By Rose Lewis, Lauren Gardner, and Adam Zeiner

Edited by Kate Payne

Introduction

The general notion of power—of systems of power, of power dynamics, of your professional proximity and access to leaders of institutions and public entities, and the historical background of your relationship to power—may not be what first comes to mind when you think about your role as a designer. Designers focus on the end users of the products and services we design, often viewing ourselves as advocates for the people who will use what we create. We see ourselves as problem solvers. We assume that for every context to which we are introduced, there is a problem to be solved and we’re the ones best equipped to solve it.  

With dual pandemics in our midst—both the novel coronavirus and the long-standing pandemic of systemic racism—the opportunity for design to make impact is great, but only if we shift our thinking about our role as designers. When you engage directly with communities in a relief or support capacity, you are intentionally or unintentionally donning an additional hat: the role of a helping professional. Helping professionals are almost always trained professionals like social workers, or at the very least individuals who have been trained by community organizations to best serve their populations. When we as designers step into this social design space, old design mantras like "fail fast" can have detrimental consequences. Failing fast can mean disrupting the flow of resources or support systems. Our design skill set alone does not always enable us to tackle complex or "wicked" and deeply rooted social issues like health inequity and racism. We can't presume we know the best way forward. We have to adapt our traditional approach that sees everything as a problem to be solved to one where we work with communities to solve the problems they identify and find value in addressing. The discipline of design can learn from the field of social work, and both can work hand in hand towards better outcomes.

Our Design Institute for Health team has benefited from the people-centered approach of social work. Rose Lewis, our social systems designer with a graduate-level background in social work, has helped our team integrate social work tenets into our design practice so that we can better understand and leverage our power and privilege to advance the wellbeing of the communities we serve.

For fellow designers working on design challenges that include people facing health disparities, systemic racism, or other complex social issues, we share four of our major takeaways from the field of social work that may help you better serve both your partners and community.

Section Header: "Individual Level: Develop a personal practice of continuing education, reflection, and active self-awareness of power and privilege."

1. Develop a personal practice of continuing education, reflection, and active self-awareness of power and privilege.

As designers, we are learning constantly. We're adept at stepping into new and unfamiliar spaces and figuring out how to navigate them, usually through research and observation. However, we don't often reflect on our own role and relationship to the issue at hand and its situational context. Viewing ourselves as external to the problem we are solving and focusing solely on end users is extremely risky. If we don’t understand our own power and privilege in relation to the communities within which we work, we can perpetuate biases in our design outputs and negatively impact the relationships we build.

Design roles are privileged positions that allow us to be change agents. With this privilege comes power that should not be taken for granted and should be exercised very carefully.i To use our privilege and power for the greater good, we must commit to a continued process of personal education, reflection, and active self-awareness. Whether we are working with historically underinvested communities, community partners and organizations, or private corporations, we should all have a deep understanding of the underlying power structures and dynamics at play, including our own unearned privileges, inherent biases, and the historical context attached to people and institutions.

In one of our grant-funded community projects at the Design Institute, we were tasked with designing health services for a low-income housing complex in East Austin. As we started the project, we struggled to initially engage the residents in our research and design efforts. Rose was reflecting on these challenges with her own therapist when the question arose: "Did they ask you to be there?" Even though Rose had studied social justice and power dynamics for years, this was a revelatory moment for her. She reflected on the implications of coming into this community as representatives of the University of Texas, a powerful institution in Austin. The team then shifted their approach from one of trying to engage residents in our research and design to focusing on building relationships with the residents first. As George Aye shares in his examination of the influence of power in design, "Without pausing to understand a designer’s relationship to power, one could unintentionally remind a community that they have little power to stop a project from happening."ii

Section Header: "Interpersonal Level: People are the experts of their own lived experiences, so a person-centered approach means meeting people where they are."

2. People are the experts of their own lived experiences, so a person-centered approach means meeting people where they are.

Respecting the inherent dignity and worth of a person is a fundamental social work principle. In practice, this means that people are the experts of their own lives and we must meet people where they are. As problem solvers and fixers, designers might think we know what's best, both for ourselves and for others. Our primary and secondary research may give us a false sense of expertise on another’s experience, but we can never truly be experts on their lives. Humility is required to listen to, respect, and honor people’s expertise and not assign prominence to your own interpretation of it.

In the same community project, we as a team and also as individuals had to continually check our own assumptions about what needs were most important to the people we were working with. During our needs assessment interviews, we asked residents to identify their top three challenges out of a list of social determinants of health (food, transportation, childcare, education, social support, financial support, housing, jobs/employment).iii A single mother of five didn't pick childcare or education because she explained that her kids went to school, so those were covered. In this instance Rose's previous career as a schoolteacher created a bias; she wondered why the mother wasn't more concerned about her children's education—whether they were on grade level or receiving adequate support at school—because she personally saw these issues as important. When debriefing on the interview with our team, Rose had to check her biases and assumptions. The woman was the expert in her life. She identified the real challenges that were important to her, and it was our job to respect that.

Section Header: "Community Level: 3. Co-design for self-determination, instead of finding optimal near-term interventions."

3. Co-design for self-determination, instead of finding optimal near-term interventions.

If you've ever worked with a counselor, therapist, or social worker, then you know that they don't just give you an answer to your problems. They facilitate your self-reflection and personal exploration so that you can solve them yourself. This approach is called self-determination. It's a fundamental shift from design's emphasis on the designer as the problem solver. Instead, social workers focus on helping people realize their strengths in order to address their own needs.

