A female focused design strategy for developing a self care information system

A FEMALE-FOCUSED DESIGN STRATEGY FOR DEVELOPING
A SELF-CARE INFORMATION SYSTEM















XUE LISHAN
(BA.ID. (Hons.), NUS)

(Volume 1)

A THESIS SUBMITTED
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
DEPARTMENT OF ARCHITECTURE
NATIONAL UNIVERSITY OF SINGAPORE



2009
ii



I have been extremely fortunate in grant support. Institutions that provided valuable help in
the form of research scholarship, funding and knowledge resource include the National
University of Singapore (NUS), School of Design and Environment (SDE), Industrial Design
(ID) Programme and the Department of Obstetrics and Gynaecology at NUHS. In particular, I
am grateful for my supervisors’ guidance – Dr Yen Ching Chiuan, Assistant Professor and
Course Director of the Industrial Design Programme, Department of Architecture and A/P
Mahesh Choolani, Research Director at the Department of Obstetrics and Gynaecology at the
Yong Loo Lin School of Medicine and Senior Consultant Obstetrician and Gynaecologist at
High Risk Pregnancy Clinic, National University Hospital (NUH) for the many discussions
and debates we have had. Dr Yen, an excellent mentor and confidant over these years,
remained firm that I needed to revise and update my material, and offered constructive
comments all the way. Dr Mahesh, thank you for your guidance which was shaped by a clear-
cut firmness to achieve highest excellence in everything I do. I appreciate your confidence in
me at moments it was needed most.

In the course of time, many went the extra mile and read early parts and versions of the
dissertation. These include A/P Chan Hock Chuan from the School of Computer, Department
of Information Systems who advised on the validation of the conceptual model and A/P Tan
Say Beng, director of the
Clinical Trials and Epidemiology Research Unit (CTERU), Duke-
NUS Graduate Medical School, who supported me much on statistical issues and
formalization of the survey data. I am grateful to Dr Christian Bourcharenc from the
Department of Architecture, Dr Leanne Chang from the Communications and New Media
Programme, Faculty of Arts and Social Science, and Dr Henry Duh from the Department of
Electrical and Computer Engineering/Interactive and Digital Media for reading portions of the
dissertation draft. I must also thank the thousand over survey participants, designers, and staff
from the National University Healthcare System (NUHS) women’s clinics and National
Healthcare Group (NHG) in participating polyclinics who have so kindly responded,
cooperated and supported in my investigation. Without them, survey research would not have
been made possible. Junior student researchers from our very own ID programme provided
much support for research and design activities. They provided extraordinarily able, cheerful,
and willing help at every juncture, and made me reaffirmed my passion for design.
Finally, there is also my wonderful family which I wish to thank them for contributing in their
own special way to my writing, especially my beloved parents and maiden family who have
always been very proud of me and cheered me on at difficult times. I would also like to thank
my husband, Jackie, who was my sparring partner in technical and emotional issues
surrounding my dissertation, design research, and practice. He has relentlessly supported,
encouraged, and inspired me on countless occasions. Lastly, I am grateful for God’s grace and
strength for allowing me to complete this dissertation over these years.
Indeed, like reason, our research is-and ought to be- a slave of our passions.


Acknowledgments
iii

SUMMARY ii
ACKNOWLEDGMENT iii
TABLE OF CONTENTS iv
LIST OF TABLES vi
LIST OF FIGURES vii
ACRONYMS & ABBREVIATIONS ix
TERMINOLOGY xi
LIST OF PUBLICATIONS xiv
INTRODUCTION xv
Research Aims & Objectives xvi
Outine of the Thesis xix
References xxi

1. AN INTRODUCTION TO FEMALE-FOCUSED DESIGN AND ITS RELATION TO
SELF-CARE OF WOMEN 1
1.1 Background 1
1.2 The Meaning of Female-focused 7
1.2.1 A Self-care Information System (SIS) 8
1.2.2 A Female-focused Design Strategy (FDS) 10
1.2.3 The Research Hypothesis 12
1.3 Method for Literature Review 14
1.3.1 Population 16
1.3.2 Technologies 18
1.3.3 Data Synthesis 19
1.4 Elements of a Conceptual Framework 20
1.4.1 Design for Self-care 21
1.4.2 Health IT and Content 25
1.4.3 Content Users: Women 27

1.4.4 Professionals: Designers and Healthcare Personnel 32
1.5 The Opportunities of the FDS 33
1.5.1 Design for Self-care as a Consequence of the FDS 33
1.5.2 Design by Means of the FDS 34
1.6 Areas of Enquiry & Discovery Contexts 35
1.7 Summary 37
References 37

2. RESEARCH METHODOLOGY: SYNCHRONISING EXISTING PERSPECTIVES
& DESIGN ANALYZES 44
2.1 Ideological Marginalization 44
2.1.1 Triangulation and Complementarity 46
2.1.2 Normative Research Method 46
2.2 Existing Design Emphasis and Problems in Design for Health 48
2.3 Overview of Research Area Framework 49
2.4 Qualitative and Quantitative Studies 50
2.5 Realm of Theory: Research for Design 53
2.5.1 Discovery 54
2.5.2 Divergence 55
2.6 Realm of Practice: Research through Design 59
2.6.1 Application 61
Table of Contents
iv

