Tamarin Howse Exegesis Amended Compressed copy

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Tamar in Howse | Product Design

I M P R O V I N G T H E P R E S C H O O L

D E N TA L VA N S E R V I C E

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This exegesis is submitted to Auckland University of Technology for the Degree of Bachelor in Art & Design, Honours, [Product].

Tamarin Kirsti HowseBachelor of Art and Design [Product]

Engaging Encounters:Improving the dental health experience for preschoolers

October 2013

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Attestation of AuthorshipI hereby declare that this submission is my own work and that, to the best of my knowledge and belief, it contains no material previously published or written by another person nor material which to a substantial extent has been accepted for the award of any other degree or diploma of a university or other institution of higher learning, except where due acknowledgement is made in the acknowledgments.

_____________________________October 16th 2013

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AcknowledgmentsI have worked with a great number of people whose contribution in assorted ways to the research and the making of this exegesis deserve special mention.

First and foremost I offer my sincerest gratitude to Andrew Withell and Stephen Reay for their continuous supervision, advice, and guidance throughout this research project Above all and the most needed, they provided me unflinching encouragement and support in various ways.

I gratefully acknowledge the experts whose crucial and ongoing contribution became a backbone for the research and so to this exegesis. Without your efforts, reaching valuable insights may not have been possible. Your time is very much appreciated.

Words fail me to express my appreciation to my family and friends whose support, love and persistent confidence in me (not to mention patience), has eased this journey.

To my classmates, thank you for your optimism and ongoing feedback. It has been a pleasure sharing studio, jokes, and the (odd) tribulations with you.

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EthicsIt is important to note that careful consideration was given to all ethical aspects of this Human-Centred design research project. Given the limited time frame, and the relatively limited scope of the project (an Honours level project undertaken over a relatively small time frame) ethics approval was not sought. This meant that research methods, such as detailed user observation and user testing of participants were not used for the research. The implications of this meant invaluable data from the child’s perspective directly or through my own interpretations was unobtainable.

To overcome this barrier, I have selected other research methods to gather data without directly involving participants. This included the use of expert interviews, personal role-playing, and analysis of third party observations from online sources including YouTube and Vimeo. Triangulation of these methods allowed me to acquire deep insights, while online sources allowed me to witness a range of situations and objectively evaluate each one.

Should this project be further developed, ethics approval would be obtained, allowing for private research and end-user concept validation.

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01DEFINE

DISCOVER

DEVELOP

DELIVER

PLANNING AND METHODOLOGY10 Abstract12 Introduction14 The Dental Van Service16 Current Van18 Design Approach19 Research Question20 Philosophy and Paradigms 21 Research Methodology 22Research Methods26 Project Map

RESPONDING TO DESIGN BRIEF47 Part A - Enrolment Experience 51 Character Research61 Enrolment Form Concepts62 Evaluation and Development63 Final Design65 Part B - Van Experience70 Van Layout Exploration 74 Furniture Concept Exploration 80 Final Concept Development82 Final Concept Refinement84 Final Van Design Proposal

DRAWING CONCLUSIONS88 Feedback90 What Informed Insights92 Limitations and Implications93 Evaluation and Further Research94 Discussion96 References 98 Appendix

DOCUMENTATION OF RESEARCH30 Initial Research31 Literature Review Summary32 Expert Interviews33 Summary of Insights34 Shadowing36 Stakeholder Mapping37 Group Mind-Mapping38 Journey of Child Through Dental Service40 Involvement of Various Stakeholders42 Points of Intervention

Contents

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01DEFINE

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Abstract, Introduction, Dental Van Overview, Current Van

Frameworks, Research Question, Philosophy and Paradigms, Research Methods, Project Map

Introduction

Planning

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Abstract

The oral health of a child at age five is often indicative of their oral health as an adult, and it is essential that our most impressionable members of society be given the best start and support possible. Mobile Dental clinics help facilitate this vision by exposing a greater number of preschoolers to medical care. This helps foster better preventative care from an early age. For many children these clinics are their first encounter with professional oral health care services, and may also be the first encounter with the medical profession that they are aware of. In terms of shaping a child’s attitude and beliefs towards the medical profession throughout their lives it is critical that their early experiences are positive. This project takes the position that the early experience of preschoolers are critical in providing a life-long positive attitude to dental hygiene. It aims to use design to begin the processes of rethinking the Auckland District Health Board (ADHB) mobile dental vans.

The dissertation documents the research and design processes, and includes key reflections drawn from my experience as a design researcher. The overarching approach uses Human-Centred design, informed by Design Thinking methods. The documentation includes key research and design methods, including literature reviews, expert interviews, roleplaying, service mapping, touch-points, concept development, prototyping and evaluation. Creative and practical design work is documented and summarised. Key discussion focuses on feedback on the design proposals from expert stakeholders (nurses and managers at the ADHB) and their views on the use of the Human-Centred design processes from their perspective.

This practice based research project demonstrates the opportunities afforded by Human-Centred design to the redesign of user experiences. In this case, the redesign of the mobile dental service experience for preschoolers and the nurses that work with them.

“In terms of shaping a child’s attitude and beliefs towards the medical profession throughout their lives it is critical that their early experiences are positive”(Ministry of Health, 2006)

11Image source: http://www.boydjane.ca/2011/10/the-lights-are-on/little-girl-is-playing-in-preschool/

12Image Source: http://www.teara.govt.nz/en/photograph/30596/dental-nursing-mobile-dental-clinic-1949

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Introduction

Early Childhood: A Critical Period of DevelopmentEarly childhood is a critical time period for establishing the solid foundations that are essential for children’s long-term health, well-being, and academic success. Early environments, nurturing relationships (particularly with families and primary caregivers), human interaction, and early experiences are among the key factors that play a critical role in a child’s development, health and well-being (Shonkoff, Phillips, 2000). Poverty, family stress and dysfunction, substance use exposure and, poor nutrition affecting children’s oral health can place young children at risk of adverse developmental outcomes and can have a profound impact on their quality of life. Self-esteem, personal relationships and employment options can all be compromised by the real or perceived consequences of poor oral health (Ministry of Health, 2006).

Fortunately, early investments in young children and their families can significantly impact child health and well-being—limiting exposure to risk and promoting protective factors—and reduce the need for more costly interventions later in life (Karoly, 1998). Cohen and Jago (1999) also acknowledge that the greatest contribution of dentistry is the improvement of quality of life through the prevention and treatment of oral diseases and as the oral health of a child at age five is indicative of their oral health as an adult, early childhood is a critical period for development.Mobile units help facilitate this development by allowing more preschoolers from an early age to be exposed to medical care thus allowing for better preventative care. For many children these units may be the first level of contact with oral health care (Ministry of Health, 2006). In terms of shaping a child’s attitude and beliefs towards the medical profession throughout their lives it is critical that their first experience be a positive one.

Healthcare Industry: A critical Period of ChangeFor the last two decades, the healthcare industry has gone through changes in healthcare service deliveries. These changes are a response to: higher service expectations from patients, ever-advancing technology, and a holistic approach to health and wellbeing concerns (Francis, 2010). Yet, with their limited resources and traditional models, they are struggling to meet existing demand. The Ministry of Health (2006) recognizes that a significant re-orientation in the delivery of publicly funded oral health services is required and acknowledges the importance for healthcare providers to understand what patients and families experience in their facilities, how they perceive healthcare service quality, and what impacts those perceptions in order to satisfy and exceed patients’ wants and needs. In short, the healthcare industry is in crisis and facing paradigm change. (Carpman, & Grant, 1993) In 2001, the Institute of Medicine (IOM) established six aims for improving healthcare quality. They are to be: safe, effective, patient centered, timely, efficient, and equitable (IOM, 2001). Of all these aims, patient centered healthcare has been a driving force for healthcare design. The healthcare industry has recognised the importance of servicescapes, or the physical environments of the organization, in shaping the service experience of its patients and families.

“Early investments in young children and their families can significantly impact child health and well-being”(Karoly, 1998)

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The Dental Van ServiceThe Tamariki Ora, a dental office on wheels, provides preventive dental care to underserved children across Auckland.

Almost every day, the Tamariki Ora mobile dental staff see children who are in pain and discomfort due to of untreated dental disease. These are children who, for a variety of reasons, have been unable to access adequate dental care. And while to many “it’s just a cavity,” in reality dental disease is painful, affects a child’s overall health and often leads to poor school performance. In fact, dental decay is the single most common chronic disease of early childhood, five times more common than asthma. And while rare, dental disease, if left untreated, can lead to death (Ministry of Health, 2002).

Because of the profound effects dental disease can have on children, in 2003 the Auckland District Health Board took partnership with the Ministry of Health to begin operating the Tamariki Ora, a dental office on wheels, to provide preventive dental care to underserved children across Auckland. Dental vans allow more preschoolers from an early age to be exposed to medical care thus allowing for better preventative care. Mobile dental care systems like these have allowed dental professionals to expand the types of services provided to local preschool programs.

The strong demand for the mobile care prompted an expansion in the mobile dental program with the addition of several larger units. These units visit schools across the Auckland district and can be based at a school for many months, depending on the size and need of the school. While the smaller vans are only able to provide preventative options, the newer vans can give fillings and other more invasive operations. This has proven incredibly beneficial to the oral wellbeing of the communities and has become many children’s primary oral health care service.

However, while general oral health status in New Zealand has seen an overall improvement, there are disturbing trends in the patterns of oral health (Ministry of Health, 2006). The Ministry of Health (2006) claim “New Zealand’s oral health statistics compare unfavourably with similar countries, such as Australia and the United Kingdom” and therefore requires much attention. Increasingly concerning are the inequalities among Maori, Pacific, rural and low socioeconomic populations all showing poorer oral health in comparison to other groups. Alongside this decrease is the “disturbing pattern of inequalities that underlies child oral health statistics.”(Ministry of Health, 2006).

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The Ministry Of Health published their ten year vision as an effort to challenge and combat inequalities within oral health. “High-quality oral health services that promote, improve, maintain and restore good oral health, and that are proactive in addressing the needs of those at greater risk of poor oral health.” (Ministry of Health, 2006).

The improvement of oral health for these groups is of the utmost priority in order to realise this oral health vision. (Ministry of Health, 2002).

The preschool mobile dental unit accepts children aged 3 months through to 5 years of age. The parent and child are given thorough oral hygiene instructions, nutritional counseling, and advice on dental care for the child. The nurse will examine the child’s teeth, checking that they’re healthy and developing as expected. If necessary dental cleaning and fluoride varnish is applied. This is entirely a non-invasive procedure, taking no more than 10 minutes and is an effective way to acclimate the child for a positive dental experience. The Tamariki Ora van is part of facilitating this vision and continues to deliver preventative treatment to the children who need it most.

Image source: http://www.livingmemory.org.nz/

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The Current Van

This dental van was described by a member from the Auckland District Health Board as a “knee-jerk reaction” to the need for a form of oral health access to low-economic areas. The furnishings and layout follow a “make-do” theme and, aside from a few stickers plastered to the walls, has not changed a significant amount since its inception.

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Design Approach

In 1973, two social scientists, Horst Rittel and Melvin Webber, defined a class of problems they called “wicked problems.” Wicked problems are messy, ill-defined, more complex than we fully grasp, and open to multiple interpretations based on one’s point of view. They are problems such as poverty, obesity, where to put a new motorway—or a complex issue of early childhood healthcare development. Horst Rittel argued that most of the problems addressed by designers are wicked problems. These problems can be mitigated through the process of design - through an intellectual approach to design that emphasises empathy, abductive reasoning, and rapid prototyping.

The ‘wicked problems’ in design, especially this particular project, require a specificapproach and attitude. Boland and Collopy describe this ‘design attitude’ as the one that acknowledges and embraces the challenge of designing new possibilities rather than select from existing alternatives (2004). This attitude privileges the importance of the process over the result; learning how to solve a problem is the real value rather than the solution achieved.

Tackling these wicked problems with any prospect of success demands the adoption of design thinking and service design frameworks (Bowen S, Zwi AB, 2005).

These frameworks focus on unwrapping the problem solving process: they suggest that the creative process is not sequential, but overlapping and iterative; they require input from people with different disciplines and backgrounds; they are argumentative, and require integrative thinking.

This research uses a Human-Centred Design approach informed and supported by a range of Design Thinking methods to improve the dental van service.