Co-design or co-creation has become a popular approach for involving users in the design process. Despite the goal of designing alongside people, co-design often takes the shape of consulting people on potential designs instead of enabling them to design for themselves. This can happen when we focus too much on the output—generating an ideal intervention for our client or whoever is footing the bill—instead of rethinking how we get there.

Designing with, not for, is a lot of work.iv It requires time, humility, and continued learning and self-reflection. True co-design goes beyond simply inviting others to your table. It requires more up-front time and energy spent building relationships with your co-designers, and after implementation, to continue receiving their feedback as your design evolves. Allowing ourselves and our design practices to be more recipient-led might afford us the unique opportunity to approach users and service recipients as whole people, living whole lives.v

While we see progress at the Design Institute in opening up our design process to members of the communities in which we're engaging, we still have a ways to go. As social workers approach helping relationships as a partnership with their clients, we as designers might situate the way we partner with users as clients.

For you, as it was for us, a first step might be bringing members of the community back in as you transition from research to design. In the same community project, we held a workshop after our research with residents to both confirm our findings and develop ideas for our service. We put our research findings on cards that said “What We Heard” and asked residents to edit, contradict, or add to them to ensure we truly heard them. We then shared “Service Ideas” on another set of cards and asked them to build on our initial ideas. We took a step back and listened as residents shared new ideas and then voted on which ones were highest priority for them.

In our debrief, we identified areas where we could have improved to make design more accessible and engaging for more community members. But overall, we saw tremendous benefit in engaging the residents early and throughout the process. The first iteration of our service was based on one of the residents’ ideas.

Section Header: "Society Level: 4. Implementation is about long-term sustainability, not your near-term deliverable."

4. Implementation is about long-term sustainability, not your near-term deliverable.

Oftentimes when it comes to community-focused design, we deliver an idea or a prototype of an idea and then we hand it off to the client and move onto the next project. We often don’t consider what happens after we leave. How will our idea be implemented? Who will maintain it? Do they have the necessary experience, tools, and support to do so? Who will lead its continued refinement and growth?

With the gift of grant funding, our diversely skilled team had three months to engage directly with the community in the project for the low-income housing complex. Within that time, we were able to move from prototyping potential interventions and service offerings to implementing the first stages of social service coordination in the community. Our continued involvement allowed us to identify what was and wasn't working, and more specifically, what gaps needed to be filled in order for our long-term intervention to be realized in a sustainable manner.

Our team decided to measure the success of this project by our ability to implement a sustainable, long-term program that extended beyond the lifetime of our grant. We didn't take it lightly that we were given the opportunity to work with a historically underinvested community, and if our project offered near-term value, then we were responsible for the longer-term sustainability of that value. Sustainability in the context of this project focused on funding (utilizing existing funding infrastructure for service provision from property management), qualifications of the service provider (leveraging a licensed social worker), and continuity of programming after the completion of the grant. 

Implementation is crucial. The shortcomings of our current health systems are felt most acutely by people who make up historically underinvested communities. During one of our co-design workshops a resident asked, "You're not going to get up and leave us one day, are you?" We built relationships with these residents and owed them an intentional and thoughtful transition. Given our seat at the table and proximity to the ear at the head of it, continuing or indirectly perpetuating a pattern of setting expectations that we can’t keep is inappropriate at the least. We implemented an onboarding period for our licensed social worker, whom we were able to hire before the grant ended. This allowed us to introduce her to the community so there was a continuity of rapport and trust, and also helped her learn about our goals for the sustainability of these services.

Another often-overlooked aspect of sustainability is accessibility. Initially, the dozens of handouts, flyers, and posters created for the community were made using professional design tools that require specific training. However, the service provider now responsible for community-wide communication is not a trained designer. In order to make our design deliverables accessible to our service provider, we transitioned all of these assets into more familiar tools like Microsoft Office, so she could iterate on them and produce her own.

Conclusion

As designers working in health we are obligated to dig into the concept of “better.” What do we mean when we say better? Better for whom? An era of dual pandemics has shed light on which groups have historically suffered from a lack of equity in health care. We are starting to do the difficult emotional work of reflecting on our roles as individuals and as designers in perpetuating the social inequities and Anglocentricity that are wedged deeply into the fault line of focus within our current health system. When working directly with historically underinvested communities, or any community that has been failed by many systems, we should take time to reframe the work—to critically reflect on the interconnected issues underpinning systems of social inequity and our individual roles in them. Working to identify and accept one’s own privilege can be an uncomfortable realization to come to terms with, one that may be easier to simply ignore or dismiss as just the way things are. Perhaps we as a profession would do well to move away from approaching every context as a problem to be solved, and move toward operating in a more facilitation-focused manner. To use our positions of privilege and proximity to power to facilitate change enacted by those previously designed “for.” May this article serve as an invitation to begin or continue learning alongside us.

About the authors

Learn more about Rose, Lauren, and Adam at the Design Institute for Health website.

Read more from the Journal of Design and Creative Technologies

i Aye, G. “Design Education’s Big Gap: Understanding the Role of Power.” https://medium.com/greater-good-studio/design-educations-big-gap-underst...

ii Ibid.

iii As stated on the Healthy People 2020 website, "Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as ‘place.’ In addition to the more material attributes of ‘place,’ the patterns of social engagement and sense of security and well-being are also affected by where people live." See: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determ...

iv August 2020 Twitter thread by Panthea Lee, Executive Director of Reboot: https://twitter.com/PantheaLee/status/1290685410742620162

v National Institute of Whole Health. “A Whole Person Approach to Health and Healing.” https://wholehealtheducation.com/a-whole-person-health-approach-to-healt...

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