Designing digital health tools for low-SES by moving beyond Human-Centered Design

Currently, the prevalent approach used in the development of digital health technologies is a human-centered design (HCD) approach. HCD practices focus on the human user, their needs, and requirements. However, as van Velsen et al. (2022) have discussed, current HCD practices in digital health innovations entail multiple limitations such as limited reach, bias, and narrow contextual and temporal focus. van Velsen et al. (2022) suggest three different directions to improve current HCD practices: value-sensitive design (VSD), more-than- human design, and citizen science (van Velsen et al., 2022). These directions offer designers the possibility to move beyond designing for usability and user experience by integrating ethical, societal, and political aspects into the design process and by making citizens co-researchers and co-designers.

While this is an issue for the development of any digital health technology, it becomes more prevalent when looking at health technologies from a socio-economic perspective. People from lower socio-economic statuses (SES) face increased barriers to living a healthy life, such as social stressors and limited environmental support for healthy behaviors (Sheehy- Skeffington, 2020). These stressors have been linked to social and environmental determinants, which HCD practices might be ill-equipped to capture. Digital health technologies and digital data are seen as promising solutions to help overcome some of the health inequalities caused by SES. However, their development is far from mature. These tools often do not have the same impact across people in different SES and might further perpetuate existing health inequalities. People with low SES have been found to find health technologies less useful (Ross et al., 2016), and are less likely to change their behaviours as the result of using health management tools, as compared to people in higher SES groups (Veinot et al., 2019). Likewise, people with a low SES are often underrepresented by research and data, market forces, and political power that in turn, shape the way these technological innovations are developed, adopted, and implemented in society (Bartels, 2016; Faber et al., 2021; Robinson et al., 2015; Rogers et al., 2014). Consequently, these interventions face the risk of not being adopted and therefore unintentionally contribute to rising health inequalities.

Especially in this context, we see the need to combine established HCD practices with the aforementioned directions. We present two possible ways. One research project involves older adults from low-SES communities in the design of digital health tools supporting a healthy lifestyle to maintain cognitive function in aging. This study adopts a more-than-human perspective to better understand the dynamic relation between humans and non-humans (organic and nonorganic things, place, and space). By decentering the human in the design process, we acknowledge agency to non-human agents. Another research project focuses on involving citizens in the development of providing healthy living as a service. In this project, limitations of HCD will be overcome by looking beyond needs and wishes of humans by investigating personal and cultural values relating to health and technology of different SES through Value Sensitive Design (VSD). With this approach, HCD is taken one step further, by not only looking at the relationship between humans and a design but also at what is important in people's lives. In this way, we aim to design more inclusive, fair, and valuable digital health technologies to allow for the responsibilization and datafication of health.