2.6.2 Convergence 61
2.7 Summary 65
References 66

3. COLLECTION AND ANALYSIS OF QUANTITATIVE AND
QUALITATIVE DATA IN RESEARCH OF A SELF-CARE INFORMATION

SYSTEM (SIS) 69
3.1 Towards Female Preferences in Design 72
3.2 Consideration for the Design of a SIS 80
3.2.1 Women’s Perception and Acceptance towards the SIS 81
3.2.2 Reasons of Women for Seeking Health Information Online 99
3.2.3 Women’s Health Concerns 102
3.2.4 Design Qualitities for a SIS 106
3.2.5 Latent Concerms for Using the SIS 109
3.3 Caregivers and Clinicians 117
3.4 Methodological Limitations 119
3.5 Implications of Findings 120
3.6 Summary 121
References 123

4. A FEMALE-FOCUSED DESIGN STRATEGY (FDS): THE FRIEND MODEL 130
4.1 Constructing the FDS 130
4.2 The FRIEND Model 133
4.3 First Level Impact of FRIEND 136
4.4 Tailoring Age Differences in the FRIEND Model 140
4.5 Implications of FDS 146
4.6 Summary 147
References 147

5. APPLICATION OF THE FEMALE-FOCUSED DESIGN STRATEGY (FDS) TO
THE DESIGN PROCESS 151
5.1 Users of Strategy 152
5.2 Understanding F.R.I.E.N.D 154
5.3 Identifying Characters 155
5.4 User Scenario Design 158
5.5 Graphical Representation of FRIEND for SIS Design 161

5.6 Concept Generation 162
5.7 Users of Application 165
5.8 Opinion about the SIS 168
5.9 Summary 169
References 170

6. CONCLUSION AND FURTHER DIRECTIONS . . 172
6.1 Application of FDS to Design 172
6.2 Challenges for Female-focused Design 173
6.3 Conclusions drawn from the Findings 176
6.4 Opportunities and Future Development 178
References 182





v


This study is derived from the desire for designers and healthcare professionals to better
create a self-care information system (SIS) for women, especially to benefit those who
practise self-care where the development of home-care products usually was assigned with
low priority although their benefits to lay-users and the community have been substantial.
Women are under-represented in the design of current information systems (IS) and female-
focused design can help improve their self-care. Acquiring user needs and acceptability levels
from the female lay user about the system which they will handle is as one of the most
important tools to better design , where the validity of female-focused design can be justified
not only from a utilitarian perspective.
The study has developed a conceptual female-focused acceptance model (FAM) which

empirically examine the derived research hypotheses concerning the perception and
acceptance of female users in the context of adopting the IS and introduce a female-focused
design strategy (FDS) which addressed fundamental issues in designing and marketing IS for
women’s health. A tripartite theoretical framework, grounded on review of literature,
followed by qualitative and quantitative surveying was structured. The normative research
approach was used which explored current models used for women healthcare; evidence of
the potential barriers; views of target audience i.e. female lay-users and their family members
and healthcare professionals; describing the FAM that highlighted women’s pragmatic
approach to technology in self-monitoring systems.
Empirical data was described and analysed using frequency tables and multiple linear
regression to access differences among the female population. This study tested and
confirmed that the FAM works well for detecting factors that influence women’s perception
and acceptance of the self-care IS. To date, this study is the only one that has examined the
underlying motives for such self-care innovation adoption by women. They would consider
adopting it only if its use proved effortless and its technological value already demonstrated.
Women want flexibility and empathic designs, which is responsive for them to manage,
intricate in its detailing, with natural dialogues used, and dependable in both physical and
virtual interactivity. Their preferences are illustrated through the FRIEND model. The study
also reveals that the social factor (intended in this work as the importance of others’ point of
view in determining our choices and attitude) does not play a fundamental role in woman
acceptance of the SIS. Women believed that the SIS is useful and easy to use and going to
have beneficiary outcomes has not only strong but significant direct contributions. FRIEND
can be represented in different graphical ways for women from different age groups to
determine and aid in the future design of healthcare and self-care technologies across society.
The FAM with its constructs and possible extensions should give new insights to overcome
age, user characteristics, and technology generation barriers, and provide a profile of how
women from different backgrounds use new communication media to seek health information.
The FDS could be aligned with design in terms of advertising, marketing, packaging, and
service. Future research can include refining sampling procedures and measurement
instrument, testing alternate conceptual models with other constructs, investigating new

research contexts, and incorporating qualitative methods such as participatory design for the
development of a potential SIS.


Summary
vi

List of Tables


Chapter 1
1.1 Common human factors activites that occur during product development 22
1.2 Five methods of learning 30

Chapter 2
2.1 Identifying three key approaches in design research 45

Chapter 3
3.1 Classification of concerns 70
3.2 Relationship between schemes and product properties 77
3.3 Summary of existing information and results from present study 78
3.4 Measures for predictors of FAM 84
3.5 Characteristics of respondents 90
3.6 Women’s expection of the SIS 91
3.7 Reliability of scale measures 92
3.8 Cross loadings 92
3.9 Linear regression analysis results 94
3.10 Correlation matrix of health topics 105
3.11 Choice of health concerns among pregnant and non-pregnant women 105
3.12 Design qualities for the SIS architecture and attributes 106

Chapter 5
5.1 Comparison of wording 151
5.2 Conceptual framework for women’s perceptions of iCare 167
5.3 Profile of respondents 167
5.4 Implications from findings 169




















vii

List of Figures

Introduction
A Design concept of ibloom xv
B Application of the female-focused design strategy within design processes xviii
C Outline of the thesis xx