Human-Centred DesignHuman-Centred Design is a framework that begins at the user level - the people we are designing for. The process and techniques of the framework allow the designer to gain a deep level of understanding through the lens of the user – the Desirability Lens – to identify needs, desires, complexities and barriers that exist within the context of the user. The process of developing empathy can reveal opportunities where complex issues can be addressed through creative product, service, system or environmental solutions (IDEO, 2011). Human-Centred design often draws upon a number of different methodologies. Design Thinking is a contemporary and increasingly recognised framework that provides a range of methodologies closing linked and informed by Human-Centred design.

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Design ThinkingDesign Thinking can be considered as a ‘Human-Centred methodology’ (framework) that supports and drives effective innovation (Bauer and Eagen 2008). Design Thinking has evolved from the study of the unique ways in which designers ‘think’, and ‘practice’. There is growing evidence of the increased uptake of Design Thinking in design, business and other disciplines (Withell, 2013). Design Thinking is also particularly useful methodology for exploring complex and complicated (‘wicked) problems, and it is now being taken up and utilised by a range of disciplines and professions outside of design to drive innovation (Bauer and Eagen 2008; Martin 2009; Leavy 2010).

Service DesignAn emerging field, service design is a multidisciplinary approach to creating more useful, effective, and efficient services. Service design, therefore, isn’t aimed at creating tangible products, but developing better ways for people to access the services they need. A key aspect of service design is the value of understanding the user experience (Gardner, 2011). This means a focus not on the organisation delivering the service but also on the person using the service. As Fordona (2010) writes, “services require designers to empathize with users, to understand interactions as a series of ‘touchpoints’ and to develop a holistic understanding of the ways in which our relationships to services govern everyday life.” Service design values users, conversations, relationships, and context, using empathy to make sense of them and their interplay.

Design thinking and service design involves much more than a reaction to present events and as such is in keeping with an approach to the oral health service that focuses on future challenges, and which seeks to promote a deeper understanding of the links, relationships, interactions and behaviours among the various components of the system.

These frameworks are both interdisciplinary processes that connect different areas of expertise. This integrative activity is critical in creating a successful project because methods, resources, skills, and experiences that various areas of experience offer are the keys to successful solution (Moritz, 2005).

Through this interdisciplinary approach, I sought to create a unique understanding of this wicked problem in oral health care for preschoolers and enhance their dental service experience while possibly giving insight to oral healthcare providers so that they are able to facilitate innovations in healthcare delivery.

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How can the dental van service be improved to enhance the experience of preschoolers and the dental nurses that work with them?

Research QuestionsThis project takes the position that a great first experience is critical in providing preschoolers with life-long positive attitude to dental hygiene. The practice based research explores:

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Research Methodology

This project aimed to contribute to the body of knowledge of design. I also hoped to foster the escalation of design integration in the public sector as well as incorporate design as a definitive driver for social change. This dynamism presented a challenge at the moment of selecting an appropriate strategy that enabled myself to focus upon action and not only ‘describe, understand and explain the situation but also to change it’ (Coghlan and Brannick 2001).

Donald Schön describes the design process as a reflective conversation with the situation in which the designer “reflects-in-action on the construction of the problem, the strategies of action or the model of the phenomena, which have been implicit in his moves” (Schön 1983). In his account, design is a discipline that creates ‘reflective practitioners’ whose techniques are especially appropriate for when changes occur during the design process. Drawing from the dynamic nature of the topic and the theories proposed by Schön I adopted an ‘action research’ oriented strategy to address my research question.

Action research is a practice-based research methodology that has become increasingly adopted by design researchers due to the similarities between its structure and the design process – that is, the iterative nature of designing (Swann, 2002). Action research is a cyclical strategy that starts with the initial idea followed by a systematic study of the problem, the definition of the plan of attack, the implementation of such plan, and monitoring and evaluation of the intervention. This evaluation feeds directly into the next cycle to ensure the intervention meets the needs and objectives of the research. This strategy allowed space to reformulate the direction of the research when necessary and reevaluate the tools and methods utilised in order to select those that better adapt to the constantly changing situation. In this project, action research was critical in making sure my product continued to be relevant to the users by letting their feedback shape the development of the project.

The cyclic nature of action research follows closely to the iterative process of designing. The effectiveness of the design process stems from the constant revisiting and reanalysing of the problem and development of revised solutions appropriate in response. The design process is a research process in itself – the act of design parallels instances of synthesis that occur within all fields of research (Swann, 2002).

The selected strategy also reflects a design practice embedded in myself that focuses on reflection-in-action and research that takes place in real-world challenges and situations with the aim to resolve them.

Plan Plan Plan

Act Act Act

Observe Observe Observe

Reflect Reflect Reflect

Action Research Cycle (Kolb, 1984)

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Project MapThis map is a visual representation of the research process and is used to help clarify key stages in the project. This map is illustrated as a linear process and suggests a methodological precision that is, in its key features, independent from the perspective of myself as the designer. However, I would like to point out two obvious points of weakness: one, the actual sequence of Design Thinking and decision making is not a simple linear process; and two, the problem addressed does not, in actual practice, yield to any linear analysis and synthesis yet proposed.

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Summary of Research MethodsUsing a combination of methods that complimented each other allowed for a more complete analysis and helped me understand the research problem to a higher degree.

Literature Review:A literature review is a summarising text that embodies a theoretical component of the research topic. The review allows a researcher to combine the insights and understandings gained from sources such as books, journal articles and dissertations and synthesize the information in a cohesive piece of writing. The literature review fell at the beginning of the project as its purpose was to provide a solid background and understanding of the context in which the research question was situated. It focused specifically on;

- How design thinking methodologies can transform organisations and inspire innovation- Fear of dentists as an inhibiting factor in children’s use of dental services, including child psychology and viewpoints as well as the role of environmental factors that contribute to a child’s perception of fear.- Improving child Oral health and deducing child oral health inequalities.

The literature review created a unique understanding of oral healthcare for preschoolers and how design thinking can be used as an integrative part of the process to enhance their dental experience.

Interviews:Expert interviews are a method commonly used by researchers and designers to gain greater understanding of the field in which their inquiry is situated or of the people they are designing for. The nature of these interviews can be highly structured, semi-structured or unstructured (Designing With People [DWP], 2011). Semi structured interviews are typically a process of collaboration, where the researcher focuses on specific topics whilst allowing in-depth conversation to develop around the perspective and opinions of the expert (Gray, 2009).

Semi structured interviews were conducted with practicing specialists directly involved in this project such as members from the Auckland District Health Board as well as professionals in fields such as child psychology, early childhood education and dental health. Such a qualitative approach was valuable here as it called on the varying personal experiences of people in their respective fields and the knowledge they gained while active in their industry. The nature of semi-structured interviews allowed for the discussions of key topics

Complementing the multi-method approach of design thinking, the mixed methods research paradigm has been created to transcend the barriers of separate quantitative and qualitative research. Mixed method projects can be thought of in two parts; research for design and research through design. Research for design covered methods such as the literature review and expert interviews. Insights from these methods shaped the direction of the project and worked toward identifying opportunities. Research through design uses the action research cycle, wherein the project, as it moves forward in development, is constantly creating new information. Using a combination of methods that complimented each other allowed for a more complete analysis and helped me understand the research problem to a higher degree. The following points are a summary each method, providing an overview of the context, the method itself and how it was implemented in this project.

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and meant experts were able to voice their personal opinions, both positive and negative, and to share what they believe would improve the dental experience for children, whilst ensuring I was able to collect key insights required. The interviews brought forth a humanistic element and helped identify key themes and evaluate key stages in this project.

Stakeholder Mapping:A stakeholder is any person, group or institution that has an interest in a development activity, project or program (E&F Spon. Newcombe, R. 2003). This definition includes all those involved: the children, ‘frontline’ staff, healthcare managers, operational managers, assistants, parents and primary caregivers.I developed a matrix table based on information gathered in my expert interviews that mapped the key stakeholders and assessed the capacity in which they could help develop the project. The stakeholder matrix identified and defined the characteristics of key stakeholders. It also allowed me to assess the manner in which they might affect or be affected by the project outcome and to help visualise the complex relationships between themselves.

Shadowing:Shadowing is an ethnographic technique often used by researchers and designers to understand a person’s real-time interactions with products, services or processes and their shifting contexts over a course of a day. It often will focus on a particular event or task that participants are willing to share. It is best suited for use in the earlier stages of the design process as it helps form an opinion quickly on a particular topic (Stickdorn & Schneider, 2010).I visited the dental van at three locations specifically chosen for their respective low, average and high decile

rating. I shadowed the dental therapists and assistants and passively observed any differences in the way the service was managed. I closely examined the entire dental check-up process and the way in which people interacted with the space both inside and outside of the van, recording my findings through a visual and written diary.This method was a critical point in the research process. It exposed latent and tacit needs as well as the behavioural patterns of the users and provided an intimate understanding of real time interactions that took place between the various stakeholders and touch points involved.Although redesigning the entire service was outside of the scope of this project, shadowing helped me uncover the reality of what people really do- as opposed to what they say they do. Shadowing the assistant and dental therapist allowed me to identify that the interior space of the van was not meeting the functional needs of the nurses and the emotional needs of the children. It helped me identify opportunities for design and quickly understand this particular design context and gave a detailed insight into the stakeholders journey through the service.

Journey Mapping:The customer journey map is an orientated graph that describes the journey of a user by representing the different touchpoints that characterises his/her interaction with the service. As it is mapped from the end users perspective it helps create a clear understanding of not only how the user interacts with the existing service but also identifies improvement opportunities (Stickdorn & Schneider, 2010)To further my understanding of the dental van service, I mapped out the child’s interaction with the service based on key touch points. These took many forms, from personal face to face contact with individuals to interactions with their enrolment form to the physical encounter with the dental van.

Summary of Research Methods Continued

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Identifying these touch points created a link between the dental van service and the preschooler, providing an overview of the factors that influenced the child’s experience from their perspective. Presenting this information in a visual format meant I could easily communicate to others the child’s interaction with the service and illustrate how these touch points are central to their overall experience. By creating this visual and simplified map, it was clear that the first and subsequently most influential touch point for preschoolers was the enrolment form and provided identification of problem areas and opportunities for innovation. Leading on from this simplified map, I was able to expand the focus of the map to the other stakeholders (assistant and dental therapist) for the purpose of exposing overlapping areas of interaction and to create a holistic overview of the service.

Ideation: There is a certain degree of magic required during the creative process. A multitude of visual research, mapping, model making, drawing and prototyping was involved throughout this process to help generate ideas as well as to help interpret data gathered. The tools, techniques and possibilities offered by these collaborating disciplines helped stimulate creativity and innovation opportunities further.

Reflection: The human aspect of healthcare experience guides the ideation phase and the translation of insights to design themes, qualities and solutions (Docampo Rama, M., and Parameswaran, L. 2006) However, there is another important factor at work within this project; a set of personal and project related values and goals that safeguard the human-focused integrity of my solution. Even in design thinking, constraints provide structure. These constraints can provide a strong framework for

goal setting and having very focused goals and values helped balance any uncertainty I encountered. This meant knowing who I am as a researcher, designer and person, as well as understanding my project, key stakeholders and the context in which these sit. With these goals and limits established, I had a certain bounded freedom to explore within, removing a lot of uncertainty and allowing for a more comprehensive reflection process.

Critical thinking: Critical thinking was something employed throughout my design project to keep myself honest- knowing when to hue to the rules or break them-and to edit things down. This was not only to ensure I was able to complete my project within the given time frame but also to make certain that the data I collected and analysed was beneficial to the overall aims of this project. It allowed me to evaluate my ideas and measure whether I was on track to creating a successful solution.

Evaluation: Additional to critical thinking, I evaluated my final responses through a combination of expert interviews, role playing scenarios and constant referral to published literature. With these I was able to create comparisons with the results of those encountered in the initial stages of this project. This gave me the ability to measure whether or not I have been successful in meeting my personal and project goals and staying true to my values. These research methods and evaluation tools were used in collaboration to develop coordinated systems of early childhood care that blend services from health, early intervention, education, social services and other community supports for children and families. These were used in an effort to create a unique understanding of oral health care for preschoolers and how design, specifically design thinking, can be used as an integrative part of the process to enhance their dental experience.

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Literature Review, Expert Interviews

Role Playing, Day in the Life/ Shadowing, Stakeholder Mapping, Group Mind-Mapping

The Child’s Journey, Service Blueprint, Points of Intervention, Developing the Design Brief

Initial Research

Empathy

Synthesis

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In order to carry out effective and rigorous research, I had to gain an understanding of the very basics of this project. Early brainstorming around the van and the context in which it sits helped me to discover areas which were in dire need of attention, as well as uncovering questions that needed further research. This diagram shows one of my early brainstorms around my initial observations and interactions with the van.

