Designing for trust: user-friendly refugee wellness center planning process and concept, a health design case study

doi:10.21203/rs.3.rs-2112797/v1

Download PDF

Research Article

Designing for trust: user-friendly refugee wellness center planning process and concept, a health design case study

https://doi.org/10.21203/rs.3.rs-2112797/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 09 Nov, 2023

Read the published version in BMC Health Services Research →

You are reading this latest preprint version

Background

Refugee and immigrant populations have diverse cultural factors that affect their access to health care and must be considered when building a new clinical space. Health design thinking can help a clinical team evaluate and consolidate these factors while maintaining close contact with architects, patients’ community leaders, and hospital or institutional leadership. A diverse group of clinicians, medical students, community leaders and architects planned a clinic devoted to refugee and immigrant health, a first-of-its-kind for South Philadelphia.

Methods

The planning process and concept design of this wellness center is presented as a design case study to demonstrate how principles and methods of human-centered design were used to create a community clinic. Design thinking begins with empathizing with the end users’ experiences before moving to ideation and prototyping of a solution. These steps were accomplished through focus groups, a design workshop, and iterations of the center’s plan.

Results

Focus groups were thematically analyzed and generated two themes of access and resources and seven culturally specific subthemes that informed the design workshop. A final floor plan of the wellness center was selected, incorporating priorities of all stakeholders and addressing issues of disease prevention, social determinants of health, and lifestyle-related illness that were relevant to the patient population.

Conclusions

Design thinking methods are useful for health care organizations that must adapt to the needs of diverse stakeholders and especially underserved or displaced populations. While much has been written on the theory and stages of design thinking, this study is novel in describing this methodology from the beginning to the end of the process of planning a clinical space with input from the patient population. This study thus serves as a proof of concept of the application of design thinking in planning clinical spaces.

Human-centered design

social determinants of health

refugees

family medicine

Patients from lower socioeconomic backgrounds are well known to suffer from an increased burden of acute and chronic diseases compared to the general population (1), and the adjustments that accompany refugee status or immigration can further compound health challenges (2). Even when practitioners and community leaders are united in seeking improved community health, it can be difficult to coordinate priorities to ensure a clinic addresses factors such as language differences, cultural history, nutrition, insurance, and immigration status, etc. to practice cohesive and holistic care (3). Furthermore, the COVID-19 pandemic exacerbated health inequalities in the refugee population due to disproportionate numbers of refugees employed in designated essential industries and manufacturing, crowded housing, and lack of access to health information due to cultural and language barriers (2,4,5).

The City of Philadelphia is a striking demonstration of the effects of these social determinants of health. For example, people living in Philadelphia’s lower income, less healthy zip codes can see a twenty-year drop in life expectancy compared to those residing in the city’s wealthier zip codes (6). Surveys of the city’s immigrants show most do not know which support systems to access when sick, and many overutilize emergency rooms while seldom receiving primary care (7). Furthermore, refugee communities are a growing yet underserved patient population that faces barriers to accessing health care due to cultural and language differences (8), manifesting in issues of trust in health care practitioners, logistical challenges in scheduling and transport, and health education (2).

We used design thinking methods to inform the planning goals of the first clinic in South Philadelphia dedicated to refugee and immigrant health, which opened in 2021. The concept design for the Hansjörg Wyss Wellness Center was a collaboration between the Department of Family and Community Medicine at Thomas Jefferson University Hospital, the community organizing group SEAMAAC (Southeast Asian Mutual Assistance Association Coalition), and KieranTimberlake, a Philadelphia-based architecture firm. The intended patient population was predominantly Southeast Asian, and the area around the center included people from Cambodian, Bhutanese, Burmese, Laotian, and Vietnamese backgrounds as well as Chinese, Latino, and Congolese residents. To integrate the diverse patient populations’ needs and the varying perspectives of the collaborative partners in creating a clinical space, we embraced a design thinking methodology that would best harmonize the different priorities of the organizations involved while respecting the patients’ cultural needs.

Design thinking is an approach to creating products and services that centers on the user experience as a source of insight (9). A design thinking approach involves methods such as empathizing with users, rapid prototyping, and multiple rounds of testing (see Fig. 1). While many articles in the past decade have offered guidelines and theoretical explanations for applying design thinking to health care, there are few documenting how design thinking in health is concretely applied throughout the length of a specific project or intervention, especially when designing new clinical spaces or involving medical students in design solutions (see (10)).