Chapter 1
1.1 Health problems pertinent to women 3
1.2 From a doctor-centred model to a patient-centred model and to female-focused
model of healthcare 7
1.3 Pictogram of a strategy 11
1.4 Literature review for female-focused design 15
1.5 Some of the questions review of literature can answer 19
1.6 Literature search tree 20
1.7 Elements contributing to the new strategy 21
1.8 Relationship between a user interface design process and the U.S. FDA design
controls 22
1.9 Brief evolution of medical design from early records to near future 23
1.10 A schematic representation of design characteristics for self-care in near future 24
1.11 Framework examining female user response to GUI for e-health information 31
1.12 A systems representation of human-technology interfaces 32
1.13 Sequence of medical procedures and design processes 34
1.14 Inter-linked agents in the design of the SIS 35
1.15 Design control and the waterfall model with feedback 36

Chapter 2
2.1 Normative study 47
2.2 Iterative design process 48
2.3 Areas of research for female-focused design study 51
2.4 Research for design 53

2.5 Lateral thinking 57
2.6 Research through design 59
2.7 Types of new product 62
2.8 Stages in concept development 64

Chapter 3
3.1 Final selection of mobile phones 74
3.2 Final selection of mp3 players 75
3.3 Final selection of fragrance bottles 75
3.4 Aesthetic key points between the genders 79
3.5 Functional key points between the genders 79
3.6 Social key points between the genders 79
3.7 Possible function and workflow of the SIS 81
3.8 Technology acceptance model (TAM) 82
3.9 Conceptual female-focused acceptance model (FAM) 83
3.10 Locations for the survey of the SIS 89
3.11 National University Healthcare System Women’s Clinics and National Healthcare
Group polyclinics 89
3.12 Full dataset results of FAM 93
3.13 Future research model 99
3.14 Reasons for seeking health information online 101
viii

3.15 Choice of health topics among women sample 104
3.16 Methods of learning medical devices 111
3.17 Items to learn of the SIS 112
3.18 Product information to know about the SIS 114
3.19 Reference of a medical device which could possibly induce stress 114
3.20 Reasons that may induce stress 115
3.21 Reasons for stress among total sample 116

Chapter 4
4.1 Preliminary model 132
4.2 The FRIEND model 133
4.3 Steps in using the FDS 137
4.4 Preferences of women aged 24 and below 141
4.5 Preferences of women aged 25 to 34 142
4.6 Preferences of women aged 35 to 44 143
4.6 Preferences of women aged 45 to 54 144

Chapter 5
5.1 FDS within the waterfall model 152
5.2 Discussion and brainstorming among the young designers 153
5.3 Exploration of isses with the FRIENDmodel 154
5.4 Expansion of user concerns from the FRIEND model 155
5.5 Static personas to dynamic archetypes 156
5.6 Personas for the SIS design 157
5.7 A potential contextual scenario for SIS users 159
5.8 Illustration of a persona using the SIS 160
5.9 Illustration of a persona in her familiar environment 160
5.10 Mood collage illustrating the Empathy attribute 161
5.11 Graphical representation of FRIEND for SIS users 162
5.12 Interaction design during concept generation 163
5.13 Project interaction process 163
5.14 Projected SIS design 164
5.15 Screen shots of the animation 166

Chapter 6
6.1 Conceptual visualisation for a future FDS design blog 180

ix


AAMI Association for the Advancement of Medical Instrumentation
BSS Breast Screen Singapore
BSRI Bem’s Sex Role Inventory
CGMP Current Good Manufacturing Practice
DIA Dynamic interactive aesthetics
DoH Department of Health
DSRB Domain Specific Review Board
EC European Council
EMR Electronic medical records
FDS Female-focused design strategy
FHAs Female-focused healthcare applications
FRIEND Flexibleness. Responsiveness. Intricateness. Empathy. Naturalness.
Dependableness
GMP Good manufacturing practice
GUI Graphical user interface
HPB Health Promotion Board
HCI Human computer interaction
HMI Human-machine interface
HSA Health Sciences Authority
ICT Information and communication technology
ICU Intensive Care Unit
IEEE Institute of Electrical and Electronics Engineers
IMG Image
IRB Institutional Review Board
ISA Information system architecture

ITU Intention to use
MDD Medical Device Directives
MeSH Medical Subject Headings
MHCU Mobile health communication unit
MDDI Medical Device and Diagnostic Industry
MOH Ministry of Health
NHG National Healthcare Group
NHS National Health Service
Acronyms & Abbreviations
x

NLP Natural Language Processing
NPD New product development
NUHS National University Health System
OQ Output quality
PACS Picture archiving and retrieval systems
PCC Patient-centred care
PDS Product design specifications
PEOU Perceived ease of use
PHR Personal health records
PNI Psychoneuroimmunlogy
PU Perceived usefulness
QoL Quality of life
RD Result demonstrability
ScHARR School of Health and Related Research
SE Self-efficacy
SIS Self-care information system
SI Social influence
SN Subjective norm
U.S. FDA U.S. Food and Drug Administration

WCC Women-centred care





xi



Concept: A design proposal for a product, through a selection of ideas. Usually
a series of different design proposals will be suggested to facilitate a
definite concept choice. A proposal may exist out of drawings,
additional text and design models.

Detailing: To create a fair opinion of the design proposals, it is necessary to
detail them equally. Detailing may concern: materials, standard parts,
manufacturing techniques, cost calculations, form details, finishing,
etc. The final concept will be tailed in greater length.

Female-focused: This term refers to a female user-centric focus, which has considered
women’s needs, preferences, and biology to enhance their user
experiences and adherence to recommendations.

Female-focused It refers to design with female user-centric focus in medical devices
Design: for women’s health, which ultimately contributes to better quality to
their healthcare, self-care, and personal well-being.