Initial Research

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Initial Research

Literature Review Summary

The literature review fell at the beginning of the project as its purpose was to provide a solid background and understanding of the context in which the research question was situated. The literature review helped create a unique understanding of oral health care for preschoolers and how design, specifically design thinking, could be used as an integrative part of the process to enhance their dental experience.

Key findings of the literature review:

The current literature in the field indicates the health care industry is undergoing significant changes. The role of oral health in specific, and its relationship with individuals, society, and the health care field as a whole is in dire need of a paradigm shift, realigning the system around the patient.

Additionally, there is a unanimous agreement in the health industry of the physical importance of oral heath as well as the social and psychological significance, resulting in an improvement of quality of life.

There is a general acknowledgment of the severe inequalities regarding child oral health, especially among Maori, Pacific, rural and low socioeconomic populations. This is considered to be unacceptable by many authors, as the oral health of a child at age five is indicative of their oral health as an adult.

As often the first point of contact with oral care for preschool children are the mobile dental units, it is critical their first experience is a positive one. However, as the literature stipulates, this is not an easy task, with many children suffering from dental fears and anxiety, often influenced by their caregivers.

Taking a design thinking approach begins with understanding and empathising with the user, follows a convergent and divergent process, all the while utilising principle ideas and methods harnessed from various frameworks such as integrative thinking and Human-Centred design.

There is evidence to suggest that the issues of preschool oral health, illustrated in this review, can be overcome by applying a design thinking methodology.

“...the health care field as a whole is in dire need of a paradigm shift, realigning the system around the patient.”

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Stakeholder MapThis map identifies key stakeholders in the dental van experience.

Due to the limitations of ethics, direct research was not undertaken with this stakeholder.

Due to the limitations of ethics and the limited time of this project, direct research was not undertaken with this stakeholder.

Due to the scope of this project, direct research was not undertaken with these stakeholders.

This research focuses on the perspectives of the ADHB and of the nurses. Expert interviews, shadowing and journey mapping helped give a unique understanding of these stakeholders and the dental service.

Roleplaying gave insight into the preschoolers experience and helped gain a better understanding of their perspectives. The literature review was also useful.

SCHOOLMANAGERS

PRE-SCHOOLERS

PARENT/CAREGIVER

NURSES

ADHBMANAGERS

GOVT

SCHOOLTEACHER

ASSISTANT

DENTAL VAN EXPERIENCE

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Power Interest MatrixThis matrix was used to analyse key stakeholders; understand if there is a relationship between them in this project and, if so, what sort; asses the manner in which they might be affected by the project outcome and; asses the capacity of different stakeholders to participate.

The dental nurse was a key player in this project as their influence, involvement and interest in the outcome was high. They are involved with the system from start to end and therefore is a stakeholder who is critical in my design and decision making considerations. The children have a high influence on my design direction as they are who I consider to be critical stakeholders in this project. After all, they are the reason this service exists!The caregivers influence is significantly less than any other stakeholders. While I recognise that caregivers do interact with the van and that their attitude towards the van can influence their children’s, it is not within the scope of this project to consider caregivers as critical stakeholders, too.

Children

CaregiversMONITOR KEEP INFORMED

KEY PLAYERSKEEP SATISFIED

INFLUENCE

INTEREST High

High

Low

Low

Nurse

Assistant

ADHB

The positions of key stakeholders were mapped onto a power interest matrix using the following guidelines: High influence, interested people (key players): these stakeholders must be fully engaged. High interest, less interested people (keep informed): provide sufficient information to these stakeholders

to ensure they are up to date but not overwhelmed with data. Low influence, interested people (keep satisfied): keep these people adequately informed, talk to them to

ensure that no major issues arise. Low interest, less interested people (monitor): provide these people with minimal communication to

prevent boredom. For example, other department members and people unaffected by any changes.

xx

x

x

x

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Expert Interviews

To build on insights gathered through examining existing literature, and to narrow the focus of my research into the context of the preschool dental van, interviews were conducted early in the research project with experts from the Auckland District Health Board as well as a psychologist with experience in early childhood perception of space, a kindergarten teacher and two oral health lecturers at AUT University with previous experience in private practices. I used these interviews to gain a deeper understanding of the complexities of preschool children and how they view the world as well as to understand the oral health industry in New Zealand, how the dental van service fits within that and finally the issues the dental therapist and assistant face while interacting with their work environment.

The following are a selection of the most valuable statements gained from semi structured interviews which both provided new information and helped narrow the scope of my inquiry.

Having a strong sense of well-being allows children to become deeply involved in activities. Feeling physically and emotionally safe are important pre-requisites to sense of well-being. We (ADHB) need to understand the patient journey

and whether this is the journey we want them to go through. “How are they enrolled? How do they know to come

here?” is the 25% of families we can’t catch. How to find those that aren’t enrolled and how do we (ADHB) get them into our system is our biggest challenge. These vans were just a response to a need. They were

never planned or design. No one thought this “is the best way to do it?” It was just a knee-jerk reaction to the problem. The internal colour scheme needs to create mood and

define spaces. The softness of a home like setting is likely to be

particularly supportive to children during the settling in phase. Careful organisation and aesthetic considerations

influence the emotional climate of a child’s environment and their learning. An unattractive, chaotic, and noisy environment is

likely to hype up children’s behaviour so they become disruptive and disrespectful of the environment.

Conversely, environments that are too pristine and immaculately tidy which do not provide enough challenges for children. Perception is an active experience, in which a child

finds information through mobility. Children’s physical participation with the architectural

elements extend to satisfaction and the experience stay in their memory. And, memory is a derivative of place attachment. It is important to let the child feel they have ownership

of the environment as it allows them to relax quicker. If a person has a good working environment they will

be able to be relaxed and calm and improve productivity. While the van ‘does not work well’ it does not mean

the system is not working well. The service is evolving demands are higher; focus has

changed from restorative work to preventative work. There are still some concerns in low economic areas

where parent’s negligence, fear and education means parents are not responding to the needs of their children. The language you use is essential in making kids (and

adults) feel comfortable. Too often it is the parents fear that causes the child

to be anxious. Children can read these sorts of things better than we know.

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Summary of Insights“...Catching the 25% of families who are not enrolled and getting them into our system is our biggest challenge.”ADHB Board Member

I regard the information here as the key relevant points from talking to these experts.

Motivating factors for dental van staff were the good relationship with co-workers, managers and patients, seeing the results of their work, and having their own responsibility and making their own decisions were described as facilitating factors. The trying factors, as described by the dental hygienists, were above all, in regards to the physical faults and limitations of the van’s interior. Both the dental therapist and ADHB board member expressed their concerns of the enrolment form based

on their interactions with it and the implications it has on their work day. For instance, the dental assistant would frequently start her work day hours earlier just to ensure all the enrolment forms are processed through the system. The ADHB board member acknowledged her fear and discontent with the amount of enrolment forms that are sent but never returned and recognised it as the ADHB’s biggest challenge. Discussions with a child psychologist and preschool teacher offered insights into how children perceive

the world and that their emotional and physical requirements from their dental van experience might be improved through the creation of an inviting and interactive space. Physical participation with the van and service will extend to satisfaction and the experience will stay in their memory. And, memory is a derivative of place attachment.

To conclude, participants directly involved with the van described their work environment as trying in several ways, despite the new technology and rewarding work. The enrolment system is not without its faults and requires an understanding from the recipient’s perspective. In order to overcome these issues, the use of interaction, colour and light could help create a more positive atmosphere and define spaces as well as encourage children to be active members of the experience.

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Shadowing“By observing the service from a neutral viewpoint, it became apparent that there were issues the dental staff could not recognise as they viewed the service solely from their adult and professional experience and not from a child’s.”Personal Reflection

These photographs document the typical activities a dental therapist and assistant perform on a normal preschool visit in the dental van. I shadowed the staff over a period of three days as it was stationed within three different socio-economic areas to gain a clear understanding of the service.

By observing the service from a neutral viewpoint, it became apparent that there were issues the dental staff could not recognise as they viewed the service solely from their adult and professional experience and not from a child’s. For example, the metal barrier between the front seats and the back of the van is a functional and important safety requirement from an adult’s perspective but from a child’s viewpoint it could be seen as an intimidating cage.

Spending time in this environment was a way to develop a truly holistic view of how the service is operating as it provided an intimate understanding of the real-time interactions that took place between the various stakeholders and touchpoints involved.

From shadowing I recognised that for the wellbeing of both the nurses and children while interacting with the dental van a redesign of the entire physical space was necessary. The design would have to balance the functional needs of the staff as well as the emotional needs of the children. This became a central theme in my project.

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Park and secure van. Plug in electrical chords.01

Set up working area.04

Therapist checks patient history.07

If necessary, referral form is completed.10

General set up of interior.02

Prepare for first screening.05

Therapist performs checkup.08

Pack away work area.11

Therapist sets up based on personal preference.03

After meeting class, assist first child on board.06

Assistant records new findings.09

Secure loose items for transit.12

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This image shows evidence of a group mind-mapping exercise which was used both to inform peers of the design process and current project progress, as well as to gather outside information in the form of ideas and opinions which may highlight avenues for further exploration. Through mapping out all aspects of the dental van (including macro influences) I realised the product sat within a larger system, or a service, which had multiple touchpoints.

Group Mind-Mapping

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Journey of Child Through Dental Van Service“The sum of all experiences from touch-point interactions colours their opinion of the service (and their future expectations)”Clatworthy, S. (2011)

Touch-points are the points of contact between a service provider and users and are one of the central aspects of Human-Centred design. They describe one of the major differences between products and services, and are the link between the service provider and the user.

Each time a child relates to, or interacts with, a touch-point, they have a service-encounter. This gives an experience and adds something to their relationship with the service and the oral health industry. The sum of all experiences from touch-point interactions colours their opinion of the service (and their future expectations) (Clatworthy, S. 2011). In this way, touch-points are central to their overall experience.

At this point in the project, research insights gathered from stakeholder maps, shadowing and interviews, indicated that the dental van, while important, was one of many touch-points in the dental service. A decision was made to indentify and analyse each touch-point. I constructed a simplified version of Docampo Rama, M., and Parameswaran, L.’s (2006) expectation model to capture a child’s interaction with the service based on key touchpoints.

Identifying the touchpoints where users interact with the service was crucial. These took many forms, from personal face to face contact with individuals to interactions with a form or physical trips to and from preschool. This map provides an overview of the factors influencing the child’s experience from their perspective.

Basing this map on user insights allowed me to chart both formal and informal touchpoints and provided identification of problem areas and opportunities for innovation.

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A 5 process model identifying critical touchpoints to understand users oral healthcare experience in a mobile van setting, from expectation through to memory. Model adapted from Docampo Rama, M., and Parameswaran, L. (2006)

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Involvement of VariousStakeholders (Blueprint)By describing and outlining all of the elements contained within the service I was able to identify the most crucial areas whilst also revealing areas of overlap.

Expectation

01First Impression

02Discovery

03TOUCH POINTS

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This diagram is an expansion of the journey map on the previous spread. It was further developed into a more detailed stakeholder map. The purpose was to specify in detail each individual aspect of the service from the points of the child’s contact with the service to behind-the-scenes processes.

This map was produced in collaboration with several key stakeholders (assistant and the dental nurse) who were able to give detailed accounts of their responsibilities and the child’s interaction with the service. I selected these stakeholders as the focus of this service illustration based on the results of my stakeholder mapping.This service blueprint was useful in creating a shared awareness of each stakeholders involvement and responsibility and to communicate to experts outside of the oral health industry.

Usage

04Memory

05

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Points of Intervention

From a triangulation of theory, interviews with experts and my own research, I was able to conclude that these are the two most critical touchpoints that are central to the child’s overall experience with the service.

A

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B

Recognising that what occurs in the home was beyond my control, a problem too wicked, and that to redesign the system as a whole is not within the scope of this project, I focused my attention to the next phase in the process- the enrolment form.

Being the child’s first touch point with the service ensuring this is an engaging and positive experience is essential. This form will determine whether or not their expectations of their visit to the van are positive or not and may even influence their attitude toward the oral health industry as a whole. Influencing their memory and opinions of the service thereafter is the child’s interaction with the van’s interior- the second point of intervention. From a triangulation of theory, interviews with experts and my own research, I selected these two touch points as I believed that:

1. They were two of the most important touch points in the overall experience;2. They are currently poor, and offer a great opportunity for redesign;3. The seem doable in the scope if the project; and4. They provide a great opportunity to demonstrate the power of human centred design.