Whereas the public is usually involved at the end of the design process for a clinical space if at all, transparency and input for the patient population from the were important goals from the beginning (see (11)). Clinical spaces perceived to be considerate of end user preferences can lead to greater patient satisfaction, feeling more welcome, and reduced stress for both patients and staff (12,13). Designing this clinic afforded a unique opportunity to observe how design thinking can integrate designer, practitioner, and patient feedback at multiple stages throughout the design process.

Stakeholder engagement focus groups

The design process began with developing empathy from a design perspective for the end-user by conducting focus groups with community members and leaders. Participants were recruited by the community organizing group with the aim of reaching a qualitative understanding of participants’ social supports and stressors (1,14). Focus groups questions were open-ended to gather diverse insights into perceived health care access barriers and to probe desires for the new wellness center (see supplementary material for example questions). Ten focus groups were conducted (n = 100 respondents) in fall 2019. Focus group participants were recruited through community bulletins and the existing constituency of the community’s organizations. Eight of these included community members of specific ethnic and linguistic groups, i.e. Mandarin Chinese, Bhutanese, Laotian, Burmese, Vietnamese, Latino, Congolese, and Cambodian; one focus group included health care and social work staff; and one focus group consisted of representatives of community organizers in the region.

Four researchers independently coded the focus group data and thematically analyzed them, synthesizing results by major general themes as well as specific themes per ethnic group (15) (12). Researchers then re-read focus group transcripts to ensure narrative quality was not lost by the separation into themes, and results were discussed and refined in consultation with community organizers to maintain the perspectives of the members of the various cultural groups that comprised the patient populations. Qualitative data elucidated the end users’ priorities and insights, which guided the team at each checkpoint in the design process.

Design sprint

Using observations from the focus groups, we conducted a design workshop (“design sprint”) in September of 2019 with a diverse group of project stakeholders to gather insights for innovating a modern exam room for refugee and immigrant populations. The exam room was chosen as the topic for the workshop because it represents the center of the patient experience and is an essential space for communicating to patients and family members. Architects, community workers, and clinicians convened to examine how cultural and socioeconomic factors could inform a design framework for a multipurpose exam room within a community wellness center. Participants engaged in brainstorming sessions on designing the ideal community clinic. Insights on the current exam room experience were recorded on whiteboards and organized into themes.

After brainstorming insights into the challenges and barriers patients face with the conventional exam room design, groups were challenged to open their minds to creative thinking through the exercise of generating a “How Might We” (HMW) statement. This technique of questioning helps designers to frame problems from a fresh perspective (9). Participants used the statements to distill common issues that arose in the brainstorming session.

HMW statements were shared and formed the basic questions for storyboards, which participants drafted to understand how the clinic might fit into their own lives and the lives of their communities. Storyboards use narratives to convey the problem identified and the possibilities for design solutions (9). Each group chose one HMW statement to develop into “wild ideas”, i.e. without constraints of time, money, or technology for solutions, that were the topics of the storyboards.

Using insights from storyboards, the groups began iterating solutions with the realistic constraint of being implemented by the end of 2020 (which ended up being delayed to 2021 due to the pandemic). Journey maps are annotated timelines of the user’s experience of a proposed product. The journey map envisions the end user's actions and experience with the product along various stages of an encounter until the product has served its use, paying attention to the actions, emotions, and physical touchpoints (9). We used journey maps to conceive of the patient visit as a culturally significant ritual, mirroring patients’ own expectations towards visiting physicians (Fig. 2). For example, Chinese and Vietnamese patients had described visits to traditional medicine as experiences of hospitality; the traditional practitioner welcomes patient and family with a tea ritual and provides quiet space for relaxation, establishing trust with the patient before attempting to balance the energies and spiritual forces in the patient’s life. Attention to hospitality and ritual space in the journey maps yielded ideas that could be feasibly implemented later in the process, such as permanent space for in-person translators, intuitive signage, and clinical spaces that could accommodate families.

Virtual Reality (VR) allowed us to experience a higher fidelity iteration of the future wellness center (16). A VR simulation presented one version of a floorplan that could be seen from a bird’s-eye view and explored through a first-person perspective. A virtual first-person walkthrough let designers envision the future patients’ clinic visits and how they would interact with built-in design features like the waiting room-as-library, the gallery hallway, the multi-purpose community education space, and the family meeting areas and exam rooms. The VR simulation thus demonstrated the desirability of the design features within a simulated space of the existing building. Five floor plans were drafted, featuring varying levels of alteration to the existing structure and including the earlier proposed design features to greater and lesser degrees, and a final plan was selected based on leadership feedback from the VR simulation.