Female-focused Such applications refers to customizable and mobile wireless
Healthcare healthcare interventions such as or network-based clinical

Applications: information system transforming a general purpose computer into a
special-purpose monitoring device component which users can
access to validated advice for effective self-care, manage, and share
their personal health information, and that of others for whom they
are authorised in a secure, confidential, and non-hospital
environment.

Female This term is understood that to achieve it, it needs to involve female
user-friendliness: users in the design-process, possibly helping in redressing the
imbalance between male and female designers and users of
information and communication technologies (ICT), hence the user-
friendliness of the design would then received more attention, such
that even computer-illiterates or women who are usually fearful of
ICT could participate.

Gender-specific: It refers to the socially constructed roles and responsibilities assigned
to women and men in a given culture.

Healthcare design: The term ‘healthcare design’ is used throughout this dissertation to
refer to the design of responsible products such as monitoring devices
and systems such as e-health applications which could directly
impact the safety, operation, clinical outcomes, and self-care
management of people now and into the future.

Idea generation: A controlled grow process of the human mind with the objective to
gain insight in developing ideas.


Medical adherence: It is defined as the extent to which a user’s behavior (in terms of
taking medications, following diets, or executing lifestyle changes)

Terminology
xii

coincides with medical or health advice, working towards better
health management.

Model: Models are used in the design process to communicate ideas and
visions. Models, when 2-dimensional, refer to diagrams and
schematic representations. When they are 3-dimensional, one can
relate them as display prototypes where they can be held up and
tested. In this way, a better understanding of the design can be
achieved/ Models are useful tools in early as well as later stages of
the design process.

Professional: The term ‘professional’ can refer to a designer or a
healthcare/medical provider (i.e. the clinician), who is the person
providing the service to the healthcare consumer. For healthcare-
related professionals, it extends to other personnel involved in the
healthcare system, including the minority of viewers involved in the
process of visual consumption such as healthcare professionals (i.e.
nurses) and women’s health advocates.

Prosumer: Prosumer is a portmanteau
formed by contracting either the word
‘producer’ or ‘professional’ with the word ‘consumer’. However, it is
also said that it refers to a “proactive” consumer. Prosumers are of
particular value to marketers looking to anticipate future trends
because they act as an early detector about the consumer “next”.
Typically making up 20-30 percent of any group, they are not
connected than others, so they function as human media, voicing out

their points of views and exerting influence over their less
“passionate” friends. Euro RSCG’s proprietary research shows that
what prosumers think now, consumers will think next, typically over
a period of 6 to 18 months.

P-value: In statistical hypothesis testing, the p-value is the probability of
obtaining a result at least as extreme as a given data point, under the
null hypothesis. The fact that p-values are based on this assumption is
crucial to their correct interpretation. Generally, one rejects the null
hypothesis if the p-value is smaller than or equal to the significance
level, often represented by the Greek letter α (alpha). If the level is
0.05, then the results are only 5% likely to be as extraordinary as just
seen, given that the null hypothesis is true. In the above example, the
calculated p-value exceeds 0.05, and thus the null hypothesis - that
the observed result of 14 heads out of 20 flips can be ascribed to
chance alone - is not rejected. Such a finding is often stated as being
"not statistically significant at the 5% level". However, had a single
extra head been obtained, the resulting p-value would be 0.041. This
time the null hypothesis - that the observed result of 15 heads out of
20 flips can be ascribed to chance alone - is rejected. Such a finding
would be described as being "statistically significant at the 5% level".
Critics of p-values point out that the criterion used to decide
"statistical significance" is based on the somewhat arbitrary choice of
level (often set at 0.05) (Kallenberg 2002).

Regression analysis: There is a null hypothesis (β = 0) and an alternative hypothesis (β≠0).
When β is 0, there is no relationship between the response and its
predictors. The reason for checking for p-values lesser than 0.05 is
xiii

because of the fact that there is a two-tail hypothesis test at 90% level
being performed. In other words, there is less than 10% of chance for
the research to accept the null hypothesis when the p-value is less
than 0.05, which in turn means that there is a relationship between
the predictors and the responses.

Self-care information It modularises software architecture, assigning specific functionality
system: for use in the prevention, awareness, monitoring and well-being of
the female user in self-care environments. The specific functionality
within the SIS would be executed by different technologies; some
components are proposed for the future design of the SIS but are still
not fully determined. For example, a partial component of the SIS
comes with sensors to detect the temperature, breath moisture and
even volume and dynamics of her voice are detected by voice
capturing systems (VCS) and analyzed for mood, microscopic drops
of saliva are captured and examined for bacteria, salinity, and other
health indicators. Besides capturing sound, the speed of her heartbeat
(i.e. heart rate, ECG), the firmness of her grip could probably be
measured and recorded. Ideally, summarization tools that would
identify important observations obtained from users and present the
information via carefully crafted visual representations could be
implemented in the SIS to assist health providers in caring for their
patients. The SIS with its significant advantages can effectively treat
patients as well as cost efficiently provides advice to users who do
not have any chronic condition at hand. The confidentiality of
healthcare information for both types of users would be maintained.