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03DEVELOP

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4765 Van Experience, Van Layout Exploration, Van Experience Concepts and Development

Enrolment Experience, Character Concept Exploration, Enrolment Form DevelopmentPart A

Part B

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Part ARedesign of the

Enrolment Experience

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Key Touchpoint: Enrolment Form

This diagram illustrates the consequences of a poor interaction with the first touchpoint. If a child does not positively engage with the enrolment form they will subsequently not have a positive first experience.

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Existing Enrolment Form“Factors affecting the brand of an organisation can be both tangible and intangible, including interior decor, organisation philosophy, design of printed materials and value-added services, just to name a few.” (Stine, 2009).

The visual language is more than how the logo is displayed, but rather the emotional and intellectual response it elicits from the target audience. The enrolment form is the first point of communication between the ADHB and the child and caregiver. It therefore should be a reflection of the ADHB and the service they offer.

The current design of the enrolment form is clinical, outdated and inconsistent with the existing oral health experience. It does not carry with it the feeling of quality and care that the child will receive during their check-up, nor does it generate, affection, trust, assurance and allure for the children or their caregivers. It is then easy to see why 25% of the enrolment forms are lost in mailboxes- along with the potential for the child to have access to the care they deserve.

An analysis of the existing enrolment process indicated that it would not only be important to redesign the layout of the form but to also re think the visual language used.

No introduc-tion to service or what parent or child can expect.

Child is holding tooth brush- only visual clue that this is relating to oral health.

Facts presented in clinical and lackluster way.

Outdated graphic design. Unclear who audience is.

No personality.

No area for caregivers to explain why they did not give consent. (ADHB have to follow up individual cases)

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Branding“When children see a character they like on a product, what comes to mind is how much theylike that character, and it carries over into their product assessment,”(Song, 2010)

Branding is important to make sure that all elements of an organisation look and feel consistent and are visually and sensually aligned with the brand. Even though services require special treatment the main competency driving the field of branding is similar to that of service design (Moritz, S. 2005). On a holistic level, the thinking in the branding field to recognise that every touchpoint with the brand is a communication opportunity needs to be employed to the design of this service, too.

While a complete set of brand management practices are not within the scope of this project, establishing a difference between similar service providers can be achieved by creating a one-of-a-kind identity and colour pallet (Speak, K. 1996). This is but one baby step in the journey to building brand equity.

According to an article by Song (2010),“children tend to react more emotionally and intuitively to events and objects than adults do, and experts believe that may be why they are particularly susceptible to advertising that relies on characters. When children see a character they like on a product, what comes to mind is how much they like that character, and it carries over into their product assessment”. Children’s brains are continuously referencing contextual information and allowing it to influence their perceptions. (Song, 2010).

With these insights, I chose to create a distinctive set of characters that not only build upon the promise of the ADHB, but also appeal to children. These characters will be consistent throughout the dental experience; they will be on the enrolment forms, in the van, on the referral forms etc- the branding will continue throughout the service building trust and familiarity between the child and the oral health service.

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Character Research“When children see a character they like on a product, what comes to mind is how much theylike that character, and it carries over into their product assessment,”(Song, 2010)

As these characters are intended to create a positive and engaging experience for the child, the preliminary ideas of this project suggest integrating some of the elements children identify into the design of the characters.

They are based on the premise that a particular set of characters, might turn the oral health experience into a better environment for the children, and minimize the children’s anxiety during the process.

To have a better understanding of how children are able to feel at ease with things or in places that may, a priori,

seem out of their world, two references are presented.The first reference is to Joan Miro and how the elements that are critical to his work might be a strong reason as to why children appreciate his art so much. After accepting that there are many ways to appreciate art and that adults don’t perceive art in the same manner as children, it is also important to agree that adults can’t exactly know what a child feels in front of a Miro painting. However, looking closely at a three-year-old child’s drawings, picked at random among the many ones parents see everyday, a surprising parallelism with “The Encircled Prophet” by Joan Miro is observed.

In both, continuous lines of different thickness, drawn in primary colors, define simple shapes. This parallelism might surely be of no relevance for an art student but, for the purpose of this project, it suggests that the child might identify herself with Miro. For the child, his paintings and sculptures are harmonic compositions of mainly bright colors, free lines and simple shapes, elements that a child is able to seize and recognize as belonging to their childhood world. Attractive colors, lines and shapes are the elements they are in touch with all the time when at home, at school or at the playground.

Image 1 (far left): “The Encircled Prophet” by Joan MiroImage 2, 3: Drawings by three year old children

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From The Child’s Point of View

Another point that needs discussion is that many times adults believe they already know how children feel and what they like. As an adult, any designer is tempted to believe so, yet she cannot afford the mistake if this project involves children. Although integrating them to the design team might be questionable, there is no doubt that the start point in developing a project involving children is obtaining precise information about them.

To date, children have been known primarily through adult observations, proxies, and accounts. As the focus of child research shifts from seeking information about children to seeking information from them, traditional approaches to data collection, such as questionnaires, survey tools, and directed interviews, seem inappropriately adult centered, dominated, and biased (Bradding & Horstman, 1999).

The drawings above are examples of draw-and-tell conversation- one example of a child-centered and directed approach to data collection which is used to explore young children’s experiences. In this instance it was used to understand their perception of their dental experience.

Children often drew themselves in the dental chair, making the chair very large and themselves very small. It seems as if the children perceive themselves to be lost or insignificant in the chair. Dental nurses were drawn with more smiles than dentists. Perhaps they are perceived as smiling, non-threatening persons because they are not always associated with the dental task (Christenson and James, 2000)

These illustrations offer insight into how children perceive their dental experience and act as inspiration for the design style of the characters.

After going through the two references that support the preliminary ideas, it can be assumed that: if the children are able to recognize familiar elements integrating a particular object or within a particular environment, even in an alien environment, they perceive the environment as “familiar”. Moreover, they feel at ease and act naturally. (Bradding & Horstman, 1999).

(1)Drawing of dental nurse by first grade girl(2)Drawing of dental experience by 8th grade boy

Images from Children Draw and Tell; Christenson & James, 2000,

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Existing Character ExamplesThe images to the below are a selection of various logos and brands from a variety of environments children commonly encounter such as preschools, and hospitals.These were selected based on their use of characters, lines and colours that a child is able to seize and recognize as belonging to their childhood world. These are not only designed for the child but for their caregivers as well. By being child focused they offer reassurance to parents.

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Child

ADHB

Caregiver

The main criteria for the child was that these characters are engaging. These characters are likely to influence the child’s perception of the oral health service and will guide them on their journey through their first oral health experience. The characters therefore must; evoke a positive emotional response.; be relatable/familiar ; easily commit to memory; be friendly and, of course, fun.

For the ADHB these characters are to become their new identity. This new identity must; consolidate and coordinate existing identities; preserve the equity residing with keystone oral health care identities and leverage those equities to build trust and equity in the new identity; incorporate the values of the organization to reinforce “living the brand.”; be appropriate to adult audience; sophisticated yet young.

Additionally, this new identity should instill trust in the caregiver towards the oral health service and re-shape their perceptions of the industry by signaling a new future-focused strategy.

Character CriteriaBuilding a strong identity in the health care category comes with a unique set of branding challenges. In order for these characters to be successful, they need to meet the needs of key stakeholders.

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A variety of characters were explored during the concept phase of this project. The challenge was to create a unique pair of characters that would not only be engaging for the child but also capture the essence of the vision of the ADHB’s oral health brand experience.

Character Concept Exploration

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Character EvaluationThree characters were chosen based on the criteria listed on the previous spread. These characters represent a spectrum from an unrefined character, similar to what a preschooler might draw, to a more detailed and sophisticated pair of characters.The chosen concepts were taken to several experts for evaluation which will proceed through to development.

More RealisticAbstract

1 2 3

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More Realistic

Character EvaluationThese experts included a preschool teacher, an animation and character designer as well as a member from the Auckland Regional Dental Service. The following are a collection of their statements towards each set of characters. From discussions with experts, referral to published literature and theory as well asmy own personal reflections, characters #2 were selected for further development. Itwas concluded that these characters were ‘fun’ enough for the child to relate to, but also sophisticated enough to meet the identity needs of the ADHB.

1 2 3Positive comments: These look like they have been drawn by a child Clearly the same language of preschoolers Children will be able to relate to Represents under 5 year old well

Constructive comments: Need to be more refined- too messy for memorable brand Seem very generic- something you could find in any kindergarten Need colour Proportions are inconsistent and peculiar

Positive comments: Eye is instantly drawn to these Is a distinct pair of characters Despite the fact that it is very generic it has as sense of originality to it Can extend out as a brand as is where as the other two can not- These characters have a sense of personality that the other two do not Seem very childlike Look as though they are enjoying themselves

Constructive comments: Need to be designed with the same rigour as characters #3

Positive comments: Believable characters Show teeth- clearly related to oral health Sophisticated for branding

Constructive comments: Certain agenda with tooth brushes and eating apples- need to look like they are having fun Need brighter colours Too sophisticated for children to relate to easily

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Character DevelopmentThe 50 year evolution of Mickey Mouse provides another example of neoteny, as the famous Disney character- through such changes as larger relative head size and larger eyes- becomes increasingly juvenile in appearance.

In 1980, renowned naturalist Stephen Jay Gould wrote an essay entitled A Biological Homage to Mickey Mouse. Gould made a convincing argument that the evolution of Mickey Mouse’s appearance followed the “nicening’ of his personality: “As Mickey became increasingly well behaved over the years, his appearance became more youthful.” (Gould, 1979)

He lists the very features of babyhood that Disney affixed progressively to Mickey: “a relatively large head, predominance of the brain capsule, large and low-lying eyes, bulging cheek region, short and thick extremities, a springy elastic consistency, and clumsy movements.” (Gould, 1979)

Through various iterations my characters, too, became more neotenic. Most notably their head to body ratio increased, while their arms and legs nearly halved in length. The characters appear to be more playful even without accessories and their relationship with each other developed, too.

I appropriated Joan Miro’s technique of using continuous lines of different thicknesses to define the simple shapes of their bodies as well as bold, contrasting colours to capture the attention of children.

For the child, these characters are harmonic compositions of mainly bright colors, free lines and simple shapes, elements that a they are able to seize and recognize as belonging to their childhood world. The characters also present a modernised version of the original concept signaling a new future-focused strategy.

Image source: http://effectivenm.blogspot.co.nz/2010/08/evolution-of-mickey-mouse.html

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Character DevelopmentProgressive evolution of characters from original concept through to a more neotonic set of characters:

1 1.1 1.2

1.3 1.4 1.5

1.6

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Familiarising the Characters“Brands have values and personalities. Brand loyalty is based an emotional commitment”.(Speak, K. 1996)

To develop emotion around the ADHB’s new identity, the characters needed to have a personality, one that is able to communicate the core values and promise of the service in an alluring manner for the children. The conclusions from my character research suggested that if children are able to recognise familiar elements integrating with the characters, they are likely to perceive them as “familiar”.

I was opposed to focusing the overall message of the mobile dental clinic around healthy teeth and gums (as many preschool children have yet to gain a comprehensive understanding of dental care itself), instead choosing to concentrate it around the positive effects that come with a healthy lifestyle. Namely, the concept of having fun, which is more relatable to the preschoolers than dental care.

The recognition and appeasement of the child’s point of view is a theme consistent throughout all aspects of this project and is crucial for the adoption and long term success of these characters.

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Enrolment Form Concepts

Having systematically developed a visual identity and branding message appropriate for the ADHB’s mobile clinic and it’s key stakeholders, I was then ready to apply those elements to the design of the tangible aspect of the brand- the enrolment form. Following the cyclic nature of action research, I began generating design ideas and concepts in response to observations and reflection of insights generated through the initial research phase of this project.

Early responses were arranged on a continuum from incremental improvements of the existing form to more complex, radical ideas. Three responses that best represented this range were chosen and are documented below:

Concept 1 Represents the notion of an enrolment form that adheres to the constraints of the existing form. Able to be printed on an A4 sheet of paper, it bids very little complications. While the characters catch the eye, the form itself does not reflect the objective of creating an engaging encounter. However, it has the potential to become a sophisticated rendition of the current form.

