under-engaged sector (Fuster et al., 2021 ).

Restaurants are complex settings that require solutions that align business goals, consumer demands, and community health, necessitating innovative and theory-driven approaches to promote change. Having restaurants facilitate healthier choices may seem at odds with the perceived lower profitability of healthier choices, related to whether owners view there is a demand for such offerings (Glanz et al., 2007 ). Moreover, restaurants serving ethnic or cultural foods face unique challenges, given customer expectations for authenticity in these cuisines, even when standards for authentic dishes are highly debatable and subjective depending on customer knowledge and perception of the given cuisine (Shahrin & Hussin, 2023 ). These aspects make Latin-American restaurants a unique and important sector for further engagement and research, with potential lessons learned for other restaurants serving ethnic cuisines in global contexts.

Our work sought to understand the complexity inherent to changing consumer nutrition food environments in Latin American restaurants, addressing contextual barriers in the design and implementation of interventions to improve intervention tailoring within diverse community contexts. This study applied human-centered design (HCD) approaches in tandem with theoretical frameworks from implementation science. We worked with two Latin American restaurants in New York City to develop tailored interventions with the goal of increasing the sales of healthier menu items. The intervention and implementation outcomes of the resulting interventions have been published elsewhere (Fuster, Dimond et al 2023a ). In brief, the resulting interventions were rated as acceptable among restaurant owners, staff, and customers, and positive changes were sustained by the partner restaurants. However, these changes yielded modest increases in sales of healthier options in one restaurant and no significant changes in sales of healthier options in the second restaurant (Fuster, Dimond et al 2023a ). To further understand the intervention development process that led to these outcomes, this manuscript describes the integrated application of HCD and the Behavior Change Wheel framework (Michie et al., 2011 ) to glean insights into how to engage independently owned restaurants, a difficult-to-reach and complex sector.

Theoretical Framework and Approach: The Behavior Change Wheel and Human-Centered Design

We applied the Behavior Change Wheel, a comprehensive and systematic framework that synthesizes 19 frameworks of behavior change found in the literature (Michie et al., 2011 ), as the theoretical framework guiding the intervention design. The Behavior Change Wheel is guided by the Capability, Opportunity, and Motivation for Behavior (COM-B) Model, which approaches behavior change as the result of the interaction of its main components: Capability is addressed as physical (i.e., whether the individual has the needed skills to engage in the desired behavior, such as offering healthy foods on the menu) and psychological (i.e., an individual’s comprehension and knowledge, such as about healthy alternatives to population dishes). Opportunity encompasses the external factors influencing the behavior, including physical (i.e., aspects of the built and food environments that influence behavior) and social opportunity (i.e., cultural and social norms that influence the behavior, such as beliefs that restaurants are places to celebrate through rich foods). Lastly, motivation encompasses the internal processes that direct behavior, including reflective (i.e., evaluations and plans) and automatic (emotions) motivation (Michie et al., 2011 ). COM-B facilitates a better understanding of what needs to change for a specific behavior to happen and results in a behavioral diagnosis with related strategies, or intervention functions, that can be applied to facilitate change and the desired behavior, as part of the Behavior Change Wheel process. The Behavior Change Wheel was selected given its comprehensive and practical approach to promote behavior change, evidenced in its wide application, including in the promotion of healthier eating behaviors (Beck et al., 2019 ; Craveiro et al., 2021 ; Lucas et al., 2020 ; Timlin et al., 2021 ; Willmott et al., 2021 ).

We complemented the Behavior Change Wheel with HCD to directly help move insights into actionable innovations that restaurant owners and staff could realistically implement and sustain. HCD can be defined as the use of a designer’s mindset and tools to collaboratively develop solutions alongside the end users that are constructive, experimental and rooted in customer needs and contexts. For this project, that meant working alongside restaurant owners, chefs and staff to co-create potential healthy eating innovations that could appeal to their customer needs and wants. We selected this approach given its potential to create needed innovations for chronic disease prevention by acknowledging and empathizing with customer needs, context and preferences as well as the restaurants’ ability to implement and sustain these needed innovations. The approach applies abductive and reductive processes to create innovations through critical and creative thinking (Holeman & Kane, 2019 ; Huang et al., 2018 ; Matheson et al., 2015 ).

In our work, we followed the processes outlined via the Behavior Change Wheel framework in parallel with those undertaken as part of HCD (Fig.  1 ). The first stage in the Behavior Change Wheel process is to understand the behavior — paralleling the empathize and define stages of HCD — to arrive at a problem statement. We then used iterative ideation and prototyping alongside the Behavior Change Wheel application of theory to identify intervention and implementation options (Fig.  1 ).

Study Overlapping Frameworks/Processes and Associated Activities. The Human-centered design (HCD) process was adapted from (Liu, 2016 ) and the Behavior change wheel (BCW) process adapted from (Michie et al., 2011 ). Abbreviations: COM-B: Capabilities, Opportunities, and Motivation for Behavior Model, NEMS-R: Nutrition Environment Measurement Survey for Restaurants, and LAR: Latin American Restaurant

The process was undertaken by a multidisciplinary team to account for and include different perspectives and motivate transdisciplinary innovation. Our design team incorporated diverse perspectives beyond public health experts and practitioners, including nutrition and culinary experts, hospitality management, designers, and public health researchers. Using insights about consumer preferences from the formative research, described next, the design team collaborated with the end users – restaurant stakeholders – through formal and informal consultation activities to plan, validate and analyze potential innovations.

Formative Research

The work presented in this manuscript builds on previous, formative research. We first conducted a scoping review of peer reviewed studies and industry reports examining healthy eating promoting changes in restaurants, including those motivated by public health interventions and those initiated by restaurants in the past twenty years. This work has been described in detail elsewhere (Fuster et al 2021 ). In brief, the review revealed differences in the type of strategies initiated by public health interventions compared with those initiated by restaurants. Changes in food availability (e.g., adding salads to menus, providing vegetarian options) were more common among corporate restaurants, while environmental facilitators (e.g., providing nutrition information, promoting healthier offerings) were more commonly initiated by public health researchers and associated with independently-owned restaurants. However, the scoping review revealed that most of these initiatives are taking place in corporate restaurants. The work also showed the need to apply practice-based evidence in the field and account for restaurant business models to tailor interventions and policies for sustained positive changes in these establishments (Fuster et al 2021 ).

Research was also undertaken to examine restaurant and customer perspectives concerning the healthy eating promoting strategies uncovered in our review. This included qualitative research with Latin-American restaurant owners and staff documenting their experiences, perspectives, barriers, and facilitators concerning healthy eating promoting strategies. This work showed that the most acceptable strategies for the Latin-American restaurant stakeholders that participated in the study were those that highlighted existing healthier items in the menu or via promotional efforts, followed by increasing healthy offerings. The least acceptable were the inclusion of nutrition information and reduced portions (including half-portions). This formative work also helped the academic team enumerate the resources needed for implementing the suggested changes, including nutrition knowledge, additional expertise (e.g., design, social media, culinary skills), and assistance with food suppliers and other restaurant operational logistics (Fuster et al 2022 ). The customer perspective included a survey with individuals that visit or order from Latin American restaurants on at least a monthly basis to examine perspectives and barriers concerning healthier eating in Latin American restaurants, applying the COM-B model. The examination revealed that while a greater proportion of the respondents had the capability to select healthier choices at Latin American restaurants, motivation and opportunity were relatively low (Fuster, Santos et al 2023b ). This previous work informed the activities conducted at each partner restaurant, detailed below.

Study Context and Restaurant Outreach

This project took place in New York City, where 28.9% of the population identifies as Latino/Hispanic (US Census, 2022 ). Our formative research began in February 2020. Restaurant outreach began in the Summer of 2020, initially adapted to a virtual approach given the onset of COVID-19. We used social media as an initial point of contact, as well as community networks and word of mouth. This initial effort included respondents representing a total of 13 restaurants, with 10 of those located in New York City, the location of the study team at the time. From this initial sample, five restaurants expressed interest in working with us in the development of tailored innovations. However, three of those dropped out due to operational issues. Specifically, one restaurant had to temporarily close due to issues with the kitchen equipment. Another restaurant was undergoing an internal dispute over ownership. The third restaurant was lost to follow-up due to the owner not being responsive when the team sought to schedule initial discussions to review the collaboration plan. These restaurants were all independently owned and relatively small in terms of size and staff capabilities (fewer than 10 employees), where the owners usually took on multiple roles (e.g., cooking, serving, managing). This was further compounded by the staff shortage that came as a result of COVID-19 (Sugar, 2022 ).

We collaborated with two Latin-American restaurants (LAR1 and LAR2). LAR1 was a counter-style restaurant located in a food hall, serving Puerto Rican food. Upon first contact, the restaurant had been in business for less than a year. As a counter-style restaurant, they were able to manage the initial COVID-19 closures because delivery and take-out were a core part of their business model. LAR2 was a full-service Mexican restaurant which had been open for two years prior to this project. They had to make major adaptations to the business upon the onset of COVID-19, including a limited delivery service and the temporary selling of packaged goods. While our engagement with the partner restaurants occurred during some COVID-19 restrictions, the intervention development process took place during the period of gradual opening when restaurants were allowed to open at full capacity starting in June 2021 ( A Demographic Snapshot , 2020 ).

The two partner restaurants received a collaboration process overview document detailing the intervention development and testing activities, including the engagement and data needs, as part of the consent process for their participation in the process and pilot study. Incentives for participation included the provision of market research insights from our data collection efforts, the covering of intervention-related costs, stipend for staff and owners to participate in interview efforts (pre- and post-intervention testing period, $50/interview), and a $300 payment to the restaurant upon the completion of the activities.

Intervention Development Process

Building from our formative research, the following sections present the intervention development process as detailed in Fig.  1 . The activities specific to the partner restaurants began in June 2021, lasting a total of 4 months, concluding with the implementation of the tailored innovations. The engagement with both restaurants happened in parallel, beginning in June 2021 in LAR1 and in July 2021 in LAR2. We first describe the HCD process and then the Behavior Change Wheel process, occurring simultaneously (Fig.  1 ).

Stage 1: Empathize (Discover)

The intervention design process began with an information-gathering stage that aimed to build understanding and empathy with the full scope of our end users, in this case, the restaurant owners, staff, and customers. This stage involved contextual structured observations, immersions, and interviews. Approaches and insights are presented below by first focusing on the context (the partner restaurants) and then examining the users within those contexts.