User: When a person turns to an object, inviting it to be a part of her world,
decides to start using it for some purpose; and as she begins to use
the object, she becomes a ‘user’. This concept of a ‘user’ is based on

an object-centric perspective, the person defined in relation to the
object (Grudin 1990). The term ‘user’ is used throughout this
dissertation mainly to refer to women who may gain access self-care
devices for personal use and better well-being. It is used throughout
this research to refer also to clients, consumers, lay users, prosumers,
participants, or respondents (who are female) and all these terms
could mean the same interchangeably. It is preferred to use the term
‘user’ to emphasize that such applications refer to tools that may be
helpful in monitoring health and wellness as well as a support to help
with illnesses that the term ‘patient’ would imply.



xiv

List of Publications

Xue, L., Yen, CC. and Choolani, M. (2006). Framework Examining Female User Response to
GUI for E-Health Information. Design Thinking and Innovation Conference, “Towards a
Global/Asian Perspective”, collaboration with Cumulus, the European Association of
Universities & Colleges of Art, Design and Media, Singapore, March 29-31 Singapore.
Xue, L., Yen, CC. and Choolani, M. (2006). Framework Examining Female User Response to
Graphical User Interface for E-Health Information. WonderGround Proceeding Book, ed. Ken
Friedman, Terence Love, Eduardo Côrte Real and Chris Rust (2006). Lisbon: CEIADE _
Centro Editorial do IADE. (WonderGround: 2006 Design Research Society Conference, 1-5
Nov 2006, IADE Instituto de Artes Visuais, Lisbon, Portugal).
Xue, L. and Yen, CC. (2006). Towards Pleasure-Based Approach in Design. Proceedings of
International Design Research Symposium, ed. Yong Se Kim, pp. 19-31. Seoul: KSME.
(Invited paper) (International Design Research Symposium, 10-11 Nov 2006, Expo, Seoul,
Republic of Korea).

Xue, L. and Yen, CC. (2007). Towards Female Preferences in Design – a pilot study.
International Journal of Design 1(3): 11-27.
Xue, L., Boucharenc, CG., Yen, CC., and Choolani, M. (2007). A Review of Healthcare
Devices: Moving Design from Object to User. Proceedings of the International Association of
Societies of Design Research (IASDR) Conference “Emerging Trends in Design Research”,
Hong Kong.
Xue, L., Yen, CC., Choolani, M. and Chan, HC. (2009). The Perception and Intention To
Adopt Female-Focused Healthcare Applications (FHA): A Comparison between Healthcare
Workers and Non-Healthcare Workers. International Journal of Medical Informatics 78: 248-
258.

Xue, L. and Yen, CC. (2008). Introducing a Female-Focused Design Strategy (FDS) for
Future Healthcare Design. Proceedings of the 6
th
Conference on Design & Emotion “Dare to
Desire”, Oct 6-9, Hong Kong.

Xue, L., Yen, CC., Boucharenc, CG. and Choolani, M. (2008). The Design Evolution of
Medical Devices: moving from object to user. The Journal of Design Research 7(4): 411-438.

Xue, L. and Yen, CC. (2009) Thinking Design for Women’s Health. Design Connexity
Proceedings of the Eighth Conference of the European Academy of Design, ed. Julian Malins,
pp. 508-512. (Design Connexity: 2009, 1-3 Apr 2009, Gray School of Art, The Robert
Gordon University, Aberdeen, Scotland.)

Xue, L., Duh, HBL., Yen, CC., Chan, HC., Tan, SB., Tang, WE. and Choolani, M (2010).
Health informatics for elderly women – an exploratory study. CHI2010 workshop - Senior-
Friendly Technologies: Interaction Design for the Elderly held in conjunction with CHI2010,
Atlanta, GA, USA, 10 April 2010.

xv



The objective of this thesis is to investigate and introduce a female-focused design strategy
(FDS) to better approach the design of medical devices for women. It offers a dimension to
understand the relationship between female users and a self-care information system (SIS)
and their acceptance levels that may result from their initial perception. The SIS found its
beginnings from a concept design named as the Ibloom (Figure A), conceived as a mobile
health communication unit (MHCU)
1
targeted at women who may need to refer to a network-
based healthcare information system (IS) that functions as a monitor, educator, and support
(Xue 2005).

It was anticipated that certain groups of women, such as the pregnant users who
required prenatal and postnatal care; the non-pregnant who may be suffering from chronic
illnesses or those experiencing an unexpected health event would be particularly interested in
managing their health routine (Roudsari 2006; Millard & Fintak 2002).




Figure A Design concept of ibloom

The home and self-care equipment has been identified by the FDA in 1998 as one of six
future major trends in medical device technology development (Lewis 2001). Many a times,
the use of patient-controlled medical devices has been proven to be significant in improving
their treatment and healing process (Orel 1995). In a study of pregnancy scanning, Yen (1995)

reported that women facing the monitor felt less nervous than those who did not do so.
Pregnant women may not understand the images displayed on the monitor screen but by
doing so it can bring them psychological assurance to allow them to participate in something
so close to them. It is also a fact that the female gender experiences a great deal of health

1
A mobile health communication unit (MHCU) was an electronic based self-monitoring device which
has health information tools which answer to pertinent women health concerns. It is conceptualised to
be inbuilt with up-to-date technological abilities, enabling the female user to play a more independent
role in self-care.
Introduction
xvi

changes throughout their life time and often find themselves as recipients of medical
treatment (Kalbfleisch & Bonnell 2006). They meet doctors more frequently during their life
time than men do, and probably seek more self-care than their counterparts (Miles 1991).
Surveys have also indicated that most patients would like to be able to access their health
records (Keeler & Newman 2001; Martin 2003; Coulter 2006). A potential lies within the fact
that more design research could be carried out for products of such nature so that the quality
of women’s health through self-care can be improved.