Concept 2 Illustrates the potential of using paper folding techniques to form a simple but memorable pull out card. This playful element corresponds with the goal of creating experiences children can consider to be familiar and part of their world. The challenge is to complement the ‘fun’ aspect of the form with design that is in tune with the requirements of caregivers and ADHB.

Concept 3 Introduces the van early on in the child’s journey with the service through a paper model. . It allows the child to familiarise themselves with the van and presents an opportunity for parent-child bonding in the construction of the model.

RadicalIncremental

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Evaluation and Development

I presented these three concepts to several staff at the Auckland District Health Board to not only get their feedback but also to develop new iterations together.Because of their limited financial resources, concept 3 was perceived as too expensive and was disregarded almost instantly. It was interesting to watch the adults find amusement in concept two. And while they all agreed concept one was most suitable for their needs they were keen to explore how we could potentially combine the two concepts. Ultimately creating an engaging yet cost effective enrolment form.

At the end of our discussion we concluded the enrolment form must: Be within the ADHB budget (similar printing cost to existing form) Be small enough to it into envelope Provide healthy oral hygiene information for the caregivers (can they keep this somewhere to remind them?) Simple Easy to read Not intimidating or clinical And lastly, to engage the child and introduce them to the new characters.

The development workshop was brief. Fortunately, Design Thinking encourages rapid prototyping and quick iterations. With some basic card and stationery from the craft-box myself and my stakeholders began development of the concepts. The session concluded with a discussion around how working together in a creative environment was a refreshing and ultimately fun experience which can lead to unexpected ideas. The stakeholders from the ADHB agreed that a few folds can drastically increase the complexity of the form and opted for a simple, compact roll-fold to be developed further.

1

2

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Final Design

This preliminary examination is not intended to comprehensively consider all design aspects of the oral health care service model. Rather, it includes some of the most common themes identified during my research and provides a step towards understanding the ways in which Human-Centred design informed by Design Thinking methods can support innovative care delivery in mobile dental clinics and explore how the practical application of these can assist to identify key service touch points, and to then drive the transformation toward a more engaging and positive mobile dental clinic experience for all user groups.

I was opposed to focusing the overall message of the mobile dental clinic around healthy teeth and gums (as many preschool children have yet to gain a comprehensive understanding of dental care itself), instead choosing to concentrate it around the positive effects that come with a healthy lifestyle. Namely, the concept of having fun, which is more relatable to the preschoolers than oral hygiene.

The recognition and appeasement of the child’s point of view is a theme consistent throughout all aspects of this project and is crucial for the adoption and long-term success of this service. The enrolment form is the first point of communication between the ADHB and the child and caregiver but despite dental health care being free for children enrolled with the service, 25% of existing forms are never filled out. Branding is another important component to make sure that all elements of an organisation look and feel consistent and are visually and sensually aligned with the service.

With these insights, I chose to create a distinctive set of characters that not only build upon the promise of the ADHB, but also appeal to children. These characters are likely to influence the child’s perception of the oral health service and will guide them on their journey through their first oral health experience. The branding continues throughout the service building trust and familiarity between the child and the oral health service. For the child, these characters are harmonic compositions of mainly bright colours, free lines and simple shapes, elements that they are able to seize and recognize as belonging to their childhood world. This brand is more than how the logo is displayed, but rather the emotional and intellectual response it elicits from the target audience.

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Final

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Part BRedesign of theVan Experience

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Current Van Experience“Precariously navigating their way up the slippery and unnerving stairs, their heart beating furiously at the unknown, the child is greeted by two intimidating metal cylinders oozing worm- like tubes... “Personal reflection from role-play

Given that many services are performed and consumed in set environments (e.g. airport, shop, hospital, etc.) the design of spaces is an important element of Human-Centred design (Moritz, S, 2005). For this service, the interior of the van is not only the stage and setting for the service performance, but also home to a variety of touchpoints that need to be designed.

The interior design of the van works to set the tone and expectation of users. To make the van engaging for children and more efficient and effective for the staff it is important that the atmosphere is in line with the image and quality that the service offers. (Moritz, S, 2005).

As Moritz (2005) concludes, integration and communication is the glue that holds Human-Centred design together. The main concept of this area of design is to make the users part of the design process. Because the users are part of the delivery of the service, they can also be part of designing the service. By engaging with key stakeholders from the outset of this project and using the knowledge, techniques and methods from Design Thinking it was possible to enable the user to contribute to the design process and create a collaborative and innovative proposal.

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Design ObjectivesImplementation of patient-centered care for underserved populations has proved challenging because of barriers such as language and other cultural differences and a lack of resourcesMinistry of Health, 2006.

The concept of patient-centeredness, as elicited from my literature review, represents a significant shift in health care philosophy from a professionally driven system toward one that increasingly recognises and incorporates individual patients’ perspectives and engages them in their own health care.

Implementation of patient-centered care for underserved populations has proved challenging because of barriers such as language and other cultural differences and a lack of resources (Ministry of Health, 2006).

In a paper sponsored by the W. K. Kellogg Foundation, Silow-Carroll, et al, proposed key components of a comprehensive approach to patient center care for the underserved.

These components became the key considerations when creating goals for the redesign of the van experience. These goals are as follows:

Provide a welcoming environment (physical, psychological, and social) that is familiar and not intimidating; Enhance socio-cultural competence by understanding and considering patients’ cultural, economic, and

educational status, Coordinating and integrating team-based care and; Comfort and support, including physical comfort, privacy, emotional support, and involvement of family and

friends;

A positive, empowering, and supportive physical environment is an essential part of providing patients care. Design of the physical environment can support implementation of patient-centered care in the mobile dental van by enhancing certain components of care for the underserved. The objectives of this next section is comprised from the components listed above.

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BarriersThe diagrams below indicate the various barriers dental staff and patients have to navigate around. The image on the left shows areas of concern such as sharp corners, potential fall areas, rolling objects and areas where heavy lifting is necessary. The image on the right shows the working areas of key users and how they interact and crossover with each other, effect work efficiency and even how they might compromise patients safety.

A

B

C

E

D

F

G

H

I

J

K

L

M

N

O

P

A

B

C

E

D

F

G

H

I

J

K

L

M

N

O

P

A: Storage CupboardsB: Battery CompartmentC: Rubbish Bin (temporary)D: Gas Tanks (not used)E: On-hand EquipmentF: Unsterilized (used) toolsG: Patients SeatH: Nurses Swivel ChairI: Stool (used as seat)J: Fold-up DeskK: LaptopL: Assistants ChairM: Back DoorsN: Storage (pens, pamphlets, etc)O: Display MonitorP: Stairs

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Van Layout Exploration“The design of the physical environment plays an important role in improving health care quality, work efficiency, and cost-effectiveness”Joseph,Anjal. et al (2011)

Effective collaboration between health care professionals is a crucial part of high-performing health care delivery systems. In team collaboration, health care professionals work together in complementary roles, sharing decision making and implementation of care plans (Bradding & Horstman, 1999).

From expert interviews and literature reviews several insights were exposed in regards to the team working environment in the mobile dental clinic. Successful collaboration improves team members’ understanding of one another’s knowledge and skills, enhances decision making, raises job satisfaction, and boosts efficiency. However, failures of team collaboration are not uncommon in this environment and can have a negative impact on outcomes and patient satisfaction. Barriers to effective teamwork include the cramped and unstructured working environment, poor placement of display screens, oversized and outdated furniture, and minimal maneuverability space.

A supportive environment with space, furniture, and technology that enables group interaction and transactions may likely encourage collaboration.Experts and key stakeholders agreed that by having clearly defined areas, a sensible layout of furniture that allows for staff and patients to navigate through without getting in the way of each other, appropriate storage, and welcoming and safe patient waiting areas, effectiveness of treatment and patent satisfaction can be maximised.

The following images show a range of layout possibilities with the existing objects (to scale). The green represents the patient and parent waiting areas, the dental assistant and their tools (desk/ computer/chair) are purple while the blue represent the dental nurse and the items she engages with regularly.The goal was to find a balance between pleasing the staff and patients, without compromising safety or space. As illustrated, simply rearranging the existing furniture did not produce a suitable solution. No one layout was better or worse than the other. A complete redesign of the interior was necessary.

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Modifying the existing interior was an initial concept for the design of the interior. I explored multiple ways in which the furniture, walls and storage might be incrementally improved. I realised that by simply rearranging items I would not be solving any problems, only making them less evident, nor would I be following the principles of design thinking.As our population increases, the need for mobile units will become greater. It is from this insight I decided to brainstorm ideas that are transferable from van to van, appropriate now and in the future.

Interior Exploration

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Re-framing the Design Direction

“...tangibles such as the furniture in the environment are crucial for users perceptions, although the service itself is intangible.”

To develop service encounters that are useful, usable, and desirable from the users perspective (Moritz, 2005). Parasuraman, Zeithaml, and Berry (1988) suggested a measurement tool to assess patient’s perceptions with service quality. The tool is composed of five dimensions of service quality that include tangibles, reliability, responsiveness, assurance, and empathy. This composition of dimensions for service quality measurement shows that tangibles such as the furniture in the environment are crucial for users perceptions, although the service itself is intangible.

The furniture in the van is a tangible service quality from which users develop perceptions about the ADHB and as such is an important components of this project.

It is not within the scope of this project to redesign the van as a whole, however by focusing on furniture, this project considers the impact that the physical environment can have on encouraging or discouraging certain behaviors and emotions (Carpman & Grant, 1993) and the positive effect they can have on a child’s development (Fottler et al., 2000).

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Exploration of furniture concepts that consider the small and mobile working environment.

Furniture Concept Exploration

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Furniture Concepts (3D)Rapid prototyping facilitated the creation of numerous 3D concept models. In order to objectively evaluate which ideas will be taken through to development, concepts were arranged on a continuum.

Concept 1 sits at the top of the scale. It proposes the idea of incrementally improving the traditional chair, making it attractive visually and eliminating safety hazards. It has the potential to modernise the van and through the use of colours could be made more appealing to children. However, being mounted permanently into the ground, it still is likely to be deemed as intimidating by the child.

Concept 2 Introduces various components that make a whole. In this case, a range of products can be used independently or in relationship with each other. It is essential to retain clinical autonomy during the examinations, and a degree of flexibility is therefore necessary to support individual variations (for both staff and patients).

Concept 3 Challenges the notion of flexibility and introduces a completely modular concept. It eliminates the idea of a ‘special’ chair and normalises all furniture in the van. It is a more radical concept but has the potential to engage children and create a memorable experience.

Radical

Incremental

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Concept Evaluation

It is important to note that the ADHB’s expectations at the start of this project was a simple redesign (or recover) of the existing chair. Because of this, I expected concept one to be their preference. However, because I have been applying design thinking tools, like codesign, throughout this project I eagerly awaited their feedback of concepts two and three.

The staff were very impressed by the small scale models and found much joy in arranging the furniture in the scaled van (see images below). Having these prototypes helped create discussion around each concept and allowed the staff to modify and rearrange the models while they told stories and reflected on the positives and negatives of each concept.

Concept 1 was seen as simple, affordable and practical. It was appealing in that it could be implemented quickly and within budget though the cost was that it was lacking in creativity. It seemed the white fold-up seat in the model was more popular than the chair concept as it served a duel purpose and was compact.

Concept 2’s most popular attribute was the ability to be modified as needed though concerns were raised about how much time the rearranging might steal from the nurses.

Finally, concept 3 was rewarded for being creative and challenging the notion of a single stand out chair, though practical issues such as cleanliness and storage of the furniture while in transit were off-putting.

After presenting each concept, the stakeholders had only agreed on one point- that each concept had impressive elements that needed to be combined into a new, final concept. So I proposed a quick rapid-prototyping session.

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Concept Development

Though our prototyping supplies were limited, our creativity was not. Having agreed upon a set of elements we wanted the furniture to include we began prototyping.

These main basics the new concept had to achieve were: Flexible/adaptable for different situations and staff Easily installed in existing and future vans at a realistic cost Engaging for children resulting in positive and memorable experience Safe and easy to clean Secure during transit Consistent visual language

Building on the fold away bench in the scale model of concept one, and combining the fold down element of the enrolment form, we created a simple fold out wall concept that we believed could meet all our needs (see images below),

The staff were beaming. Eager to see where I might take this concept and went away excited for future possibilities within the ADHB. Hearing these stakeholders passionately discuss possibilities of bean bags and fold-out furniture was a giant leap from the discussions at the start of this project. I felt a great amount of pride in knowing I facilitated in their experience with Design Thinking.