Contextual Insights: Environment and Menu Assessments

We gathered key insights from the partner restaurants using semi-structured interviews with owners and staff (completed during the formative research, see Fuster et al 2022 ), non-participant structured observations, an assessment of the consumer nutrition environment, and the nutritional analysis of best-seller items to discover potential areas for innovation or for enhancement, with the goal of motivating healthier choices.

The structured observations involved the systematic recording of phenomena in a given context, using a fly-on-the-wall technique where researchers watch activities as an unobtrusive observer to avoid changing people’s behaviors (Penin, 2017 ). We carried out onsite and virtual observation exercises. For onsite observations, we developed an observation protocol that incorporated the AEIOU of design: activities, environment, interactions, objects and users. Activities refers to what people do and how they do it (i.e., standing in line, reviewing menus, customizing orders and answering/asking questions). Environment refers to the restaurant servicescape , including the layout, size, atmosphere, and appearance, evaluated using all five senses. Interactions include people-people, people-object, and people-environment interfaces or exchanges. Objects can be understood as touchpoints, or the physical materials that support or facilitate service (i.e., serveware, signage, technology). In this exercise, Users included customers, staff and others (purveyors, neighboring restaurant personnel, and online customers) (Penin, 2017 ). Two trained research assistants visited the partner restaurants to carry out the observations, collecting and taking note of independent observations and then comparing and merging their fieldnotes and insights. During this observation exercise, the trained research assistants also applied the Nutrition Environment Measurement Survey for Restaurants (NEMS-R), a validated measure to examine environmental barriers and facilitators for healthier choices in restaurants, including an assessment of the menu and environmental factors (e.g., promotional materials, pricing) (Saelens et al., 2001 ). This was complemented by observations of the partner restaurant’s social media activity, focusing on Instagram as the main medium for restaurant promotion during COVID-19, as indicated by our restaurant partners. We reviewed daily posts for a period of one week, coding these according to the image content (i.e., food, alcohol, community, environment images), and, if the image presented foods, we coded these to note potentially healthy foods (i.e., showcasing vegetables, non-fried items). The inductive coding process was done by two trained research assistants and reconciled during team meetings. This was complemented by reviewing promotional material including website and others, to get a sense of the restaurant brand and how the cuisine was defined and promoted.

The environmental analysis revealed potential areas for improvement and emerging differences between the partner restaurants (Table  1 ). We found fewer facilitators and more barriers to healthier choices in LAR1, particularly the emphasis on large portions, a prominent display of fried snacks, and the low availability of healthier options. While LAR2 did not actively promote the existing healthier choices, the overall environment did not encourage over-eating. Contrary to LAR1, LAR2 did not encourage large portions nor had unhealthier options (Table  1 ). The menu provided the option for half-portions for some dishes. When comparing the foods available, almost none of the dishes in LAR2 were fried and the restaurant included a healthy main-dish salad, an item not present in LAR1. LAR1 did offer a potentially healthy side — a green salad — although, according to owner and chef interviews, this was not often purchased by customers.

We also conducted a nutrition analysis of the restaurants’ top-five sellers or dishes that best captured the essence of each restaurant, as identified by the partner restaurant owners and chefs. We used Nutrium, a nutrient analysis software based on the USDA 2018 nutrient database to calculate the nutrient profile for each recipe, including calories, fat, saturated fat, fiber, and sodium. The USDA Guidelines for Americans, 2020–2025 and the FDA Regulatory Requirements for Nutrient Content were then used to interpret the nutrient profiles from each recipe ( Dietary Guidelines for Americans: 2020–2025 , 2020 ; FDA, 2013 ). To help contextualize the calorie count, the recommended daily allowance for calories published in the USDA Guidelines was divided by three, as a standard procedure to divide total daily allowances by the typical number of main meals consumed each day in the United States ( Dietary Guidelines for Americans: 2020–2025 , 2020 ; FDA, 2013 ). While we recognize that there tend to be more than three eating episodes in a day, we felt apportioning calories in this manner was a realistic and consistent way of accounting for calories. Nutrient analyses were also compared to the FDA regulatory requirements for nutrient content claims (FDA, 2013 ). This provided a specific metric with which to compare total fat, saturated fat, sodium, and fiber.

Our analysis revealed the more popular menu items from both restaurants were high in both total fat and saturated fat (Table  2 ). LAR1 menu options were all high in sodium. When the results were shared with the chef, he attributed this to the use of salt-based seasoning blends. At the same time, as a result of the incorporation of beans and green plantains in their dishes, the restaurant had some items that provided at least 10% of the daily allowance of fiber. Conversely, all but one of LAR2 dishes met the criteria for healthy regarding sodium content and all provided at least 10% of the recommended daily allowance of fiber (Table  2 ). Hence, confirming the NEMS-R menu assessment, LAR2’s menu seemed to offer more healthy options for diners.

Insights from the Customer Experience and Perspectives

Customer perspectives were gathered via immersion, on-site short interviews, and contextual structured observations, building on insights gained from the formative research. Immersions refer to team members taking on the role of customers at each restaurant to understand the experience from the perspective of the customers rather than just as researchers. The team practiced immersion to best understand the customer experience by becoming customers, ordering from partner restaurants and others serving similar cuisines. The team took self-reflective notes on the process, documenting their experience approaching the menu, including which dishes called their attention and whether the menu promoted or facilitated healthful orders. The resulting notes were discussed in team meetings, providing insights on their experience as customers, further facilitating our building empathy with the end user. This was complemented with short, semi-structured customer interviews conducted during the structured context observation exercise described above. Two trained team members carried out the interviews with a convenience sample of potential customers in the vicinity of the restaurants (6 per restaurant). All interviews were completed on the same day for each location, during the work week. In LAR1, the interviews took place around lunchtime, and in LAR2 the interviews took place in the late afternoon, given the different opening hours in these locations. These were individuals who might not necessarily be visiting the restaurant but who provided insights about potential customers to get a sense of their needs and preferences, which might not be met by the restaurant in its current state. The short structured interviews captured general experience with Latin-American restaurants, previous experience with the partner Latin-American restaurant (i.e. Have you eaten at a Latin American restaurant? If yes, how was your experience? If no, what would motivate you to eat at [partner Latin American restaurant]? ), and opinions concerning healthier eating at Latin American restaurants including soliciting ideas about potential changes. We collected minimal demographic information (gender, age, race/ethnicity).

The information gathered was synthesized using two approaches: The development of customer personas and the application of the COM-B Model. Personas are broad archetypes based on the data meant to portray potential end users for the team to keep in mind throughout the rest of the HCD process (Pearl & Intriligator, 2023 ). In this case, the personas were loose consumer archetypes based on interviewee’s stated preferences and priorities around healthy eating and their relationships and associations with Latin American restaurants, complemented by our additional data collection experiences. We reviewed the qualitative interview notes, distilling them down to each person’s most basic needs within them. Rather than defining every possible reason why people went to Latin American restaurants, we aimed to identify and map out some general themes so that we could tailor our interventions for the people who were most likely to benefit from or be interested in them. This resulted in five personas, showcased in Fig.  2 , mapped on a spectrum from prioritizing taste/authenticity to prioritizing health/dietary preferences. We used these personas to understand not only what was important to customers but also to identify which customers might be receptive to healthier options at Latin American restaurants. In conversations with the restaurant owners, as part of the next phase in the process (to be expanded below), we used this spectrum to illustrate that there was an audience that wanted healthier options, but that we would not be able to please everyone, such as customers following strict or restrictive diets.

Consumer Priorities Spectrum and Identified Opportunity Area

Our formative work surveying Latin American restaurant customers provided initial insights into perceived barriers and facilitators for healthier choices in Latin American restaurants mapped using the COM-B Model (Fuster, Santos et al 2023b ). We used our immersions and short interviews to develop the model further (Fig.  3 ). The COM-B diagnosis revealed the need to address psychological capability (knowledge), motivation (Automatic and reflective), and opportunity (physical and social) that would lead to ordering healthier choices at Latin American restaurants. Low knowledge concerning Latin American cuisines among the people interviewed led to the view of healthier options as not being authentic or an attempt to whitewash the cuisine. Specifically, there was a lack of knowledge concerning healthier ingredients (such as quinoa being native to South America) and cooking techniques. However, motivation and opportunity were more salient aspects. Motivation to select healthier options was thwarted by social opportunity (social and cultural norms) and physical opportunity (the availability of healthier options that are also perceived as enjoyable). In general, eating out was seen as a treat, where health was not the main focus. This was also expressed through the notion that “I can cook/eat healthier at home”.

COM-B Model Examining Customer Healthier Food Choice. x denotes areas that are lacking (barriers),✓denotes facilitators, and [mixed] denotes mixed results. Model based on formative and Empathize stage research

Stage 2: Define

The information gathered during the Empathize stage was used to define what needs to change, as shown in the COM-B analysis. This stage was undertaken with partner restaurants. We carried out workshops to share and discuss the results of our formative and discovery/empathize research and began brainstorming ideas for change (as part of the ideation process, presented in the next section). Each workshop lasted about three hours, engaging the owner and staff members (chef and marketing staff in LAR1 and chef in LAR2) through hands-on activities to facilitate the collaborative problem definition. The workshop was carried out onsite. We were able to discuss our findings within each restaurant context, which allowed us to deepen our understanding of the partner restaurants and validate the initial insights gathered as part of Stage 1. The discussion was focused on addressing opportunity and motivation for customers to engage in healthier choices – as the main areas of concerns revealed in the COM-B analysis (Fig.  3 ).

In LAR1, a key area for change was the need to increase the availability of healthy options – addressing physical opportunity through the environmental restructuring intervention function. While the establishment offered a side green salad, this was not selling, leading to food waste and consideration for elimination from the menu. This translated into the question: “How might we increase the availability of attractive healthy offerings, specifically, non-starchy/non-fried options?” with the related target behavior of having the chef increase the availability of attractive/innovative non-starchy/non-fried menu options. In LAR2, our analysis revealed that while the restaurant was already offering potentially healthy and innovative options, they faced the issue of some customers not accepting these offerings as authentic, pressuring the restaurant to offer less healthful options. This translated to “How might we change perceptions of healthy offerings as being inauthentic/not traditional?”, with the associated target behavior of having the restaurant owner increase social media messaging to promote healthier options as palatable and authentic. The emphasis on perceptions was geared to changing knowledge (psychological capability) and reflective motivation, COM-B drivers associated with the education intervention function.