The review of current literature reveals little of design for female users in self-care. A new
term needs to be defined for the purpose of this research, entitled as female-focused design. A
simple and direct understanding of it would relate to design that considers the healthcare
needs, emotions, and experiences of female users and to what extent the technology through
self-monitoring systems and devices can benefit them. It then depends on the field of design
to explore the right attributes in defining a design strategy for this purpose. In the design of
most medical devices, the focus tends to be on the technologies and clinical engineering for
interface platforms (Lewis 2001, Protti 2007). Little research attempts to define the user
experience in a way that is theoretically informed, not to say – female-focused user

experience towards medical adherence. This thesis proposes that to study about female-
focused design, and the reaction and justification for the SIS. It would create new knowledge
which should benefit in the field of gender design, and in the real social and marketing, policy
making, and physical contexts of future healthcare and female users’ lives. By surveying the
qualities that are valued after and how female users across different levels in society interpret
and respond to medical devices designed for their perspectives, researchers, designers, and
practitioners can develop a holistic understanding of the elements that are relevant for female
users.

Research Aims & Objectives

What was the gap identified before this study?
• Patient-centred care (PCC)
2
and self care, explored in areas such as medical
informatics, nursing informatics, telemedicine, telehealth, telecare, and ehealth, have
underlying differences but are overlapping expanding fields of interest.


2
There are three definitions which place close meanings on what is considered to be Patient-centred care (PCC).
(1) It can refer to the redesign of patient care so that hospital resources and personnel are organised around patients
rather than around various specialised departments (Sherer 1993, p.14). (2) PCC is that of patient autonomy
whereby patients are involved as participants in their own treatment (HFN01 1993, p.7). (3) PCC is healthcare that
is closely congruent with and responsive to patients’ wants, needs and preferences (Laine & Davidoff 1996,
p.152).

xvii

• Actual applications are rare in the domain of industrial design towards technological

innovations meant for women in self-care.

What are the objectives of this study that potentially adds to new knowledge?
• To understand female users’ perceptions and experiences of using medical devices
and to integrate such information in identifying designs which are female-focused,
enabling women to effectively enhance their health management and well-being.

• To suggest a Female-focused Design Strategy (FDS) for health information system
design.

• To publish in the design field investigating about female-focused designs as well as in
the medical field dealing with women’s health, well-being, and self-care.


This study aims to introduce the concept of a FDS into the design of medical devices,
especially self-care devices since there is an increasing number of self-care products made
easily available over the counter. The method for this developing the FDS would consist of
both linear (i.e. a typical design process) and non-linear (i.e. PCC principles) design (see
Figure B). There are various non-linear PCC principles that provide a range of design
alternatives. The aim of PCC principles adopted within design practice is to enhance the
relationship between industrial designers, patients, clinicians and manufacturers. Such
principles also provide a useful framework to identify the patients’ and doctor’s needs, to
prioritise such needs and to measure outcome performance, in order to design an appropriate
product for the patient. The methodology is a continuous process within which information is
continuously being updated through practice. Consequently, it will grow, adapt and continue
to evolve according to individual needs and experience. To provide a clear picture of the use
of the methodology in design practice, developed by Roy and Bruce (1984) was applied, in
order to demonstrate how the PCC methodology can be integrated within it.

Consequently the FDS would not erode away existing design procedures and product

development protocols, but rather suggests an alternative option for the designers and
marketers involved in this field to consider in future design work. What could be observed
from this design strategy is that emerging products would have included user characteristics
and primary considerations from the major disciplines involved. This is central to the research
study whilst it hopes to provide conceptual aids for other disciplines such as psychology and
sociology in the future. It is hoped that the FDS can help enable future medical device designs
to cater more specifically to female users’ illness-prevention and treatment, subsequently
improving on their well-being.

xviii

1
The feedback based on the clinical assessment according to statutory regulations.
2
The feedback may include the response of operators, clinicians, and patients, etc., and the
performance of the equipment itself.
3
The report is based on the health authorities’ policies and regulations.
Figure B Positioning of the female-focused design strategy (FDS) within design
processes (Source: Adapted from Roy & Bruce 1984, EC MDD, and Yen 1998)







Project background
research
Design brief
Concept design
Detail design
Design Engineering,
Manufacturing &
Marketing
Industrial Design &
Design Development
Female-focused
Design Strategy
Design for

manufacturing
Pre-clinical assessment
CE Marking
Marketing research
& testing

Outcome measurement
Medical technology
development & testing
Production, marketing
and sales
Post-marketing
surveillance
Mock-up development
& testing
Final design concept
& design engineering
Test
Feedback
1

Market
Feedback
2

Adverse
Incident
Reporting
3

Establishment of patient
& clinical operator’s
database for future
design

Manufacturer
Industrial Designer
Investigation and
identification of female
user needs, perspectives,
for self-care devices
and systems
New knowledge update
on
Female-focused design
xix

The contribution of this study from the three objectives would be in terms of information
reference for design (data collected from surveys), design attributes and guidelines (FDS), and
the collaboration of multi-disciplines (the reconciliation, generation, and sharing of new
knowledge between self-care and design). It examines specifically what future designers need
to consider in the design of these highly challenging devices which may concern much user
safety, involvement, experience, and identity. For sub-areas of research it could enhance the
current knowledge of female gender analysis, which is a highly controversial topic in design
theory as debates concerning its validity have been central to discussions of modernism in
design (Benton 1990). The parameters, flexibility, and benefits would be further elaborated
through the outline of the thesis that follows.

Outline of the Thesis

This thesis is organised around the objectives introduced in this chapter. Broadly speaking,
each chapter takes into account and consideration at least one objective. The main structure is
depicted in Figure C.

Chapter 1 explores, reviews, and analyses current literature within gender, health, and design
disciplines. Attention is paid to describing the terms such as design strategies and healthcare
information systems, establishing a conceptual framework, areas of enquiry, and its discovery
context. Furthermore different terms will be explained to its underlying context and the
implications of this research topic discussed. This chapter will be often referred to in the
following chapters.