Codesign is essential for long term sustainability and hopefully including the stakeholders in the design process generated a sense of ownership, especially as it was initiated early in the development process. Of course, I feel as though the greatest success of the workshop was not producing a final concept but rather having provided opportunities for learning for both myself and stakeholders themselves.

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Exploring different fold-out methods and how they might lock away during transit

Initial concepting and rapid prototyping around idea and basic colour play

Creating scaled models using precision tools, such as a laser cutter, to ensure correct proportions. Exploring organic lines and shapes for seating (below).

Final Concept Development

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Combining storage with graphic design elements (above) Playing with fold out shapes (below)

Testing various proportions of furniture

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(Above) Exploring materials for seating and colour options. Testing whiteboard as interactive wall for children (right)(Below) Refining details of final concept.

Final Concept Refinement

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(Above) Refining how the seat closes and is supported, taking into consideration aesthetics and pragmatic issues.(Below) Final concept to be presented to stakeholders. Detailed with inclusion of LED screen and stool for assistant.

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Interior Design Proposal

This project suggests that designing services and environments for the users experience poses a formidable, but highly worthwhile, challenge for the improvement of the Auckland District dental van. It was not just about being more patient-centred or promoting greater patient participation. It went much further than this, placing the experience goals of the children and key users at the centre of the design process and on the same footing as process and ADHB goals.

In the redesign of the dental van, I worked as the coordinator between key stakeholders employing my strong skills of empathy, integrative thinking, optimism, experimentalism and collaboration to ultimately deliver a new approach to an out dated service.

User involvement in this design process was essential. When the stakeholders and the end-users participated in the design process, new ideas, service needs and different ways of utilising technology were encountered. Possibly the most leading example of this are the proposed foldaway seats in the interior of the mobile unit- had I not co-designed with dental therapists and observed the van in operation I would not have discovered that there is not always a need for waiting chairs. This insight combined with ideation tools from design thinking and the open-mindedness of stakeholders led us to an engaging and creative alternative to the existing bench.Furthermore, the role of visualisation and hands-on experimentation, and creating quick prototypes, which were made simple enough to get usable feedback, was an integral part of the redesign of the dental van. Prototyping provided a way for a dialogue to take place and scaled van mock-ups made the intangible become tangible. Various ways of visualisation such as concept sketches, rough physical prototypes, stories, role playing and storyboards were on-going processes and activities where the user was part of creating value.

The interior design of the van works to set the tone and expectation of users. To make the van engaging for children and more efficient and effective for the staff it is important that the atmosphere is in line with the image and quality that the service offers. Foldaway seats allows space to be maximised when not in use and invites children and parents to interact with the space, shaping it to improve their comfort levels. Additionally, white-board walls offers an engaging and positive experience for the children. This playful element corresponds with the goal of creating experiences children can consider to be familiar and part of their world.

White-board wall to keep child stimulated while awaiting their turn. Interact with characters.

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Steps to assist children onto chair. Folds into back of chair when in transit.

Notice board: for communication between changing assistants.

Storage area for pamphlets or brochures for caregivers

Fold-away chairs: engaging for child, space-saving. Bungee chords link old van and new van.

LCD screen: Communicate

messages to caregivers on board. Can also

show x-rays of teeth to caregiver/nurse/child

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DELIVER04

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8895 References, Appendices

What Informed Insights, Limitation and Implications, Feedback, The Next StepDiscussion

References

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Feedback From Key Stakeholders

Following the completion of the design proposal, a final round of expert interviews were conducted with the oral health experts involved throughout this project as well as key stakeholders from the ADHB to evaluate my chosen concept. The nature of these interviews were unstructured, allowing for a large amount of feedback and freely expressed suggestions to be collected during the presentation of design ideas and concepts, and highly structured, where feedback to specific questions was required. See appendix D for the feedback guide.The feedback can be analysed and grouped into three main categories; enrolment form and characters, and the interior of the dental van, and the design process.

Enrolment Form and Characters: Both the ADHB staff and oral health practitioners took

delight in the simplicity and playfulness of the drawings stating, “their little faces are basic but are fun and inviting- similar to a stamp and very modern”. The ADHB felt that the characters were a good compromise

and that they illustrated the “perfect balance between what is desirable for the child, the parent and the ADHB and might even be appealing to the older children”. Both experts and members of the ADHB appreciated

seeing the exploration and development of the characters presented in a linear, step-by-step manner and enjoyed being involved during the development and feedback phases of the process. As their involvement through this research project was high

my stakeholders already had built a relationship with these characters and suggested I “name the characters! Wouldn’t be great if ‘Bob and Erin’ told a story everytime they met with the children and grew up with them at the same time. They could possibly take them through the intermediate dental service as the children will already know them- it will help their transition into their adolescent stage.” This was a very positive comment as it illustrated that my key stakeholders saw the value in this aspect of my project and the potential

for the characters to add value to their existing service. The invitation style of the enrolment form was well

received, with the only improvement being suggested was that “it highlighted that ‘Bob and Erin’ would be there too.”

I encouraged my experts and stakeholders to suggest where they might see areas for further development: A member from the ADHB felt it is still important to have

the option of the characters with an open mouth on cards and posters to help educate the children about healthy teeth before they enter the van but appreciated that the characters used on the enrolment invitation celebrated having a healthy lifestyle. The ADHB staff identified that the Ministry of health already

have their own characters and branding but suggested that their characters adopt the same storytelling aspect of ‘Bob and Erin’ to guide the children through their dental van experience and to support them throughout their oral health journey from preschool through to intermediate.

Dental Van Experience: Comments about the interior design of the dental van were

generally positive with oral health practitioners appreciating the stow-away seats for space maximization and cleaning ease. One expert even clapped her hands saying “Finally! Something new! This will allow us to invite 3-4 children into the van to give more of a classroom experience and even let children sit on their caregivers laps or bean-bags.” Much positive feedback was given in regards to the interior

walls. “I like the colours inside the van and the drawing wall is a great idea especially because there are issues of hygiene and it is easy to clean.” Another expert said he loves the white-board wall “as it’s a fun way to distract the kids before their turn- especially on cold and wet days when they have to wait inside the van.” Presenting the development process to experts and

stakeholders who were not involved during that stage of the project proved valuable with one member of the ADHB

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Feedback From Key Stakeholders

saying it was “great seeing the numerous layouts of the vans interior. Interesting and surprising to see visually that it could not work just by rearranging!” All stakeholder and experts said that they would prefer to

have the child lying down with their head facing the nurse as opposed to the back wall as that is how they are trained and agreed that there is a need for more direct lighting.

ADHB Board Presentation:In the final stages of the refinement phase, I was invited to present my project at an ADHB Board meeting to members who had not been involved in the project and had not been introduced to different thinking methods such as Design Thinking and Human-Centred Design.

This meeting took place at the Greenlane Clinical Centre in Auckland and involved 30 people of the ADHB board such as managers from Strategy, Funding and Planning.

The purpose of this presentation was to demonstrate how new types of thinking can be used in order to develop empathy for users and possibly assist in the redesign of services in the organisation. I also sought to gain an additional level of validation for the design process, enrolment form solution, and van interior outcome of this project.

Over the twenty minutes I was allocated, I presented a very high level overview of this project. I introduced members to Design Thinking and Human-Centred Design and used key findings from this project to illustrate how these frameworks can be used effectively. Much like the layout of this exegesis, I told the story of this project from the exploration phase through to the final design proposals with visual examples of methods, processes and insights. Questions were held until the end where a discussion was encouraged.

Members were engaged throughout the presentation and expressed their keen interest in learning how design could

influence other parts of the organisation they are directly involved with.

I asked the audience to give any comments or feedback on the design proposals and the design process.

“I think it has been an excellent process” One member said. “Along the way it has worked from the general to the specific and in that way it has, therefore, not just been a rubber-stamping process.”

A nurse specialist commented on the method of roleplaying and the child’s touchpoint journey that was generated as a result: “hearing about the patients’ experiences is critical in helping the service implement small changes that can make a big difference.”

In response to the enrolment form design, another board member said “this project has helped me understand how to better convey information in a way the patient understands and the importance of doing so.”

Overall the feedback was constructive and positive with one member asking why this hasn’t been implemented yet.

At the conclusion of the presentation, the Dental Service program coordinator asked for my collaboration in the redesign of the ADHB’s 2014 enrolment forms for preschool and school aged children. This is perhaps the ultimate validation of my project.

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Insights About Service Design

A number of key insights emerged from my project regarding service design in the public sector:

Design Process:Telling the story of the dental van experience from the child’s perspective to stakeholders and experts helped foster empathy for the users. By taking these stakeholders and experts through the journey of my design process before presenting the final design solution, they were able to see the value of creativity, visual thinking and co-design which, according to Brown (2008), has the potential to transform the way services, processes or even strategies are developed in organisations. It was important that my stakeholders and experts participated in both the design and evaluation of this project as this is a significant benefit of Human-Centred Design. Levasseur (2001) has suggested, ‘a fundamental principle of effective change management is that people support what they help to create’. The feedback from these stakeholders and experts is critical in obtaining support from the industry and maintaining momentum with the project.

One oral health practitioner acknowledged the organic nature of the design process saying “Obviously you had a lot of looseness and explorative work. Zaney and wacky and everything that a design process should be. Very refreshing.” Another expert, who is an oral health lecturer at a university,

saw the value in the non-linear approach to design and admired that I was “not too precious about doing things perfectly.” That the “rough models are more intriguing and important than the laser cut models because the minute you start trying to do things perfectly you stop concentrating on playing”. An ADHB member thanked me for showing her the van

from the child’s perspective. “Knowing what the children see at their eye-line is so important. It’s the little things like that that we often overlook- getting down to their level. Sometimes you forget how they see the world and how you

see the world are so different! Seeing it through their eyes is truly ‘eye opening’.” she said. I was encouraged to take this project further and “test

out these ideas with parents and children see what their perspective is on the service and their own dental health. Do they even know what ‘health’ means?”

Feedback from my stakeholders and experts accentuates and supports the notion that the measure of success for this kind of research is that if the process and research methodology is understood, then the design solution is minor.

Make the right connections with service users:Creating the right connections between a service and its customers is essential. For this project I looked closely at each interaction between the service and the individual service users to design those interactions carefully. Through my research I identified two interactions (the enrolment form and the van interior) to be the most important aspects of the service.

25% of enrolment forms are never filled out due to forms appearing too complicated and clinical - there is clearly a missing connection. I proposed a new enrolment form that captures the child’s attention and invites the child to engage and familiarise themselves with the characters (brand) through the fold out ‘invitation’ style letter and stickers.The ability to keep important information and facts on the fridge appeals to parents and caregivers and acts as a daily reminder of appropriate care for their child’s oral hygiene and that there is support from the ADHB should they need it.

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Personalising the service:It is my opinion that services cannot be ‘commoditised’ and be truly satisfactory. Many service providers have adopted commodity approaches in order to improve efficiency or increase output. However, to create a great service I needed to understand that services are subtly or substantially different for every single service user. Thinking this way encouraged me to design a service that is flexible and can adapt to satisfy each individual user’s requirements.

For the mobile dental unit this meant empowering staff to be more efficient in their work environment. I saw that the poor layout and ergonomics of the existing van, combined with their disorganised and cluttered surroundings meant staff wasted a lot of time and energy trying to “make-do”, unnecessarily straining their bodies and increasing their stress levels. I proposed a new layout for the van’s interior which would allow each user to adapt and personalise their environment to their preference and varying needs.

Engaging experience:Shifting my focus to the individuals I was then able to design the experience they have of a service. The right experience can ensure that a patient engages with the service. This makes the service more positive for all parties as their latent needs are being met and ensures that users get the value they need from the service.

In my on-going observations and role-play I noted children got restless while waiting for their turn. I saw that observing their peers in the dental chair was stressful and intimidating. Therapists would divide their attention from their patient to try put the waiting child at ease with toys or colouring books. In response I designed a white-board interaction area where children were able to actively engage with their environment in a creative and constructive way,

while at the same time creating an interior sensitive to the child’s preferences. This experience ensured children were made to feel more at home in their environment and allowed the therapists to focus on the patient without getting distracted.

Long-term sustainability:Services are temporal but service thinking makes us think about opportunities in the long run. Because resources – time, money and material - are finite I needed to think about how to make best use of them. It gave me the opportunity to imagine how this preventative dental service can be sustainable for the future.