Stage 3: Ideation

Once we defined what needed to change via the tailored “How might we” questions for each restaurant, these were used to guide an ideation session as part of the onsite workshop described above (see Stage 2). The session was facilitated through an initial presentation of ideas developed by the team, with more ideas added through discussion with the restaurant partners. We then engaged the restaurant partners in a sorting activity, where the ideas were sorted in three piles: Yes, No, and Maybe. In this exercise, the sorting process incorporated elements of the Behavior Change Wheel APEASE criteria, which stands for Acceptability, Practicability, Effectiveness, Affordability, Spill-over effects, and Equity (Michie et al., 2011 ). Among these criteria, our sorting process revealed the importance of acceptability, practicability, and affordability, when discussing potential changes with our restaurant stakeholders. Evaluation of these elements was guided by perceived limitations around cost, space, equipment, and staff capabilities, further detailed below by partner restaurant.

In LAR1, the focus was under the Behavior Change Wheel environmental restructuring intervention function to facilitate healthier choices. When ideas were sorted, those grouped under “yes” were ideas that were perceived as the most acceptable, practicable, and affordable. Some ideas involved incorporating new vegetables and healthier ingredients, including using farro or other whole grains, traditional vegetables (e.g., cabbage, squash, taro) and different types of beans. Resulting from this, another change discussed was redesigning the menu to create a small selection of pre-built bowls, including new healthier combinations to facilitate customer choice. Ideas that did not rise to the top (classified as no and maybe) were those proposing to change portion sizes, cooking techniques (e.g., replacing frying), and incorporating plant-based alternatives to meat (e.g., tofu). The proposal to offer half-portions for bowls also failed to meet the affordability criteria, as the owner noted the need to purchase additional bowl sizes as an added cost. Changes in cooking technique and the provision of meat substitutes was deemed as unacceptable for the restaurant, given perceived customer expectations and the vision for the restaurant.

In LAR2, the ideas were focused on how to change perceptions of the cuisine and promote healthier dishes on the menu. The ideas that were seen as the most acceptable, practicable, and affordable were those under the Behavior Change Wheel education intervention function, as ideas related to social media messaging around offerings, highlighting ingredients in connection to the country of origin and its sensorial qualities. The owner expressed interest in this, given the potential to increase social media engagement as part of restaurant promotional efforts, as a key factor for augmenting customer outreach and sales. Beyond social media, a second idea was having servers promote healthier offerings when talking to customers, including the co-development of training resources, but this was not seen as practicable, given the owner and staff time constraints, compounded by the potential for ongoing staff turnover. Other ideas discussed were related to potential environmental restructuring to motivate healthier choices, such as eliminating less healthful offerings, adding more healthful offerings, and providing healthful markers in the menu to facilitate customers selecting these choices. However, while these were acceptable, the owner did not see these as affordable or practicable at the moment, given his time constraints and the lack of staff to delegate these changes on. The completion of the in-person workshop was followed up with a team debriefing meeting, where ideas were further discussed, including potential effectiveness, spill-over effects, and equity considerations, as part of the APEASE criteria.

Stage 4: Prototyping and Resulting Interventions

The takeaways from the workshops were shared with the owners and staff as part of a subsequent meeting, where ideas were narrowed down for initial trials and quick tests (prototypes), prior to full implementation. During these meetings, we worked with the restaurants to devise a plan of action to test and refine the ideas. While we provided support, the processes were led by the restaurants, including when and how to test the ideas and their benchmark for success. This process took several meetings with the partner restaurants, allowing for the final intervention to be refined and implemented, as described below.

LAR1: Menu Redesign Based on New Healthy Offerings

In LAR1, the restaurant decided to move forward with two main changes: (1) the addition of new menu items based on a new component — a hardier version of a salad, including ingredients found in the traditional cuisine — and (2) redesigning the menu to feature pre-made bowls (including two healthier options, with the new vegetable offering) and eliminate a menu heading that highlighted fried foods, renaming it from frieds to snacks. The new vegetable component, initially called roasted, sofrito seasoned veggies (Verduras) included cabbage and a mix of other healthier vegetables (pumpkin, peppers) used traditionally in the cuisine. The dish underwent in-house testing, led by the chef. The menu redesign was done collaboratively between the research team and the restaurant owner, undergoing several rounds of revision before a quick test (soft-launch) to ensure clients and staff understood the new menu format and terminology. The process of developing and prototyping the updated menu required us to factor in both the consumers’ experience while ordering — the restaurant owner said that even though the original menu starts with the rice base, customers typically started with the type of protein they wanted in their bowls — as well as the restaurant’s computer system — similar to the original menu, orders were originally put into the computer system starting with the rice base, so the staff had to guide customers through the order process. Additionally, we factored in new customers’ unfamiliarity with the menu, introducing Signature Bowls to help guide their decision-making process. These pre-built bowls included best seller combinations and two new combinations, featuring the healthier verduras as base (instead of white rice) and as side, including a vegetarian option. The owner also agreed to eliminate a section highlighting fried snacks. While the fried offerings remained, these were placed under a Snacks section, which also allowed the restaurant more flexibility in adding new, non-fried snacks into this section of the menu in the future. The previously vegetarian option, called sin carne (without meat) was eliminated, with beans and verduras serving as additional mains for the menu. While the Sin carne was a bean-based bowl, the naming of the dish as without meat implied gave a sense of lack or deprivation, whereas listing beans as a main (alongside verduras) allowed clients to see these as equally important mains, as the animal-based offerings (chicken, pork, shrimp). Other additions included seltzer water as an alternative to plain water and sugary beverages and avocado slices as a healthy side dish traditionally consumed in the cuisine. Working with the owner and chef, the new vegetable offering (Verdura) was incorporated to different parts of the menu, moving beyond just a new side, as was the case of the green salad that was in place before.

LAR2: Social Media Promotion of Existing Healthier Items

In LAR2, the owner decided to move forward with a revamping of the social media strategy, with a focus on Instagram and Facebook, as the main platforms used at the time. We informed the process by seeking examples of similar restaurants showcasing healthier options in an appealing way, where these offerings were promoted primarily based on their sensorial enjoyable qualities and connections to the heritage cuisine. This approach was informed from our research, as well as other work that has documented how customers associate dishes labeled with deprivation and blandness, and not with the enjoyment and indulgence typically associated with eating out (Jun & Arendt, 2016 ). We worked with the owner and our team’s dietitian to identify the healthier items on the menu. These items were those identified as nutrient-rich, with known health benefits. Specific examples included items such as avocado (healthy fats), beans (high fiber content), vegetables, fish, and seafood.

The testing period involved a team member initially working with the owner to create posts and a schedule that would be feasible and promote healthier choices in the restaurant. The prototyping was focused on strategies that would ease the owner’s engagement in social media, seeking to address initial barriers identified. These included lacking appealing images for highly visual social media channels (as in the case of Instagram) and providing the owner for initial messaging and information to facilitate the image’s accompanying text. The team worked with the restaurant partners and engaged in further research to develop a toolkit of potential posts and keywords to highlight dishes’ flavor and historical connections to the cuisine. During this time, the team had ongoing discussions with the owner, allowing us to fine-tune postings and develop a toolkit for the owner to use to facilitate postings. We worked with a professional food photographer to provide the owner with a bank of new images to draw from, featuring these healthier dishes in an appealing way. The resulting intervention involved the owner continuing to devise these postings, seeking to increase the visibility of the healthier dishes, along with ongoing communication with the team to provide guidance as needed, facilitated through our ongoing monitoring of the owner’s social media activities and team check-ins.

Discussion and Implications

In this manuscript, we set out to describe the process of applying HCD alongside the Behavior Change Wheel to devise tailored interventions in two Latin American restaurants, engaging restaurants as a vehicle for health promotion via participatory approaches that leveraged their existing needs and strengths. In this study, our integrated use of HCD and the Behavior Change Wheel guided our conceptualization of the problem and the selection of interventions and implementation strategies. We also described specifically the use of the COM-B model for behavioral diagnosis and intervention function identification, along with the APEASE criteria to select the changes to be implemented. The resulting tailored interventions corresponded to identified areas for change based on the COM-B diagnosis, as follows: In LAR1, the intervention focused on increasing the availability of healthier options, corresponding to the need to address physical opportunity through the environmental restructuring intervention function. In LAR2, the intervention focused on changing perceptions of healthier options, corresponding to the need of changing knowledge (psychological capability) and reflective motivation, COM-B drivers associated with the education intervention function.

Our application of HCD was designed to facilitate a process of learning and discovery through our research and discussion with the owners and staff, which eventually enhanced the development and implementation of changes with the potential of facilitating healthier choices in these establishments. The changes were driven by the restaurants, with our team serving as facilitators to first motivate and then fine-tune and support the desired changes. This user-centered approach was essential in our collaboration, ensuring a relationship of trust and respect that greatly enhanced the process and our understanding about the perspective and challenges faced by this sector. While the resulting changes were limited to owner’s preferences, interests, and operational capacity, our application of HCD opened the doors for change to happen in the first place, even if limited, resulting in changes in attitude about engaging in changes in business practice, particularly in LAR1. The changes implemented responded to the perceived needs of customers and the level of feasibility for restaurant owners and staff. Additional strategies that may have had a greater impact on healthier menu item sales may have been viewed as irrelevant or not of interest in the establishments. At the same time, the alternative approach of implementing researcher-driven ideas from the get-go may simply be unsustainable, infeasible, and a waste of resources. Top-down approaches may even potentially close the opportunity for restaurant owners to open the door to future collaborations with public health researchers if relationships are perceived as uneven or not truly accounting for their lived experience in the sector.