Chapter 2 describes available knowledge within design research that links design
methodology, theory, and practice. It will be explained that the overall research setting (e.g.
research population, ethical considerations, etc.) has been designed to ensure that the results
are of strong interest and good quality. Second, the chapter describes the proposed research
methodology and data analysis methods for this topic area and options for answering research
questions and objectives previously generated.

Chapter 3 investigates the research topic extensively through a number of quantitative and
qualitative studies. The rationale, methods, findings, and data analysis from the surveying will
be discussed and, based on the previous chapters, what is needed to further the design
research will be represented for analysis later on. The research objectives and questions are
examined again in detail.
xx

Figure C Outline of the thesis

Chapter 4 proposes a way to represent the FDS through a model known as FRIEND and uses
age as a differentiator within the model to enhance its usefulness to designing specifically for
the needs of women from different age groups. The data collection material provided in
Chapter 3 will generate most of the materials for this chapter.

Discussion of available
literature
Chapter 1
An Introduction to
Female-focused Design
and its Relation to Self-

care of Women
Chapter 2
Research Methodology -
Synchronising Existing
Perspectives and Design
Analyses
Chapter 3
Collection and Analysis of
Quantitative and Qualititative Data
in Research of a
Self-care Information System (SIS)
Chapter 4
A Female-focused Design Strategy (FDS):
the FRIEND model
Chapter 5
Application and Evaluation of the
Female-focused Design Strategy (FDS) in the Design Process
Chapter 6
Conclusions and Further Directions –
Comprehensive Vision Documentation
Structure of
Female-focused
Design
System
Architecture
Existing Design
Protocols and
Processes
Relationships, Strengths and Weaknesses
Theoretical contribution

to literature
Illustration and exploration
in practice
xxi

Chapter 5 describes the application of the FDS to a new product development and design
process and its evaluation from both the users of the strategy and the application is
documented. The chapter comprises sections such as Identifying Characters, Concept
Generation, and Evaluation and Refinement of Final Designs which they are to be described
in detail. Secondly, the final proposed concept design of the SIS will be presented to a group
of potential users for a series of deep and open-ended interviews. The explication of
subjective-meaning structures of women’s view on the system and their relation to the more
readily observable outcomes - both strengths and weakness will then be presented.

Chapter 6 concludes the research. It should comprise comprehensive vision documentation
where female user values, systems, and technology enablers are considered. The conclusion
and directions for further research are suggested.

References

Benton, T. (1990). “The Myth of Function”, in P. Greenhalgh (ed.), Modernism in Design, London:
Reaktion Books.
Coulter, A. (2006). Engaging Patients in their Healthcare. Oxford: Picker Institute Europe. Available:
/>
[4 Mar 2008].
Council Directive 90/385/EEC (1990), “On the Approximation of the Laws of the Member States
Relating to Active Implantable Medical Devices”, Official Journal of the European
Communities, No L 189: 17-35.
HFN01 (Health Facilities Note 01) (1993). Design for Patient Focused Care. London: HMSO.
Kalbfleisch PJ. and Bonnell KH. (2006). “Menarche, Menstruation, and Menopause: The

Communication of Information and Social Support”, in R. Parrott and C. Condit (eds.),
Evaluating Women's Health Messages. London: SAGE Publications, pp. 265-278.
Keeler, J. and Newman, J. (2001). Paperless Success: The Value of E-Medical Records. Healthcare
Information and Management Systems Society (HIMSS) Proceedings. 2(45): 1-7.
Laine, C. and Davidoff, F. (1996). The Patient-Physician Relationship, Patient-Centered Medicine: A
Professional Evolution. Journal of the American Medical Association 275(2): 152-6.
Lewis, C. (2001). Emerging Trends in Medical Device Technology: Home Is Where the Heart Monitor
Is. U.S. Food and Drug Administration, FDA Consumer Magazine 35(3).
Martin, JB. (2003). Effectiveness, Efficiency, and the Value of IT. Journal of Healthcare Information
Management 17(2).
Miles, A. (1991). Women, Health and Medicine. Buckingham: Open University Press.
Millard, RW. and Fintak, PA. (2002). Use of the Internet by patients with chronic illness, Disease
Management & Health Outcomes 10(3):187–194.
Orel, T. (1998). The Technologies of Self-Fashioning: Beyond University and Variance of the
Industrial Product. Design Issues 4 (1) & (2), special issue: 38-51.
Protti, DJ. (2007). Informing the Future with Emerging Clinical Information Technologies.
Available at: www.connectingforhealth.nhs.uk/newsroom/worldview/protti9.
[11 Nov 2008].
Sherer, JL. (1993) Putting Patients First: Hospitals Work to Define Patient Centered Care. Hospital
67(3): 14-18.
Roudsari, A. (2006). Patient Relationship Management in response to fragmented healthcare: A
vision realized through technology. NHS Connecting for Health Website. Available at:
www.connectingforhealth.nhs.uk/worldview/comment11/
[11 Nov 2008].
Roy, R. and Bruce, M. (1984). Product design, Innovation and Competition in British
Manufacturing - Background, Aims and Methods, Working Paper, WP-02, Milton Keynes:
Open University.
Xue, L. (2005). Mobile Health Communication Unit, Unpublished Bachelor of Arts (Industrial
xxii

Design) HONS Thesis, National University of Singapore, Department of Architecture.
Yen, CC. (1995). The Application of Patient-Centred Principles to Medical Equipment through
Industrial Design Practice: Registration Document, (unpublished), Birmingham: The University
of Central England in Birmingham.
Yen, CC. (1998). The Application of Patient-Centred Principles to Medical Equipment through
Industrial Design Practice (unpublished), Birmingham: The University of Central England in
Birmingham.