There are clear inconsistencies in the existing graphics and branding, for example on the enrolment form and van signage as well as their promotional tools used such as posters and stickers. This means that children and their families fail to associate a particular image or even a consistent emotional response to the ADHB’s existing brand. With this insight, I proposed a unique brand that promises the user the new and empathetic direction for the ADHB that, if used consistently, will become more established and trustworthy over time ensuring long-term brand sustainability. Additionally, through the reflective and cyclical nature of design thinking and Human-Centred design and its application, the ADHB, should they choose to adopt this practice, will need to continuously reflect, plan and act over time to ensure that the service is growing with the community. Achieving this goal is a Human-Centred design challenge rather than a clinical or operational challenge. It starts with understanding patient needs and experiences and then designing new services to meet those needs effectively. Service thinking is essential if the ADHB are to achieve and maintain the vision of a positive oral health care experience for preschool aged children.

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Personal Reflection of this Research

This section explores some of my personal reflections regarding this project.

Project ScaleWhile the project had no preconceived outcomes, I have to concede there was a great deal of underestimation on my part as to the breadth of scale implicit within this project. There is a tendency to want to find a positive answer to a research question, a conclusion that justifies both the time and effort invested in a project. This undermines the true learning that can come from failure. Many of my assumptions have been proven wrong and more questions and potential areas of exploration have been opened than closed. I had begun this project thinking that I could use time like a layer of paint, which would stick uniformly to my work. I have discovered it is more like quicksilver ; flowing and pooling in some areas and not others, generally resisting the touch. Designing with time comes down to a question of intent, observation and a heuristic approach.

Project Complexity I also underestimated the complexity involved in a project like this. I had to make all kinds of decisions and judgments, such as, how to frame the situation, who to listen to, what to pay attention to, what to dismiss, and how to explore, extract, recognise, and chose useful information from all of those potential sources. There were certainly times were I suffered from a sort of design paralysis when confronted with such endless opportunities. These design situations are sometimes characterised as “under determined” problems, or in Schön’s words as a “messy” situation, or in Rittel’s words a “wicked problem” (Schön, 1983; Rittel & Webber, 1974).

Other People’s Perceptions of DesignA key limitation I faced during this project was other people’s perceptions of design. One of the most common misunderstandings about design is that since it is not as intellectually and methodologically well developed and reined as the scientific approach, it is often seen as fuzzy, intuitive, subjective, and difficult to grasp. Sometimes this fuzziness was even labeled as irrational. And of course, sometimes it was... Bad design practice is as fuzzy and irrational as bad scientific practice. The point is that even though my design process was not structured in the way other rational processes are, it did not mean that others needed to see the process as a “black art”. I used this opportunity to instead illustrate to my experts and stakeholders

that design has its own internal structure, procedures, activities, and components that are well recognised by skilled designers and that also are explicated in the design literature mentioned earlier in this exegesis.

Practical LimitationsOther more practical limitations included restricted access to the dental van and inadequate knowledge of mechanical engineering, which prevented me from being able to further explore the implementation of my final concept.

Experience DesignThe focus of this project was on designing experiences, not processes or systems or just the built environment. In contrast with traditional process mapping techniques, the focus here was on the subjective pathway- the touch points- rather than the objective pathway.

Importance of Co-design:Co-Design emerged as essential aspects of this project. The “co” suggests more of a partnership and shared leadership, where the mobile unit’s therapists played a key part in leading Human-Centred design and enabled them to input their perspectives and experiences on level terms.

“Without citizen participation and community engagement fostered by public service organisations, it will be difficult to improve penetration of interventions and to impact on health inequalities” (Marmot 2010 p151).

Because of ethical limitations however, I was unfortunately not able to co-design with children and parents. This meant the therapists and ADHB staff were more highly involved in interpreting the environment and offering insights as to how the child and parent engage with the space. At the same time, it did not mean trying to make these users design “experts”, but having them there for their precious and very special kind of first-hand knowledge we call experience. They were not necessarily there for any prior expertise they may have been able to offer (although such expertise may still be useful and, over time, users may well develop new forms of expertise if they are sensitised to what a good oral health care experience could be and how their own experiences might be improved).

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Conclusions

This project took the position that positive early experiences of preschoolers are critical in providing a life-long positive attitudes towards dental hygiene. It aimed to use design to begin the process of rethinking the Auckland District Health Board mobile dental service.

This project suggests that designing services and environments for the user’s experience poses a formidable, but highly worthwhile, challenge. The nature of this challenge was to understand the experience of oral health care for preschoolers at a deeper and more empathetic level, always bearing in mind that this included all aspects of subjectively experiencing a product or service— physical, sensual, cognitive, emotional, kinetic and aesthetic—and to use this understanding to design an experience that will be more engaging and fulfilling than it has been before. Human-Centred design, informed by Design Thinking methods were applied to help frame the problem, gather and interpret information and create solutions, and was used during the ideation, development and evaluation stages in proposing a new service solution for the mobile dental unit. The Design Thinking process helped capture unexpected insights and produced innovative solutions that more precisely reflected users needs and wants. By working as a coordinator between all of the stakeholders, I found that when the stakeholders and the end-users participated in the design process, new ideas, and service needs were discovered and added value was created.

A number of key issues emergent during the project:

The project overall was significantly more complex and larger in scale than was first anticipated. For example, while the project was initially conceived of as a redesign of the dental van, it quickly became apparent that the overall dental

van service needed rethinking; A service design approach helped reframe the problem into more manageable experience touch points, of which two afforded the most

potential for redesign; Co-design, a very important approach for service design, relies on a deep connection with and understanding of the needs of all users.

Due to the nature of the project however (limited time and scope), ethics approval to observe and interview children and caregivers was not possible; and In spite of this, the use of researcher shadowing, roleplaying, and expert interviews did provide some valuable insights to help drive initial

design directions and concept development; and The overall resolution of ideas and concepts would have benefited from full-scale prototyping, testing evaluation and further development.

This should happen in partnership with key stakeholders.

The final presentation to industry experts and managers, and ADHB board members indicated that the final concepts, while somewhat limited in resolution, did generate a very positive response, and was a catalyst for in-depth and critical discussion and dialogue around opportunities for innovation afforded by human-centred design approach in the public health sector. It also resulted in an invitation to the researcher to continue with a more in-depth project focusing on the enrolment process in 2014. I believe this was a very successful outcome to the project.

How can the dental van service be improved to enhance the experience of preschoolers and the dental nurses that work with them?

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Recommendations for Further Research

Arguably any further research would take the lessons from this research to drive a more holistic reexamination for entire dental van service across all the touch points identified. This may even involve questioning the whole approach to the service. My feeling is that the ADHB may not be ready for this more holistic approach. If not then the work undertaken could be taken further. Future design research could involve the prototyping testing, evaluation and realization of both the proposed enrolment form and van interior solutions. Ideally this would be approached from true co-design perspective.

Van Interior Redesign ProcessTesting of the van interior design proposals would include 1:1 mock-ups and prototypes of work completed to date (initially quick and less refined and becoming progressively more sophisticated). The goal of the prototyping process is not initially to complete the design, but to learn about the strengths and weaknesses of key ideas and to identify possible alternatives and drive new directions. The full-scale prototype would represent the interior design, and components and focusing on the children’s perceptions, social interactions, work flow and overall user experiences. Importantly the prototyping and testing must involve key stakeholders including preschool children and caregivers in addition to nurses and assistants. The researcher acknowledges the process that would be needed to secure full ethical approval before this could happen. The work to date would support the ethics application process.

In addition to user testing the full size prototypes would also help communicate the overall service proposition and prompt questions on the technical feasibility and economic viability of the van redesign. Engineers, transport experts and other industry experts would be engaged throughout the prototyping process. Ideally a final prototype would be constructed within a van and tested with key stakeholders on location in the field.

Enrolment Form Redesign ProcessThe next phase of design development will focus on refining the design of the enrolment form concept to a much higher level of detail. This will include refining and detailing all graphics, copy and printing specifications. This will be achieved through methods of prototyping and phases of critical observation and reflection to analyse and assess the detail design development. Content of the form will be revised and amended, as will the colour pallet, to better suit the ADHB’s existing visual language and form requirements. Refinement of this form will be made in conjunction with Communication staff at the Auckland District Health Board.

Testing of the enrolment form proposal will commence mid 2014 once full ethical approval has been secured. This will involve observing how children and caregivers interact with the enrolment form and will include seeking further feedback from caregivers, preschool teachers and ADHB board members.

Sending out a number of ‘trial’ enrollment forms has been discussed between myself and the ADHB. The return/response ratio of these test enrolment forms will be comparable to the existing response ratio and will give an indication of whether they have been more or less engaging than the existing form.

It is envisioned that with the key aspects discussed above, together with my role as a coordinator between all the stakeholders, will lead to the development of a holistic service.

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Appendix A

Colour The internal colour scheme needs to create mood

and define spaces. It is important to determine floor colours first so

that the walls can be painted to complement the floor colour. Use primary colours cautiously. Too many bright

colours may make children distracted and agitated or cause them to shut down their senses.

Light Use natural lighting whenever possible – natural light

is healthier and has varying qualities of illumination throughout the day. Avoid harsh fluorescent lighting – these can create

agitation. Consider having a range of different light sources

e.g. lights with dimmers, lights with upward facing tubes that do not glare into babies eyes, wall mounted goose-neck lamps, etc.

Belonging Warm soft, textured spaces invite children to snuggle

up to adults (or their favourite teddy), lie down and observe others or reflect on photos from home. The softness of a home like setting is likely to be particularly supportive to children during the settling in phase. Good presentation of items which interest children

will encourage their curiosity and tendency to become involved. Well presented materials invite children to explore and making the ‘ordinary extraordinary’ will support this tendency.

Wellbeing Having a strong sense of well-being allows children to

become deeply involved in activities. Feeling physically and emotionally safe are important pre-requisites to

sense of well-being. The organisation of spaces, defined areas of activity, and areas that encourage interaction (where individual needs are met and relationships can become robust) will support children to develop feelings of emotionally and physical safety.

Conclusion Expert strongly emphasised how careful organisation

and aesthetic considerations influence the emotional climate of a child’s environment and their learning. She pointed out that an unattractive, chaotic, and noisy environment is likely to hype up children’s behaviour so they become disruptive and disrespectful of the environment. Conversely, she has seen environments that are too pristine and immaculately tidy which do not provide enough challenges for children. Children who are bored, who have their creativity stiled by too many controls in the environment, and who are not challenged enough will also manifest disruptive and disrespectful behaviour.

Early childhood is a period of incredible fantasy, wonder, and play. They learn the world as a forum for imagination and drama that is as they reinvent the world, try on new roles, and struggle to play their parts in harmony.

“Perception is an active experience, in which a child finds information through mobility.”Moreover, children’s physical participation with the architectural features and natural landscape elements extend to satisfaction and the experience stay in their memory. And, memory is a derivative of place attachment.

Summary of Expert Interview with Child Psychologist.