Limitations

At the same time, the application of this approach has limitations and potential barriers that need to be taken into consideration. HCD is a new approach to developing interventions, digressing from other commonly used approaches, where, for instance, public health researchers approach community sites with an intervention or change already in mind. While our partner restaurant owners appreciated our co-development approach, this also confused in the beginning, requiring owners who were comfortable with the uncertainty and open to the process, a factor that was facilitated via the building of trusting relationships. Hence, this process requires time from all parties involved, which is a barrier when working with restaurant owners. Our team worked within their schedules, requiring a high level of flexibility. Another consideration is the need to be open about problem and solution definition when applying HCD, which requires the breaking of hierarchies among all involved, to shift views of who holds the expertise to facilitate innovations. Our HCD application was facilitated by our multidisciplinary team, including the participation of a designer with a background in food studies, who assisted in the development and facilitation of the workshops with restaurants, bringing key know-how on approaches to promote innovative thinking, with an understanding about the complexities involved in working with the sector.

The integration of HCD and the Behavior Change Wheel approaches is novel in public health, with notable exceptions particularly in the realm of technology-based interventions (Hendrie et al., 2019 ; Huang et al., 2020 ). In agreement with past conclusions derived from these studies, the use of HCD enhances the application of the Behavior Change Wheel framework, moving beyond more traditional data collection approaches to elicit user-driven innovations (Huang et al., 2020 ). The HCD process has empathy at its core, where the research team needs to understand and accommodate the process from the business perspective and allow the stakeholders to guide the direction of the process. This user-driven approach is a key strength of HCD, with the potential to enhance intervention design and implementation approaches, as is the case of the Behavior Change Wheel. Furthering public health engagement with HCD has the potential to move the needle on addressing diet-related health disparities by centering our focus on community needs and preferences. While our process uncovered tensions between the business and public health goals, these tensions are front and center in the process of iterating to make realistic changes in a dynamic system, in this case, restaurants, but more broadly, in a wide range of public health-focused community settings.

Implementation science is yet to be fully applied to inform and examine interventions implemented in complex community settings, particularly in under-engaged sectors such as Latin American restaurants. This work expands the application of this approach, enhanced by the use of HCD, following emerging trends and calls to bridge these approaches closer together to enhance the operationalization and uptake of evidence-based public health strategies (Chen et al., 2021 ; Dopp et al., 2019 ; Gottgens & Oertelt-Prigione, 2021 ). While HCD shares many characteristics with community-based participatory research, HCD can enhance collaboration and resulting interventions through an explicit focus on creativity, innovation, and the inclusion of multi-sectoral and multi-disciplinary perspectives (Chen et al., 2021 ). This distinction has immense potential to elucidate new solutions to persisting, complex problems, meriting the need for future work and engagement with HCD methods. Hence, HCD has the potential to be an innovative way to engage restaurants by ensuring that projects seek to include and meet their needs. The work presented is an advance on previous applications of HCD in public health (Bazzano et al., 2017 ), applying both HCD and the Behavior Change Wheel in an innovative setting and building on the sparse literature applying HCD to healthy nutrition (individual-focused) interventions (Cradock et al., 2022 ; Joshi et al., 2019 ).

References

Bazzano, A. N., Martin, J., Hicks, E., Faughnan, M., & Murphy, L. (2017). Human-centred design in global health: A scoping review of applications and contexts. PloS One , 12 (11), e0186744. https://doi.org/10.1371/journal.pone.0186744

Article   PubMed   PubMed Central   Google Scholar  

Beck, A. L., Iturralde, E., Haya-Fisher, J., Kim, S., Keeton, V., & Fernandez, A. (2019). Barriers and facilitators to healthy eating among low-income latino adolescents. Appetite , 138 , 215–222. https://doi.org/10.1016/j.appet.2019.04.004

Chen, E., Neta, G., & Roberts, M. C. (2021). Complementary approaches to problem solving in healthcare and public health: Implementation science and human-centered design. Transl Behav Med , 11 (5), 1115–1121. https://doi.org/10.1093/tbm/ibaa079

Article   PubMed   Google Scholar  

Cradock, K. A., Quinlan, L. R., Finucane, F. M., Gainforth, H. L., Ginis, K. A. M., Sanders, E. B., & ÓLaighin, G. (2022). Design of a planner-based intervention to Facilitate Diet Behaviour Change in Type 2 diabetes. Sensors (Basel) , 22 (7). https://doi.org/10.3390/s22072795

Craveiro, D., Marques, S., Bell, R., Khan, M., Godinho, C., & Peixeiro, F. (2021). Behavioural change box? Applying the COM-B model to understand behavioural triggers that support consumption of fruits and vegetable among subscribers of a fruit and vegetable box scheme. Public Health Nutrition , 24 (18), 6488–6498. https://doi.org/10.1017/s1368980021003839

Daviglus, M. L., Pirzada, A., & Talavera, G. A. (2014). Cardiovascular Disease Risk factors in the Hispanic/Latino Population: Lessons from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Progress in Cardiovascular Diseases , 57 (3), 230–236. https://doi.org/10.1016/j.pcad.2014.07.006

A Demographic Snapshot: NYC’s Latix Immigrant Population . (2020). https://www.nyc.gov/assets/immigrants/downloads/pdf/Hispanic-Immigrant-Fact-Sheet.pdf

Dietary Guidelines for Americans: 2020–2025 . (2020). https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf

Dopp, A. R., Parisi, K. E., Munson, S. A., & Lyon, A. R. (2019). A glossary of user-centered design strategies for implementation experts. Transl Behav Med , 9 (6), 1057–1064. https://doi.org/10.1093/tbm/iby119

Federal Drug Administration (2013). A Food Labeling Guide: Guidance for Industry . https://www.fda.gov/media/81606/download

Fuster, M., Abreu-Runkle, R., Handley, M. A., Rose, D., Rodriguez, M. A., Dimond, E. G., & Huang, T. T. (2022) Promoting healthy eating in Latin American restaurants: A qualitative survey of views held by owners and staff. BMC Public Health, 22 (1), 843. https://doi.org/10.1186/s12889-022-13294-7

Fuster, M., Handley, M. A., Alam, T., Fullington, L. A., Elbel, B., Ray, K., & Huang, T. T. K. (2021). Facilitating healthier eating at restaurants: A Multidisciplinary Scoping Review comparing strategies, barriers, motivators, and outcomes by Restaurant Type and Initiator. International Journal of Environmental Research and Public Health , 18 (4), 1479. https://www.mdpi.com/1660-4601/18/4/1479

Fuster, M., Dimond, E., Handley, M. A., Rose, D., Stoecker, C., Knapp, M., & Huang, T. T. (2023a). Evaluating the outcomes and implementation determinants of interventions co-developed using human-centered design to promote healthy eating in restaurants: An application of the consolidated framework for implementation research. Front Public Health, 11 , 1150790. https://doi.org/10.3389/fpubh.2023.1150790

Fuster, M., Santos, M. P., Dimond, E., Huang, T. T., & Handley, M. A. (2023b). Examining capabilities opportunities and motivations for healthy eating behaviors in Latin American restaurants: A quantitative application of the COM-B model to inform future interventions. BMC Nutrition, 9 (1), 57. https://doi.org/10.1186/s40795-023-00712-1

Glanz, K., Resnicow, K., Seymour, J., Hoy, K., Stewart, H., Lyons, M., & Goldberg, J. (2007). How major Restaurant Chains Plan their Menus. American Journal of Preventive Medicine , 32 (5), 383–388. https://doi.org/10.1016/j.amepre.2007.01.003

Gottgens, I., & Oertelt-Prigione, S. (2021). The application of human-centered design approaches in Health Research and Innovation: A narrative review of current practices. JMIR Mhealth Uhealth , 9 (12), e28102. https://doi.org/10.2196/28102

Hendrie, G. A., James-Martin, G., Williams, G., Brindal, E., Whyte, B., & Crook, A. (2019). The development of VegEze: Smartphone App to increase Vegetable Consumption in Australian adults [Original Paper]. JMIR Form Res , 3 (1), e10731. https://doi.org/10.2196/10731

Holeman, I., & Kane, D. (2019). Human-centered design for global health equity. Inf Technol Dev , 26 (3), 477–505. https://doi.org/10.1080/02681102.2019.1667289

Huang, T. T. K., Aitken, J., Ferris, E., & Cohen, N. (2018). Design thinking to improve implementation of public health interventions: An exploratory case study on enhancing park use. Design for Health , 2 (2), 236–252. https://doi.org/10.1080/24735132.2018.1541047

Huang, Y., Benford, S., Price, D., Patel, R., Li, B., Ivanov, A., & Blake, H. (2020). Using internet of things to Reduce Office Workers’ sedentary behavior: Intervention development applying the Behavior Change Wheel and human-centered Design Approach. JMIR Mhealth Uhealth , 8 (7), e17914. https://doi.org/10.2196/17914

Joshi, A., Amadi, C., Schumer, H., Galitzdorfer, L., & Gaba, A. (2019). A human centered approach to design a diet app for patients with metabolic syndrome. Mhealth , 5 , 43. https://doi.org/10.21037/mhealth.2019.08.13

Jun, J., & Arendt, S. W. (2016). Understanding healthy eating behaviors at casual dining restaurants using the extended theory of planned behavior. International Journal of Hospitality Management , 53 , 106–115. https://doi.org/10.1016/j.ijhm.2015.12.002

Article   Google Scholar  

Kityo, A., & Park, P. S. (2022). Eating away from home is associated with overweight and obesity among Ugandan adults: The 2014 Uganda non-communicable disease risk factor survey. Nutr Res Pract , 16 (3), 379–391. https://doi.org/10.4162/nrp.2022.16.3.378

Liu, J. (2016). Visualizing the 4 Essentials of Design Thinking. Medium . Retrieved March 24, 2023, from https://medium.com/good-design/visualizing-the-4-essentials-of-design-thinking-17fe5c191c22

Liu, J., Rehm, C. D., Micha, R., & Mozaffarian, D. (2020). Quality of meals consumed by US adults at full-service and fast-food restaurants, 2003–2016: Persistent low quality and widening disparities. Journal of Nutrition , 150 (4), 873–883. https://doi.org/10.1093/jn/nxz299

Lucas, G., Olander, E. K., & Salmon, D. (2020). Healthcare professionals’ views on supporting young mothers with eating and moving during and after pregnancy: An interview study using the COM-B framework. Health and Social Care in the Community , 28 (1), 69–80. https://doi.org/10.1111/hsc.12841

Matheson, G. O., Pacione, C., Shultz, R. K., & Klügl, M. (2015). Leveraging human-centered design in chronic disease prevention. American Journal of Preventive Medicine , 48 (4), 472–479. https://doi.org/10.1016/j.amepre.2014.10.014

Meza-Hernández, M., Durán-Galdo, R., Torres-Schiaffino, D., & Saavedra-Garcia, L. (2023). Sodium content in commonly consumed away-from-home food in three areas of Metropolitan Lima, Peru. Rev Peru Med Exp Salud Publica , 40 (3), 340–347. https://doi.org/10.17843/rpmesp.2023.403.12939 (Contenido de sodio en preparaciones de consumo frecuente fuera del hogar en tres zonas de Lima Metropolitana, Perú.).

Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci , 6 , 42. https://doi.org/10.1186/1748-5908-6-42

Pearl, D., & Intriligator, J. (2023). Persona multiplication: A method to avoid designed injustice. The International Journal of Design in Society , 17 (1), 31–44. https://doi.org/10.18848/2325-1328/CGP/v17i01/31-44

Penin, L. (2017). An introduction to service design . Bloomsbury Publishing.

Polsky, J. Y., & Garriguet, D. (2021). Eating away from home in Canada: Impact on dietary intake. Health Reports , 32 (8), 18–26. https://doi.org/10.25318/82-003-x202100800003-eng

Saelens, B. E., Glanz, K., Sallis, J. F., & Frank, L. D. (2001). Nutrition Environment measures Study in restaurants (NEMS-R): Development and evaluation. American Journal of Preventive Medicine , 32 (4), 273–281.

Salleh, R., Ganapathy, S. S., Ibrahim Wong, N., Cheong, S. M., Ahmad, M. H., Palaniveloo, L., Othman, F., Baharudin, A., Megat Radzi, M. R., Selamat, R., Aziz, A., Ambak, N. S., R., & Aris, T. (2021). Is socio-demographic status, body mass index, and consumption of food away from home associated with high sodium intake among adults in Malaysia? Findings from the Malaysian Community Salt Survey (MyCoSS). Journal of Health, Population, and Nutrition , 40 (Suppl 1), 12. https://doi.org/10.1186/s41043-021-00236-z

Shahrin, N., & Hussin, H. (2023). Negotiating Food Heritage authenticity in Consumer Culture. Tourism and Hospitality Management-Croatia , 29 (2), 183–193. https://doi.org/10.20867/thm.29.2.3

Sugar, R. (2022). Deranged diners, inflation and staff shortages: American restaurants are struggling. The Guardian . Retrieved February 23, 2023, from https://www.theguardian.com/food/2022/oct/26/post-pandemic-restaurant-industry-inflation

Timlin, D., McCormack, J. M., & Simpson, E. E. (2021). Using the COM-B model to identify barriers and facilitators towards adoption of a diet associated with cognitive function (MIND diet). Public Health Nutrition , 24 (7), 1657–1670. https://doi.org/10.1017/s1368980020001445

USCensus (2022). Population Estimates, July 1, 2021: New York city, NY. https://www.census.gov/quickfacts/newyorkcitynewyork

Wellard-Cole, L., Davies, A., & Allman-Farinelli, M. (2022). Contribution of foods prepared away from home to intakes of energy and nutrients of public health concern in adults: A systematic review. Critical Reviews in Food Science and Nutrition , 62 (20), 5511–5522. https://doi.org/10.1080/10408398.2021.1887075

WHO (2017). Promoting health in the SDGs. Report on the 9th Global conference for health promotion, Shanghai, China, 21–24 November 2016: all for health, health for all. https://iris.who.int/bitstream/handle/10665/259183/WHO-NMH-PND-17.5-eng.pdf?sequence=1

Willmott, T. J., Pang, B., & Rundle-Thiele, S. (2021). Capability, opportunity, and motivation: An across contexts empirical examination of the COM-B model. BMC Public Health , 21 (1), 1014. https://doi.org/10.1186/s12889-021-11019-w

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Acknowledgements

We are thankful to the restaurant owners and staff that took a chance and embarked in this journey with us! The authors wish to acknowledge additional members of the team, Tamara Alam and Michelle Rodríguez for their contributions to the process, and the restaurant owners and staff that lent their time and trust throughout the process described in this manuscript. We also wish to thank the editor and anonymous reviewers for their feedback, and Annie Pasterz for her assistance in making these final revisions in response to the feedback.

The research was supported by the NIH-National Heart, Lung, and Blood Institute (Award # K01HL147882). Additional funding support for TH was provided by the Centers for Disease Control and Prevention (U48DP006396). The funders had no role in the design, analysis, or writing of this article.

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Department of Social, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA

Melissa Fuster & Cara Conaboy

Steinhardt School of Culture, Education, and Human Development, Department of Nutrition and Food Studies, New York University, New York, NY, USA

Shelby Hipol & Lourdes Castro Mortillaro

Center for Systems and Community Design and NYU-CUNY Prevention Research Center, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA

Terry TK Huang

Department of Global Health, Milken Institute of Public Health, George Washington University, Washington, USA

Uriyoán Colón-Ramos

Hospitality Management Department, New York City College of Technology, City University of New York, New York, USA

Partnership for Research in Implementation Science for Equity (PRISE) Center, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA, USA

Margaret A. Handley

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MF was responsible for the conceptualization, writing, and funding acquisition for the manuscript. SH led the project design efforts and contributed to manuscript writing and revisions. TTKH contributed to the conceptualization and manuscript revisions. UCR, CC, RA, and LCM contributed to the design process, and manuscript writing and revision. MAH contributed to the conceptualization, analysis, and manuscript writing and revision. All authors read and approved the final version of the manuscript.

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Correspondence to Melissa Fuster .

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Fuster, M., Hipol, S., Huang, T.T. et al. Bridging Implementation Science and Human-Centered Design: Developing Tailored Interventions for Healthier Eating in Restaurants. Glob Implement Res Appl (2024). https://doi.org/10.1007/s43477-024-00133-7

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Approach to Human-Centered, Evidence-Driven Adaptive Design (AHEAD) for Health Care Interventions: a Proposed Framework

Meredith fischer.

1 Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA USA

Nadia Safaeinili

Marie c. haverfield.

2 Department of Communication Studies, San José State University, San Jose, CA USA

Cati G. Brown-Johnson

Dani zionts, donna m. zulman.

3 Department of Medicine, Stanford University, Stanford, CA USA

Human-centered design (HCD), an empathy-driven approach to innovation that focuses on user needs, offers promise for the rapid design of health care interventions that are acceptable to patients, clinicians, and other stakeholders. Reviews of HCD in healthcare, however, note a need for greater rigor, suggesting an opportunity for integration of elements from traditional research and HCD. A strategy that combines HCD principles with evidence-grounded health services research (HSR) methods has the potential to strengthen the innovation process and outcomes. In this paper, we review the strengths and limitations of HCD and HSR methods for intervention design, and propose a novel Approach to Human-centered, Evidence-driven Adaptive Design (AHEAD) framework. AHEAD offers a practical guide for the design of creative, evidence-based, pragmatic solutions to modern healthcare challenges.

Human-centered design (HCD) offers a novel approach for developing solutions to “wicked problems” in healthcare that involve complex interactions between population health demands, rapidly advancing technology, financial pressures, and workforce strain. 1 By definition, wicked problems, such as childhood obesity, physician burnout, and access disparities, lack one-off solutions. 2 Due to their complexity and interdependence, working to solve single aspects of these problems often affects other components, 2 , 3 and attempts to address multidimensional issues in public health and healthcare using traditional research methods lead to gaps between research and practice. 2 , 4 A framework integrating HCD principles and practices with evidence-grounded research methods has potential to generate interventions acceptable to stakeholders that positively influence outcomes of interest. 4 , 5

WHAT IS HUMAN-CENTERED DESIGN?

Human-centered design is an empathy-driven problem-solving approach with inspiration, ideation, and implementation stages. 6 HCD examines human desirability (what the user really needs) and uses those insights to develop technologically and economically feasible solutions. 6 The design process values “failing fast and often,” prioritizes outside-the-box thinking over prescribed processes to generate unique solutions, and has been increasingly used in fields like marketing and product design. 6 , 7 While HCD can rapidly produce pragmatic interventions, this approach typically does not integrate frameworks and rigorous methods central to evidence-based health services research. As such, adoption of HCD principles by health services researchers has been relatively slow. 4

Two recent systematic reviews examine the emergence of HCD methods in healthcare. Both Altman 2018 ( n  = 24 studies) and Bazzano 2017 ( n  = 21 studies) noted the feasibility of using HCD in multiple healthcare domains and across diverse patient populations and conditions to produce solutions that may not be considered in traditional research settings. Both reviews found that most instances of HCD use in healthcare contexts were technology related. Importantly, the reviews noted discrepancies in quality and methodological rigor among the studies and found that few studies evaluated the solutions derived using HCD. Theevaluate care delivery in multidisciplinaryse limitations in HCD methods present barriers to wider healthcare acceptance and adoption.

HEALTH SERVICES RESEARCH METHODS FOR INTERVENTION DESIGN: STRENGTHS AND LIMITATIONS

When used appropriately, health services research (HSR) methods produce effective, evidence-based interventions. Developed in response to complexities in modern healthcare settings, HSR utilizes qualitative and quantitative methods to improve and evaluate care delivery in multidisciplinary healthcare fields and considers psychosocial factors, access, cost, quality, and health outcomes 8 , 9 to test interventions. Recognized ways to deal with complexity and human uncertainty in HSR include consideration of concepts like causal inference, 10 , 11 treatment effect heterogeneity, 12 , 13 and regression to the mean. 14 Theoretical frameworks, particularly those from implementation science, 15 – 17 guide delivery and evaluation of interventions. HSR approaches incorporate rigorous testing and re-testing to lend credibility and proof of prior causality when designing new interventions; validated records of past failures and successes can inform predictive models and provide insights when considering solutions.