An Introduction to Female-Focused
Design and its Relation to Self-
care of Women

1.1 Background

Medical devices, products and information systems (IS) are increasingly made available in
many countries, to encourage home and self-care, thus changing the façade of how people
view and approach health systems. People are able to play a greater part in maintaining their
own health. The potential benefits of self-care are substantial and a large research agenda
surrounds it. Self-care is defined as “the actions individuals take to lead a healthy lifestyle; to
meet their social, emotional and psychological needs; to care for their long-term condition;
and to prevent further illness or accidents” (Barlow et al. 2002). The process of self-care is

facilitated by the use of devices, such as home glucose monitors, customised wearable
devices, mobile electronic patient records, wireless network-linked systems and potentially
"smart devices" that can think by themselves (Lewis 2001; Noury et al. 2003).

Mobile information technologies (IT), information communication technologies (ICT) and IS
applications in healthcare can be recognised as both emerging and enabling technologies
(Ammenwerth et al. 2003; Haux 2006). The promotion and maintenance of health is now a
critical consideration in the design of medical devices and healthcare portals. Such
personalised tailored tools are intelligent and effective enough to help people manage
illnesses and improve health management (Schneider et al. 1993; Bental & Cawsey 2002).
Interest in creating a personalised health portal extends internationally. Many healthcare
organisations in the United States (US) have already offered portals that “enable patients to
schedule appointments, request prescription renewals, receive laboratory and test results,
review their medical records, and obtain an ‘online consultation’ directly with one’s
physician” (Weingart et al.2006). In Singapore, the current status of IT use in the health sector
is partly driven by governmental efforts (Teo et al. 1997; eCitizen 2004). The latest blueprint
consists of a ten year plan to implement the use of infocomm over the next ten years, known
as the Intelligent Nation 2015 (iN2015) (IDA 2008). According to IDA (2008), “Infocomm
will link hospitals, clinics, nursing homes and laboratories with patients’ homes, enabling
healthcare professionals to access comprehensive patient information instantly. An integrated
healthcare delivery system will give individuals the ability to better manage their health and
1
1
Chapter 1 An Introduction to Female-Focused Design and its Relation to Self-care of Women

2

access high quality clinical care, providing cost-effective healthcare and supporting strong
clinical research”. Singapore’s National Healthcare Group (NHG) is offering a NetCare portal
that enables patients to view their online personal medical and health dossier and to make

appointment changes and electronic payments (NHG 2000; Weingart et al.2006).

Other public organisations, such as SingHealth, the Breast Cancer Foundation, Health
Promotion Board (HPB), and the Ministry of Health (MOH) are increasingly exploring
methods by means of IT to promote self-care for long term costing reasons and raise
awareness for women’s health (Health Feedback Group 2004). Besides mammography, there
is health screening for conditions, such as HIV and Hepatitis for women at appropriate times.
According to Leong and his colleagues (2007), “in the year 2002, the HPB embarked on
Breast Screen Singapore (BSS) which is a national screening programme for breast cancer
and the NHG polyclinics which started its first mammographic screening service within one
of its polyclinics in year 2000 gradually established mammographic screening in all nine
polyclinics by year 2004, leveraging on the BSS”. SingHealth has also compiled a list of
screening options for conditions ranging from eye diseases to stomach ailments which is to
allow the person to gain intimate knowledge of his/her body and help one make informed
decisions should the time come for his/her to treat any conditions (SingHealth 2006).

Although the design and services provided by health portals were promised to be improved
greatly, evidence suggests that the people who would access to such systems tend to be
younger, more affluent, and healthier than the average patient (Fox 2003; Fox 2004; U.S.
Department of Commerce 2000; Weingart et al.2006). There is a need to better understand
what lay people expect of health advice and care and their essential needs, the appropriate
ways of helping them to deal with their health concerns themselves, and of methods to enable
them to maximise services effectively as the systems mentioned before begin to be introduced
into their homes. According to Jones (2000), “research into the efficacy of self help
information about minor illness and common symptoms needs to be extended to examine the
value of better targeted and more sophisticated sources of information, including interactive
communication”.

By introducing personalisable self-care applications along with such a national vision, it could
well become one of the mechanisms towards improving the quality of life for the citizens. In

fact, creativity may well provide resolution to new technical hurdles and the challenges of
new market and user needs. Sadly, the determination of the design and the allocation of
Chapter 1 An Introduction to Female-Focused Design and its Relation to Self-care of Women

3

requirements of self-monitoring devices do not include factors, such as the perception and
efficacy of the genders, especially the females (Fries & Bloesch 2004).

Women, however, are catching up with men in most measures of online life, so much so that
they have consistently engaged more in health-related online activities; interestingly,
according to Miles (1991), “…women are significantly more likely than men to look for
health and medical information”, in particular, over the Internet (Fisk & Stevens 1993;
Hawisher & Sullivan 1998; Fallows 2005; Burst Media 2007). 80% of women accessed the
internet and 62% accessed health related information from the Internet while 70% of women
expressed a perceived need to obtain more information from the Internet if they were
diagnosed with a condition, e.g. breast cancer. This study supports using the Internet as a
viable way of communicating health information to women in all age groups (Dey et al.
2006).


Figure 1.1 Health problems pertinent to women (Source: Adapted from Kunz & Finkel 1987)
The planning and implementation of design in healthcare care should be tailored to
address the differences demonstrated by age and psychosocial life stage, and to
enhance quality of life issues, for both young and old.