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Appendix B

Felt the name “screening van” is too close to “screaming” Kids are not aware of quality of van. More concerned

with colours etc Challenges with children- Louise (in her previous years

of experience) very seldom had a trouble child. It was very important to build a relationship with the child and get them used to the environment. -She felt it was important to let children feel they have ownership of the environment- allows them to relax much quicker (mini tasks- open drawers, put on gloves etc) It takes a lot of time to “desensitize” the child to the

environment Problems with van- lack of space/storage/ bounces

all the time. They need storage facilities that lock down and are easy to access. Easy maintenance is important. Functionality is key to a successful van Make the environment as worker friendly as possible- if

person has a good working environment they will be able to be relaxed and calm and improve productivity. This attitude of the therapists will have a huge influence on the child’s experience so is of utmost importance. Daniel accentuated the fact that although things might

not work very well, it does not mean the system is not working very well. With the limited budget they are doing the best they can and at that point in time it was acceptable and met the needs of communities. He also noted that the service is evolving- demands are

higher- focused has changed from restorative work to preventative work. It is important to try and encourage parents to bring

their children in when their first tooth appears. “Up until the age of 2 years children are OK to watch

their parents have dental treatment. After 2 they start to get worried with someone touching their parents but by then they would have already had a ride on the up-down

chair, had their teeth counted etc... gradually over time familiarizing them with the environment and process so they trust you” Language you use with children “sleepy juice” is essential

in making kids (and parents) feel comfortable Fear from parents... influencing children etc... All comes

back to communication. Oral health is changing dramatically (has “evolved”)- in

the past every school had a clinic for six months then they would move on to the next school. Now the focus has changed and is more focused on community oral health- there is more clinicians working together as a team to treat a large population. The concept is now encouraging the parents to take responsibility of their own children. Now it’s more like private practice based. This is good because you end up knowing your community base quite well. However there are till some concerns in low decile

areas... parents negligence, fear, education... Parents are still not responding to the needs of their children. They don’t know they can prevent bad oral health in their children. So, there is now an emphasis to ensure parents are present so that parents can receive information on how to look after their children’s teeth and see how the system has changed since they were young. Concept of school dental service is changing. What therapists do is “look at the community as a

block of people and then pull out the individual. Look at them in an unbiased manner. Parameters may be true to whole community but must be set aside when working with a patient so as to build a new picture of this patient on an individual basis. From there you can establish what they do and don’t know”

Notes from Expert Interview with Oral Health Lecturers

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Appendix C

Chair too high for child to climb onto so nurse has to lift child on and off (bad for back!) Lighting is poor- Only one out of the five lights work

- Overhead light only works at certain angle as it cannot reach where necessary Stairs are “a death trap” Slippery when wet, small footing area, uneven heights,

no hand rail. Nurses close door in fear child will fall out which is OK in winter when it is cold but means the van is scorching hot in summer! Currently, the nurses communicate over a screen that

displays what is on the laptop. The nurse kept touching the screen- trying to point to which tooth needs work etc but assistant could not see. A touch screen would be beneficial. Van is only used for 3-4 hours a day -Heating is essential

in winter. Currently run small fan heater. Not secured. The dental seat is too long for van- when the nurse

tries to turn it, the base hits the wall, restricting the pivot potential. Nurse has to crane her neck in order to see inside the child’s mouth. Horrible cage-like feature on left as you enter (part of

van but very scary for children) Assistant told me she got up two hours ear- lier than

she needed to in order to input the data and enrolment forms into the system. Could this be done over a website? Rubbish bin sits next to heater. Nurse tells me she

brings in her own one. (cheap plastic- not sterile) There is a list of numbers on the wall beside the

assistants laptop but not many of the numbers are up to date. Assistant has to spend five minutes trying to locate

new number for parent. Preschool teacher brings in the next children. They wait

inside and get bored. Nurse tries to distract them with mirrors and stickers. When parent comes on van with child (which is what

they want to encourage) there is not place for them to sit. They just hover uncomfortably and cannot be next to their child. Preschool teacher tries to take photo- graphs of the

child while they are with the nurse to add to the child’s portfolio. However she does not have time and instead asks me if I could take pictures while she gets the next child. Position of chair means the nurse must be right hand

dominant- difficult for left-handed nurse to access tools and examine the child appropriately. Essential papers (enrolment forms, referral letters etc)

all over the place. No organisation Kids disappointment when they see animals on van and

find out it is a dental van and not a zoo van! Tools in inconsistent places

Notes from Day-in-the-Life

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Appendix C

The van was operating in a low income area and was situated between a primary school and the preschool. There were only about a dozen children enrolled from the preschool so the van was only there for that day.

Walking up to the van I felt nervous and scared- I was not sure what to expect as, aside from a meeting time, we had not arranged much more. The van was raised a good metre off the ground, towering over me as I approached. The sun was trying it’s best to warm up the earth but was failing earnestly and a brisk breeze stole my breath as I prepared to walk up the stairs.

I was hit by a wall of hot air about halfway up, escaping from the mouth of the van. Even the air molecules would rather freeze than be in there?! I ventured on. Straight ahead of me was a pile of boxes, spilling over the seat and the floor, filled with what could be anything from gloves to torturing devices. By now it was too late to turn around. I was immersed in the heat of the van, and while this warm embrace should have soothed and comforted me, I was still reminding myself to breath, looking around anxiously for something familiar to quiet the screaming child in my head.

Despite the smiley faces of the therapists on board and our awareness of me joining them, I did not feel welcome. Of course, Meryle was right at the back... I clambered my way past oversized chairs and out of place (or in place?) boxes to meet her. I found a corner in the far right of the van where I could stand without feeling like I was in anyones way or feeling claustrophobic. Incidentally it was next to the fire exit...

After a friendly chat, my shoulders relaxed and I was able to look around the van with a positive lens. I noticed there was a small boy on the chair in front of me. With one hand he was holding a yellow toy digger and with his other he held his mothers hand.

He was very calm as the therapist peered into his mouth and spoke gently to his mum about his teeth. She was listening intently, awkwardly perched on the edge of the narrow waiting chair, craning her neck from left to right as if she had never had seen the inside of his mouth before. The nurse counted his teeth and rubbed some fluoride on a few, the whole checkup was over in about five minutes. The nurse told the mother that her son had to have an appointment with a dentist for some follow up work and they arranged a time convenient to them. What concerned me was how long this procedure took. The nurse left the family alone while she went into the centre of the van to fill out some paperwork. Naturally, the child got bored waiting and made way for the favourable fire exit. This caused a bit of a commotion and prompted another child who had just walked up the stairs to freeze in terror. Now there were two children that needed to be comforted...

Notes from Day-in-the-Life

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Day-In-The-Life“By stepping into someone else’s shoes I was able to learn about and foresee the opportunities for collaboration from different perspectives through my own eyes” Personal Reflection

In order to successfully foster an understanding of the industry landscape and my own position within it, I had to learn to develop an empathic approach to other stakeholders and their audience. This meant establishing an open dialogue with all the parties involved. Consequently, a fundamental skill that I needed to have was to communicate using traditional design skills to translate ideas and views into the media best suited to converse with other stakeholders and the eventual users of the service. Finding a personal approach to this required an understanding of the art of conversation, which entailed a balance between speaking and listening.

This type of conversation, in the context of design, has been called empathic (Raijmakers et al., 2009) because when working in multi-stakeholder collaborations, the chosen language should be inclusive, allowing people to cross the barriers between disciplines, while being accessible to the very people who will ultimately use the service.

Role-playing exercises were of great benefit, on both a practical and theoretical level to help foster communication and empathy. By stepping into someone else’s shoes I was able to learn about and foresee the opportunities for collaboration from different perspectives through my own eyes, and hypothesise various directions and outcomes. Reflections upon this process and the processes of others, as well as developing several iterations of this process e.g. swapping roles, was extremely valuable in reining the service concept and developing future steps. These practices are perhaps more common to anthropology, philosophy and documentary film making (Raijmakers, 2007), to name but a few, however, I felt inspired by these professions and processes, to adapt and develop my own ad-hoc tools for co-creation.

I spent a great deal of time observing and empathising with the users to truly understand their needs and requirements. Role-playing as a tool has proven useful within this project, especially in early conceptualisation of the service and its placement within the existing oral health industry.

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InsightsThe following categories synthesise research into a set of key Insights.

There is a need to improve the current dental van experience for preschoolers, caregivers and staff

Early childhood is a critical time period for establishing the solid foundations essential for children’s long-term health, well-being.

The healthcare industry is in crisis and facing paradigm change. A significant re-orientation in the delivery of publicly funded oral health services is required.

The healthcare industry has recognised the importance of servicescapes, or the physical environments of the organisation, in shaping the service experience of its patients and families.

A solution that, in essence, is transferable could facilitate the improvement of other mobile clinics

Many children suffer from dental fears and anxiety, often influenced by their caregivers or negative early experiences.

Having a strong sense of well-being allows children to become deeply involved in activities. Feeling physically and emotionally safe are important pre-requisites to sense of well-being.

Careful thought should be given to the organisation and aesthetic considerations that influence the emotional climate of a child’s environment and their learning.

The softness of a home like setting is likely to be particularly supportive to children during the settling in phase.

Perception is an active experience, in which a child finds information through mobility.

If a person has a good working environment they will be able to be relaxed and calm and improve productivity.

Getting the 25% of families who are not enrolled into the system is the ADHB’s greatest challenge.

Because the enrolment form is the child’s first touchpoint with the system this form will determine whether or not their expectations of their visit to the van are positive or not.

Influencing their memory and opinions of the service is the child’s interaction with the van’s interior.

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Appendix DFeedback guide.

Dental Van Nurses and ADHB Program co-ordinators:Thanks for taking the time to talk to me today.Now that I have finished this project I am very interested in getting your feedback on my proposal for the van:

1. As the person who interacts with the end user, do you feel this would promote a positive user experience and how/why?

2. From your perspective what aspect of this this design proposal do you consider to be most valuable in improving/enhancing your job? (i.e. is flexible and adaptable to different situations and staff? - is safe and easy to clean? - secure during transport?)

3. What aspects to you think are/maybe problematic and why?

4. What aspects of the proposal would you like to be developed further?

5. What do you consider to be the main advantages/disadvantages of

this design proposal?

6. Do you have any suggestions about anything that could be improved?

7. How well might this design proposal be accepted by staff and management in your opinion?

8. Would you promote this concept to the person who would endorse and implement it?And why?

9. If you needed a redesign in the future, would you be willing to use design thinking again?

10. Any other comments/questions about the interior proposal of the van?

Okay, now I am going to ask you a few questions about the enrolment form and characters:

11. Tell me about your first impression of the characters?

12. How do you think a child might respond to these?

13. As you helped evaluate these

characters early on in this project, how do you feel they have been executed?

14. Do you have any suggestion about would could be improved/changed?

15. From our rapid prototyping workshop in October, do you have any further recommendations for the enrolment form?

16. Do you have any further comments/questions you would like to give?

I am also very interested in how this project worked from your perspective:

17. We met on average every fortnight, was this too much or too little interaction/communication?

18. Do you feel your contributions were valued?

19. How did you find working with Design Thinking methods such as rapid prototyping?

20. What did you gain/realise/learn from working like this that you might not have had you not used it?

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21. Would you consider working like this again?22. What was most/least beneficial/valuable/interesting? 23. Do you have any suggestions for how a project like this could be improved in future from your perspective?24. Do you have any other comments or feedback that you would like to give?

ADHB Staff(not involved in rapid prototyping session)

Now that I have finished this project I am very interested in getting your feedback on my proposal for the dental van:

1. What aspects of this project do you consider to be most valuable and innovative and why?

2. What aspects to you think are/maybe problematic and why?

I am also very interested in your feedback on the viability of implementing my concept (taking it further)

3. Would you consider implementing parts or the entire proposal?

4. If not – why?

5. If yes (which parts?), would you implement it as a staggered output or all at once?

6. Do you see any other problems with implementing this design proposal?

7. What further requirements will you need before considering implementing this project?

8. If this should go ahead, how long would you allow for each rollout?

9. Would you be willing to use design-thinking methodologies in the future?

Do you have any other comments?

Do you have any suggestions for how a project like this could be improved in future from your perspective?25. Do you have any other comments or feedback that you would like to give?

CloseMany thanks for your time it’s been really valuable spending time with you (both). If something pops into your head after I leave that you think is relevant to this interview please feel free to flick me an email or text to let me know.

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Philosophy and Paradigms

The situations analysed in this project are relatively complex and unique, thus require some understanding of the appropriate research philosophies. The philosophies chosen for this project are interpretivism and realism, which will be utilised in order to understand the “subjective reality and meanings of the users” (Saunders 2003) as well as the contexts where such situations take place.

On one hand this project follows an interpretivist research philosophy since it aims to start to analyse the complexity of social situations; in this case the application of Human-Centred design with design Thinking methodologies to address the social challenges of oral health and its development. Drawing from the social constructivism position, I also recognise the importance of ‘understanding people’s socially constructed interpretation (subjective reality) around this topic in order to define the relevant aspects of those interpretations to the research’ (Saunders 2003).

On the other hand it is crucial to be aware of the existence of larger forces that affect people’s perceptions, behaviours and therefore, their interpretations of the situations they are in such as historical events or technological advances, or even home dynamics that trigger demographic and behavioural changes.

This is where this project adopts a realism philosophy and seeks to understand broader social forces, structures or processes that “affect, influence or even constrains those interpretations” (Saunders et al. 2003). It is important to note that such forces affect people whether they are, or are not, aware of their existence. In order to explore the scope of the topic of this research, this project combines deductive and inductive research approaches. The inductive approach allows the construction of a flexible methodology that permits alternative explorations of what is happening in the different stages of the research. This approach provides a closer understanding of the research context and the nature of the problem (Saunders et al. 2003).

DeductiveExperimental Research

Theory

Hypothesis

Observation

Confirmation

InductiveAction Research

Expert InterviewLiterature ReviewIdea Generation

2D Drawing

3D prototyping

Concept Testing

Self Reflection

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