Employing HSR methods, however, does not ensure successful implementation and evaluation. 4 , 18 – 20 Implementation science has documented countless cases of failure to scale evidence-based interventions, and users often adapt interventions to suit their environment or needs, potentially affecting the fidelity of intervention delivery. 21 , 22 When brainstorming and designing interventions prioritizing spread or scale, traditional methods can prevent consideration of unique or creative solutions. 4 , 23 For example, focusing on “average patients” disadvantages patients who represent vulnerable minorities, 24 , 25 and designing for common healthcare scenarios overlooks insights from unusual or exceptional cases. 7 , 26

HUMAN-CENTERED DESIGN: STRENGTHS AND LIMITATIONS

HCD addresses many gaps evident in HSR. Because the HCD process begins by exploring user desires and motivations, interventions developed using HCD may be more desirable and feasible to implement and sustain. HCD emphasizes the user’s (e.g., patient, provider, or caregiver) needs throughout the design process. By meeting users in spaces they live, work, or play; learning about their experiences; valuing their insights throughout the design process; and drawing inspiration from analogous fields, HCD exposes teams to unique possibilities and creative solutions. 27 – 30 HCD nearly always involves interdisciplinary teams that harness expertise from diverse fields to provide a range of perspectives. 27 – 30 Additionally, HCD typically uses rapid prototyping, testing, and iteration—a practical alternative to time- and resource-intensive steps required by traditional research. 6 Public health research methods like Intervention Mapping and Community-Based Participatory Research (CBPR) also engage users and patients in intervention design processes. 29 , 31 , 32 The distinction between these research methods and HCD lies in the nature of community involvement; CBPR values long-term, collaborative relationships between research teams and communities, while HCD focuses less on design team-community integration and more on gathering insights and involving stakeholders at strategic points to produce usable and desirable products or interventions. 29

Applying HCD to healthcare settings presents challenges. Structures and ethical requirements within traditional academic settings such as institutional review boards (IRBs), legal contracting, and protection of confidentiality place necessary constraints on human-centered design teams, forcing compromises on a flexible and rapidly iterative process. 5 , 33 Funding agencies may be skeptical of HCD’s unconventional methods, although organizations like USAID and the Bill & Melinda Gates Foundation are beginning to support projects grounded in HCD. 34 Finally, a lack of widespread understanding and variation from traditional research processes makes publication of HCD intervention work in peer-reviewed journals difficult, limiting the dissemination and long-term evaluation of such designs. Table ​ Table1 1 outlines the similarities and differences between traditional research and human-centered design.

Comparison of Intervention Design Steps Using Traditional HSR vs. HCD Methods

AHEAD FOR HEALTH CARE: A PROPOSED FRAMEWORK

A framework combining principles of empathy-driven HCD with evidence-grounded HSR methods has the potential to generate pragmatic, high-impact healthcare interventions. 4 , 5 Fig.  1 presents an Approach to Human-centered, Evidence-driven Adaptive Design (AHEAD) for healthcare. This framework was initially developed for the Stanford Presence 5 project, which demanded a combination of HSR and HCD methods. 35 Table ​ Table2 2 illustrates how the AHEAD framework was used in study activities for this project. Each component of AHEAD is described below. After defining a problem and assembling an interdisciplinary team, information gathering activities draw on evidence and inspiration to generate a knowledge base for synthesis. Guiding principles inform the design phase, which involves rapid iterations through brainstorming, prototyping, and testing cycles to develop an intervention that is subjected to rigorous evaluation.

Approach to Human-centered, Evidence-driven Adaptive Design (AHEAD). After defining a problem and assembling an interdisciplinary team (a), information gathering activities draw on evidence (b) and inspiration (c) to generate a preliminary knowledge base for synthesis (d). In the design phase, teams establish guiding principles (e) and ideate (f), which involves rapid iterations through brainstorming, prototyping, and testing cycles to develop an intervention that is subjected to rigorous evaluation (g).

Case Example AHEAD Framework: The Stanford Presence 5 Project

Step 1: Define the Problem and Assemble a Team

What problem is the team interested in solving who can help solve it.

In step 1 of AHEAD, elements from HCD and HSR are integrated to define the problem. These two processes approach problem identification from opposite ends of the inquiry spectrum. Health services researchers form defined research questions and hypotheses at the project’s outset and remain neutral and objective when working with subjects. In HCD, designers search for problems through need-finding activities. The design process often begins with in-depth exploration into user needs to identify a problem requiring a design solution. This approach leads to insights about overlooked problems but lacks the theoretical grounding and systematic approach of traditional research methods. 5 In public health and healthcare settings, the process of need-finding might involve qualitative interviews with patients and physicians, which generate valuable themes and typically require IRB approval. 5

Both HCD and HSR approaches have well-established methods for need-finding, but this process is given greater emphasis in HCD (which may explain one observation that interventions developed with design thinking have greater satisfaction, usability, and effectiveness than traditional interventions). 30 Incorporating diverse perspectives is essential during problem identification—and assembling an interdisciplinary team is an integral part of AHEAD. Many reviews of HCD in health emphasize the importance of assembling a diverse team within and outside of academia and including stakeholders touching multiple problem aspects. 27 – 30 , 36 Purposeful assembly of interdisciplinary teams can prevent deviation toward familiar designs. 27 , 36 , 37 HSR also values interdisciplinary teams, but team member expertise often stays within medical and academic fields. When using AHEAD, teams should include the expansive range of voices more typically found in HCD. For example, one project examining childhood asthma management included not only physicians and public health researchers on their team, but social workers and design scholars as well. 38 Although each team member may have different roles and expertise, there should be one AHEAD team often works together instead of team members working separately on their expertise-specific components.

After assembling an interdisciplinary team, establishing a supportive, cohesive dynamic is essential. 39 HCD emphasizes team building as equally as team assembly, 7 while HSR often prioritizes assembly over cohesion. The field of team science identifies several characteristics of effective teams and strategies to strengthen team dynamics that can be applied within AHEAD. 40 Broadly, interdisciplinary teams share a strong vision and goal; create communication channels for defining roles, assigning responsibilities, and resolving conflict; establish trust; and promote fun through team-building exercises and celebrations of success. Activities to strengthen team dynamics include highlighting individual strengths, checking in during group meetings, and setting the expectation that every team member can and should contribute. 40

Step 2: Gather Information through Evidence and Inspiration

What is the experience of users dealing with this problem what strategies have been tested in the past.

After defining the problem and assembling a cohesive interdisciplinary team, the researchers begin information gathering to identify themes for potential solutions. In this phase, AHEAD incorporates methods from both HCD and HSR. Traditional research typically involves systematic or exhaustive reviews of the medical literature to examine previous evidence. 41 In contrast, HCD inspiration activities use direct observation and immersion in the field to expose the design team to typical and unusual user experiences. 5 , 7 , 27 , 29 , 30 , 36 Teams can also observe and interview individuals outside healthcare who have “analogous experiences” (i.e., similar or relatable challenges) to describe or inspire solutions with implications in healthcare. 27 , 36 , 42 AHEAD recommends reviewing existing research and evidence while also seeking inspiration from users (with special consideration for patients), extreme cases, and analogous fields to highlight themes or topics that may be overlooked in traditional evidence bases.

Step 3: Synthesize

What common themes emerged from information gathering what values will guide the team throughout the rest of the design process.

Formative information gathering from evidence review and inspiration generates a comprehensive understanding of the problem and preliminary ideas about intervention structure and content. Next, in the synthesis phase, the team identifies emerging themes and insights arising from both methods or that showed up disproportionately in one over the other. This process should include critical review of gathered evidence to evaluate past successes and failures, consider how real users might react to potential interventions, and flag themes meriting further exploration.

After gathering evidence and inspiration from a wide range of perspectives, the team should solicit feedback from outside individuals on their synthesis and any conclusions drawn. HCD acknowledges the value of outside perspectives to avoid information silos and “groupthink” within teams. 27 , 43 HSR methods often use structured approaches for synthesis such as Delphi panels, a validated method for quantifying expert opinion through multiple rounds of independent ratings. Typically, researchers conduct Delphi panels to generate consensus around clinical guidelines or quality indicators, 44 , 45 but they can also be applied to the design of innovative healthcare delivery interventions. 35 When seeking opinions, teams should include diverse voices (e.g., gender, race-ethnicity, and expertise) and gather both quantitative (e.g., rankings of feasibility) and qualitative feedback.

Step 4: Intervention Design: Guiding Principles and Ideation

How can the team rapidly iterate to design a meaningful intervention, guiding principles.

After synthesizing findings and before entering the HCD-driven ideation phase, the team establishes guiding principles and defines the scope of the problem space for their intervention. Agreement on principles like the degree of evidence-backing, inclusiveness and sensitivity to diversity, and budgetary constraints helps ground and focus the team before ideation. HCD strategies for creating guiding principles include writing a team mission statement or brainstorming values that the intervention should reflect (e.g., easily adopted, minimal training, appropriate for diverse settings). Teams can also use more traditional frameworks to ensure that the intervention content aligns with an evidence-based or theoretical model. These HCD- and HSR-inspired activities also strengthen the collaborative dynamic established during team assembly.

After establishing guiding principles, the research team goes through several rounds of ideation—rapid cycles of brainstorming, prototyping, and testing. In HSR contexts, researchers sequentially design and test a pilot before refining the intervention and studying it in a formal trial. In HCD, the ideation phase is characterized by flexibility and speed. The team aims for quantity rather than quality of ideas and creates sacrificial prototypes for learning purposes. This emphasis on creative output has proved successful in the business world; IDEO, a global design company, found that that when teams iterate on five or more ideas, they are 50% more likely to successfully launch a product or solution. 46

Brainstorm During early prototype brainstorming, all ideas are welcome, and team members should suspend disbelief to extend creative boundaries. Brainstorming with multiple team members helps incorporate diverse perspectives and generate ideas rooted in different disciplines. Specific guidelines for brainstorming published by HCD leaders include sketching, movement between ideas posted around a room, and creation of and interaction with rough physical prototypes to boost creativity and generation of a large quantity of ideas (100 ideas in an hour-long brainstorming session is one recommended target). 7 After brainstorming, preliminary ideas can be organized to combine ideas or elements of ideas in logical ways. This is best done visually (e.g., physically rearranging ideas on index cards) to reveal connections between ideas or concepts. 7

Prototype The team then progresses to prototyping. Rapid prototyping refers to the cycle of quickly creating ideas out of cheap and disposable materials, soliciting feedback from potential or analogous users in a convenient setting, and incorporating that feedback to refine ideas and create new prototypes. 7 Complementary activities include storyboarding (drawing the journey of the intended user interacting with the prototype) 47 – 49 and role-playing (acting out the intended users’ interactions with the prototype). 50 Prototype design sessions with users and stakeholders, including physicians, patients, family members, and health system leaders, can yield insights beyond those considered by the design team. 36

Test After development, prototypes are tested with end-users. Unlike HSR, testing during ideation does not incorporate control groups or formal evaluation measures. This process is a low-cost and efficient way to gain insights about early prototypes. When applying these methods to healthcare settings, however, ethical considerations limit contact with patients and caregivers, and safety concerns often prohibit the use of rough prototypes in clinics. In some circumstances, it may be possible to test rapid prototypes with patient representatives or clinicians outside of clinical settings while staying compliant with IRB requirements. 51 – 53 For example, after conducting patient needs assessment interviews, a group from the University of Chicago used testers demographically similar to patients at their target clinics to design a waiting room app for contraceptive counseling. 51 This use of “analogous testers” proved successful; real patients using the app reported higher knowledge of contraceptive effectiveness and a greater interest in long-acting reversible contraceptive options. 51 Another team ran participatory design sessions with a Patient and Family Advisory Committee (PFAC), comprised of leaders from various patient support groups the design team worked with in the need-finding phase, to design a dashboard displaying trends in prostate cancer care. 52

After field testing, the research-design team can further develop the prototype to prepare for formal implementation and evaluation or take lessons learned and reenter the earlier stages of the ideation process.

Step 5: Evaluate

Does the intervention promote positive outcomes.

Once design activities are complete and the intervention is implemented, a rigorous evaluation should be conducted to examine the intervention’s effectiveness, as well as potential adverse consequences. A hybrid design 54 that incorporates qualitative and quantitative methods can evaluate effectiveness across key outcomes (e.g., health outcomes, patient/provider experience, utilization, and costs) and generate important information about implementation (e.g., feasibility and fidelity, implementation costs, sustainability). 55 Rigorous evaluation methods, including randomization when appropriate, increase the study’s credibility with health system leaders and policymakers and the likelihood that findings will be incorporated into future reviews and clinical guidelines, thereby leading to more widespread and lasting impact. Importantly, findings should also prompt reflection about and improvement of the intervention design.

This paper proposes a framework for integrating HCD and traditional HSR methods in the development of healthcare delivery interventions. Drawing on the strengths of both methods can counterbalance their individual limitations and facilitate the design of innovative, acceptable, and sustainable solutions in healthcare settings. Interventions derived using AHEAD have the potential to offer practical solutions to providers and healthcare managers due to the framework’s reliance on existing evidence and focus on stakeholder acceptability throughout the entire design process.

AHEAD builds on previous studies that examined opportunities to harness HCD for specific healthcare intervention design purposes. One study proposed “best practices” for using HCD to improve user experience with at-home health devices for patient users. 28 These practices highlight aspects of design thinking that are valuable in designing for patients, such as the assembly of diverse, multidisciplinary design teams; centering design around empathy for users; developing deep understandings of tasks and setting; user involvement throughout the design process; and iteration through flexible prototype development.

Human-centered design has also been used in CBPR to design innovative solutions in collaboration with vulnerable populations. 32 HCD focuses on understanding and designing for the user, while CBPR approaches intervention design through equal partnership between community members and researchers to define problems and identify solutions to improve health and reduce disparities. 29 , 56 HCD methods echoed in CBPR include co-creation, user engagement throughout design stages, and multiple rounds of iteration. 29 One study used an approach that combined HCD and CBPR methods to address violence and other adversities that influence the health of Latinx youth. Engaging youth in design activities promoted dialogue between opposing individuals and groups and revealed opportunities for health promotion and change. 57

Others have proposed combining HCD with implementation science to identify promising strategies for intervention design. For example, Dopp et al. conducted a conceptualization exercise in which a multidisciplinary panel of experts identified implementation science and human-centered design strategies that are similar or complementary and described how drawing on these disciplines might improve use of evidence-based practices. 58 Two other examples are the SHIFT-Evidence framework (which focuses on three principles: “act scientifically and pragmatically”; “embrace complexity”; and “engage and empower”) 59 and the Veterans Affairs’ Quality Enhancement Research Initiative, 60 which focuses on addressing the “knowing-doing” gap, need-finding for problem definition, ongoing stakeholder engagement, and robust evaluation. These frameworks were designed with the goal of facilitating implementation of evidence-based practices. The AHEAD framework offers a unique contribution by drawing on principles of HCD that examine analogous fields and adjacent experiences when there is a clearly defined problem but limited evidence about potential solutions.

Innovating within the scientific method can be lengthy, inflexible, and resource-intensive, and proposed solutions often fail to address the users’ real needs. Development of the electronic health record (EHR) provides a stark example of consequences when users are excluded throughout the design process. Excluding providers from designing a system they use daily has had monumental consequences, with an association between physician EHR use and increased stress, burnout, and job dissatisfaction. 61 , 62 By including users from the outset, human-centered healthcare approaches can avoid similar disconnects. For example, one research team in Argentina used HCD techniques to redesign the alert system for drug-drug interactions in the EHR. After implementation, the new system resulted in fewer errors and unnecessary alerts and improved workload optimization and user satisfaction. 63 , 64

LIMITATIONS

This paper proposes a framework for integrating HCD and HSR to drive healthcare innovation. Our review of existing literature was scoping but not systematic in its approach, and may not have captured all existing HSR and HCD frameworks. Future research is needed to validate this framework and determine whether solutions derived achieve the desired and predicted effectiveness, implementation, and dissemination outcomes. Time and resource constraints may limit use of this framework, as well as gathering financial and institutional support needed to assemble interdisciplinary teams. 40 Additionally, not all teams have access to collaborators with HCD expertise and contracting with outside design firms can be expensive. 36 However, there are a growing number of academic institutions with design schools and many opportunities to gain exposure to design methodology and skills. 65

Complex factors influencing population health and healthcare drive demand for innovative intervention design frameworks. An opportunity exists to integrate creative approaches from HCD with rigorous methods from HSR; the resulting AHEAD framework can guide the design of healthcare delivery interventions. Future efforts should examine whether interventions derived from this integrated framework generate effective solutions for “wicked” healthcare challenges.

This study was supported by a grant from the Gordon and Betty Moore Foundation (#6382; PIs Donna Zulman and Abraham Verghese).

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The views expressed herein are those of the authors and do not necessarily reflect the views of the Gordon and Betty Moore Foundation, or the Stanford University School of Medicine.

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The Application of Human-Centered Design Approaches in Health Research and Innovation: A Narrative Review of Current Practices

Affiliation.

• 1 Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands.
• PMID: 34874893
• PMCID: PMC8691403
• DOI: 10.2196/28102

Background: Human-centered design (HCD) approaches to health care strive to support the development of innovative, effective, and person-centered solutions for health care. Although their use is increasing, there is no integral overview describing the details of HCD methods in health innovations.

Objective: This review aims to explore the current practices of HCD approaches for the development of health innovations, with the aim of providing an overview of the applied methods for participatory and HCD processes and highlighting their shortcomings for further research.

Methods: A narrative review of health research was conducted based on systematic electronic searches in the PubMed, CINAHL, Embase, Cochrane Library, Web of Science, PsycINFO, and Sociological Abstracts (2000-2020) databases using keywords related to human-centered design, design thinking (DT), and user-centered design (UCD). Abstracts and full-text articles were screened by 2 reviewers independently based on predefined inclusion criteria. Data extraction focused on the methodology used throughout the research process, the choice of methods in different phases of the innovation cycle, and the level of engagement of end users.

Results: This review summarizes the application of HCD practices across various areas of health innovation. All approaches prioritized the user's needs and the participatory and iterative nature of the design process. The design processes comprised several design cycles during which multiple qualitative and quantitative methods were used in combination with specific design methods. HCD- and DT-based research primarily targeted understanding the research context and defining the problem, whereas UCD-based work focused mainly on the direct generation of solutions. Although UCD approaches involved end users primarily as testers and informants, HCD and DT approaches involved end users most often as design partners.

Conclusions: We have provided an overview of the currently applied methodologies and HCD guidelines to assist health care professionals and design researchers in their methodological choices. HCD-based techniques are challenging to evaluate using traditional biomedical research methods. Previously proposed reporting guidelines are a step forward but would require a level of detail that is incompatible with the current publishing landscape. Hence, further development is needed in this area. Special focus should be placed on the congruence between the chosen methods, design strategy, and achievable outcomes. Furthermore, power dimensions, agency, and intersectionality need to be considered in co-design sessions with multiple stakeholders, especially when including vulnerable groups.

Keywords: design thinking; design-based research; human-centered design; methodology; mobile phone; review; user-centered design.

©Irene Göttgens, Sabine Oertelt-Prigione. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 06.12.2021.

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Conflict of interest statement

Conflicts of Interest: None declared.

PRISMA (Preferred Reporting Items for…

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart of the screening…

Illustration of human-centered design processes.…

Illustration of human-centered design processes. HCD: human-centered design; HPI: Hasso Plattner Institute; UCD:…

Levels of end user involvement…

Levels of end user involvement during human-centered design processes.

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Title: an overview of research on human-centered design in the development of artificial general intelligence.

Abstract: Abstract: This article offers a comprehensive analysis of Artificial General Intelligence (AGI) development through a humanistic lens. Utilizing a wide array of academic and industry resources, it dissects the technological and ethical complexities inherent in AGI's evolution. Specifically, the paper underlines the societal and individual implications of AGI and argues for its alignment with human values and interests. Purpose: The study aims to explore the role of human-centered design in AGI's development and governance. Design/Methodology/Approach: Employing content analysis and literature review, the research evaluates major themes and concepts in human-centered design within AGI development. It also scrutinizes relevant academic studies, theories, and best practices. Findings: Human-centered design is imperative for ethical and sustainable AGI, emphasizing human dignity, privacy, and autonomy. Incorporating values like empathy, ethics, and social responsibility can significantly influence AGI's ethical deployment. Talent development is also critical, warranting interdisciplinary initiatives. Research Limitations/Implications: There is a need for additional empirical studies focusing on ethics, social responsibility, and talent cultivation within AGI development. Practical Implications: Implementing human-centered values in AGI development enables ethical and sustainable utilization, thus promoting human dignity, privacy, and autonomy. Moreover, a concerted effort across industry, academia, and research sectors can secure a robust talent pool, essential for AGI's stable advancement. Originality/Value: This paper contributes original research to the field by highlighting the necessity of a human-centered approach in AGI development, and discusses its practical ramifications.

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DRS2020 Research Papers

Human-centered AI: The role of Human-centered Design Research in the development of AI

Jan Auernhammer , Stanford University, United States of America

Artificial Intelligence has the tremendous potential to produce progress and innovation in society. Designing AI for people has been expressed as essential for societal well-being and the common good. However, human-centered is often used generically without any commitment to a philosophy or overarching approach. This paper outlines different philosophical perspectives and several Human-centered Design approaches and discusses their contribution to the development of Artificial Intelligence. The paper argues that humanistic design research should play a vital role in the pan-disciplinary collaboration with technologists and policymakers to mitigate the impact of AI. Ultimately, Human-centered Artificial Intelligence incorporates involving people and designing Artificial Intelligence systems for people through a genuine human-centered philosophy and approach.

Human-Centered; Artificial Intelligence; Design Research; Ethics

https://doi.org/10.21606/drs.2020.282

Auernhammer, J. (2020) Human-centered AI: The role of Human-centered Design Research in the development of AI, in Boess, S., Cheung, M. and Cain, R. (eds.), Synergy - DRS International Conference 2020 , 11-14 August, Held online. https://doi.org/10.21606/drs.2020.282

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Human-Centered Design (HCD)

What is human-centered design (hcd).

Human-centered design is a practice where designers focus on four key aspects. They focus on people and their context. They seek to understand and solve the right problems, the root problems. They understand that everything is a complex system with interconnected parts. Finally, they do small interventions. They continually prototype, test and refine their products and services to ensure that their solutions truly meet the needs of the people they focus on.

Cognitive science and user experience expert Don Norman sees it as a step above user-centered design .

“The challenge is to use the principles of human-centered design to produce positive results, products that enhance lives and add to our pleasure and enjoyment. The goal is to produce a great product, one that is successful, and that customers love. It can be done.” — Don Norman, “Grand Old Man of User Experience”

See why human-centered design is a vital approach for accommodating real users—real people.

• Transcript loading…

The Trouble with “Users” is They’re Only Human

At many points in technological history, Don Norman helped designers understand their responsibility to the people who use the things they design. Great advances were made in electronics and computing throughout the second half of the 20th century. The problem was, the designers of many systems often overlooked the human limitations of the people who had to interact with them.

Early computers were extremely hard to understand. The first ones — created in the 1940s — required specialists to operate them in closed environments. By the 1980s, things had changed; A large portion of smaller computers were being used by people without specialist knowledge. Problems were bound to arise, and did. The early Unix system Ed (for “Editor”), for example, did not prompt users to save their changes, causing many users to erase their work when turning off their computers. Highly visible prompts to save our work were yet to come.    

From no save prompts, to the “Do you want to save changes” dialog box, to auto-save: The save functionality in documents has been iterated over the years to improve the experience for the people working with these tools.

Don Norman also studied the control rooms of potentially hazardous industrial centers and aviation safety. Following the Three Mile Island nuclear accident in 1979, he was involved in analyzing the causes and potential solutions. A partial meltdown of a power-station reactor had released dangerous radioactive material into the environment. The problem centered around, not the highly competent staff members, but the design of the control room itself.

From design mistakes such as this, we learned crucial lessons. It was clear that designers had to accommodate the human needs of their systems’ user ship. There could be no room for ambiguity or misleading controls, for instance. Designers would instead have to anticipate human users extensively through how each system looked, worked and responded to them, which aligns with circular economy principles to maximize resource efficiency and sustainability. So, rather than focus on the aesthetics of the interface and the design itself, designers needed to understand and tailor experiences for the people at the controls, accounting for their various states of mind while interacting with and reacting to changes in the system. To avoid disasters, the dehumanizing idea of “users” had to vanish so designers could put people first in design. It was time for human- or, better still, people-centered design .

Follow the Clear Path to Human-Centered Design

In 1986, Norman and co-author Stephen Draper’s User Centered System Design: New Perspectives on Human-Computer Interaction was published. The result of extensive collaboration between researchers across the U.S., Europe and Japan, this comprehensive volume represented a shift in human-computer interaction. However, the authors realized they didn’t like the term “users”; the emphasis demanded a more “human” entity in control. Their timing was superb. Not only had the home-computing market exploded, but strides in technology would soon usher in the Internet age, greater connectivity and more complexity in the systems that people of all types would use.

Norman coined the term “user experience” shortly afterwards. This signaled a focus on the needs of the people who used products throughout their experiences. Norman explained the reason for the evolution away from “user” was to help designers humanize the people whose needs they designed for. Human-centered design has four principles:

People-centered : Focus on people and their context in order to create things that are appropriate for them. Participatory design ensures user involvement in the process.

Understand and solve the right problems , the root problems: Understand and solve the right problem, the root causes, the underlying fundamental issues. Otherwise, the symptoms will just keep returning.

Everything is a system: Think of everything as a system of interconnected parts.

Small and simple interventions: Do iterative work and don't rush to a solution. Try small, simple interventions and learn from them one by one, and slowly your results will get bigger and better. Continually prototype, test and refine your proposals to make sure that your small solutions truly meet the needs of the people you focus on.

It's important to remember, as we focus on the human aspect, we expand our scope to societies and, ultimately, humanity-centered design . And as our world becomes more intricately involved with complex socio-technical systems and wicked problems to address, the insights we leverage from human-centered design will continue to prove essential.

Interaction Design Foundation, CC-BY-SA 4.0

Learn More about Human-Centered Design

To learn more on human-centered design, take our courses:

Design for the 21st Century with Don Norman

Design for a Better World with Don Norman

Norman, Donald A. Design for a Better World: Meaningful, Sustainable, Humanity Centered . Cambridge, MA, MA: The MIT Press, 2023.

Read this JND article for additional insights about the human-centered design principles.

This thought-provoking MovingWorlds post explores human-centered design extensively.

Questions related to Human-Centered Design

Human-centered design is vital because it ensures that we create solutions tailored to human needs, cultures, and societies. It is a discipline that emphasizes a people-centric approach, solving the right problems, recognizing the interconnectedness of everything, and not rushing to solutions. It involves working with multidisciplinary teams and experts, and most importantly, it has to come from the people, embracing a community-driven design approach. This approach is a subset of humanity-driven design, which aims to address the major challenges humanity faces and, ultimately, save the planet.

Human-centered design (HCD) is a methodology that places the user at the heart of the design process. It seeks to deeply understand users' needs, behaviors and experiences to create effective solutions catering to their unique challenges and desires. HCD emphasizes empathy, extensive user research, and iterative testing to ensure that the final product or solution genuinely benefits its end-users and addresses broader societal issues.

Agile is primarily a project management and product development approach that values delivering workable solutions and iterating based on customer feedback. Agile teams break projects into small, manageable chunks and work in short bursts, called  "sprints," which allows for frequent reassessment and course corrections.

While there's some overlap in their collaborative and iterative natures, the core difference lies in their objectives: HCD is about understanding and solving for the human experience, while agile is about efficiently managing and adapting work processes to changing requirements. 

Design thinking is a broader concept that includes human-centered design to solve major problems on a global and local scale. Human Centered Design is narrower in scope and aims to make interactive systems usable and useful.

For a more thorough understanding of these design approaches, please watch this informative video.

Human-centered design, as explained by Don Norman in the video above, focuses on people and their needs, even when addressing broad societal issues. It emphasizes creating solutions that cater to individuals, communities, and larger groups. Although it tackles significant challenges, its essence remains rooted in understanding and designing for humanity.

Human-centered design is used to design efficient and usable products. However, Don Norman encourages designers to apply the principles of human-centered design to address large societal problems to ensure solutions meet the needs and experiences of people.

As highlighted in the video above, human-centered designers collaborate with professionals from other fields like engineering, computer science, and public health. HCD’s uniqueness lies in emphasizing design by the people and for the people.

While both prioritize the user, human-centered design is broader than UX design. UX often focuses on websites and digital interfaces, as mentioned in this video.

In contrast, human-centered design encompasses all types of products and indeed even larger societal challenges to ensure solutions cater to people's needs and experiences.

Human-centered design prioritizes understanding and addressing the needs of people. Unlike designs that emphasize aesthetics over usability, human-centered design values function and user well-being, as highlighted in this video.

It considers the broader socio-technical system, ensuring sustainable and user-centric solutions.

Discover the principles of human-centered design through Interaction Design Foundation's in-depth courses: Design for the 21st Century with Don Norman offers a contemporary perspective on design thinking, while Design for a Better World with Don Norman emphasizes designing for positive global impact. To deepen your understanding, Don Norman's seminal book, " Design for a Better World: Meaningful, Sustainable, Humanity Centered ," from MIT Press, is an invaluable resource.

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What is the primary goal of Human-Centered Design (HCD)?

• To create aesthetically pleasing designs
• To focus on people and their needs
• To reduce the cost of production

Which of the following is a core principle of Human-Centered Design?

• Everything is a system.
• Implement the first idea quickly.
• Solve the most superficial problems first.

Why is iterative prototyping important in Human-Centered Design?

• Because it continually tests and refines solutions.
• Because it finalizes designs quickly.
• Because it only applies the first round of user feedback.

How does Human-Centered Design approach problem-solving?

• It addresses surface-level issues.
• It focuses on technical specifications first.
• It understands and solves root problems.

Why is understanding the context important in Human-Centered Design?

• To apply a singular solution
• To reduce the time spent on research
• To tailor solutions to specific user environments and needs

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Literature on Human-Centered Design (HCD)

Here’s the entire UX literature on Human-Centered Design (HCD) by the Interaction Design Foundation, collated in one place:

Learn more about Human-Centered Design (HCD)

Take a deep dive into Human-Centered Design (HCD) with our course Design for the 21st Century with Don Norman .

In this course, taught by your instructor, Don Norman, you’ll learn how designers can improve the world , how you can apply human-centered design to solve complex global challenges , and what 21st century skills you’ll need to make a difference in the world . Each lesson will build upon another to expand your knowledge of human-centered design and provide you with practical skills to make a difference in the world.

“The challenge is to use the principles of human-centered design to produce positive results, products that enhance lives and add to our pleasure and enjoyment. The goal is to produce a great product, one that is successful, and that customers love. It can be done.” — Don Norman

All open-source articles on Human-Centered Design (HCD)

Human-centered design: how to focus on people when you solve complex global challenges.

• 3 years ago

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