Focus groups yielded 2 major themes of “access” and “resources” and 7 subthemes shared among multiple groups as well as priorities particular to each ethnic group (Table 1). Subthemes included language concerns, hospitality, location, flexibility, health education, cultural education, and services.

Table 1

Focus group themes.
Theme	Access
Subthemes	Language barriers and need for good interpretation (8 FGs). ● Lack of understanding of medical terminology (2 FGs). ● Difficulty making appointments (2 FGs). ● Language barriers impede health education (3 FGs). ● Language differences contribute to feelings of distrust and fear of suffering from discrimination (4 FGs). Hospitality. Kind and welcoming staff are important (5 FGs). ● Yelling for patients and loud noises may make some patients feel unwelcome. Location. Convenient location of the building is an asset (5 FGs). ● Elders can use the space for formal and informal purposes. ● First refugee wellness center in the area of South Philadelphia. Flexibility. The space should accommodate many different needs (5 FGs). ● Different family arrangements will be present as well as a variety of activities.
Theme	Resources
Subthemes	Health education (4 FGs). ● Secondary and tertiary prevention for common diseases, especially lifestyle diseases (4 FGs). ● Traditional and alternative medicine is used alongside Western evidence-based medicine. ● Mental health education is important (3 FGs). Cultural education. The space may facilitate intergenerational bonding and teaching (8 FGs). ● Murals and public artworks can convey cultural values. Services. The space should accommodate children and have activities for the whole family (5 FGs). ● Children should be able to learn about their cultural heritage. ● Other issues related to social determinants of health, such as immigration status, food security, etc., can be addressed.
FG Focus group

Access

The major theme of access primarily concerned barriers that patients faced to accessing clinics and organizations promoting their health. The subthemes included under access were language concerns, hospitality, and location. Common to 8 groups was an emphasis on language barriers as a barrier to healthcare, leading to requests for in-person interpreters for their ideal wellness center. Patients in these communities often rely on children or grandchildren to translate; in addition to complicating the important roles relating elders to youths in these communities, translation difficulties can lead to difficulty in making appointments, understanding medical terminology, and receiving health education, as the Laotian, Burmese, Bhutanese, and Vietnamese groups especially noted. Language barriers contributed and were related to cultural differences in communication, especially for how hospitality and honor are expressed.

5 of the groups thus expressed that their standards for how a welcoming and kind staff should treat them are important and differ from their typical prior experiences in healthcare settings. These groups noted that their ideal setting has moderate activity, space for casual conversation, and warm greetings, but typical waiting room behavior such as yelling for patients is unacceptable. Such findings help explain why some communities could eschew Western health care practitioners in favor of alternative sources on the basis of their perceived hospitality, as previous studies of immigrant attitudes have noted (17). The traditional medicine settings can have features that immediately put the patient at ease, such as beginning meetings with tea and displaying herbs and culturally familiar artifacts, and the team envisioned ways of incorporating similar features in the process and space of the new wellness center. The spaces were conceived as places in which rituals of continuing welcome could take place in a way similar to how spaces are used in Asian traditions (see (18)). The waiting area was reconfigured as a library and cafe, leading into a gallery and community meeting space before the exam rooms, which were treated as intimate family meeting areas. These spaces were developed to convey a vision of professionalism less reflective of clinical distance or impassivity and more premised on showing honor to patients and understanding for cultural preferences.

5 of the focus groups appreciated the wellness center building’s convenient location, as elders from the Asian communities have often been able to meet there for formal and informal social events. Jefferson Family Medicine chose the site in part because of its proximity to the planned patient populations. The wellness center’s potential to continue as a community meeting space therefore provides an opportunity to help patients feel welcome and has been a prominent guideline for the team. Therefore, the space needed a modular flexibility to accommodate different types of activities and arrangements of families. Exam rooms and meeting rooms needed to allow effective placement of translators or family members who would participate in the patient encounters. A flexible space would allow room for solutions such as translators or culturally appropriate artwork that could help resolve patients’ barriers to access like language issues or feeling foreign and unwelcome. Flexibility would also allow insights of the following theme, resources, to be fully realized in the wellness center’s space.

Resources

Related to the previous issue of language barriers was 4 focus groups’ expressed need for health education, particularly on secondary and tertiary prevention for chronic conditions such as diabetes, hypertension, and hepatitis B (19). While community members tended to be aware of many chronic diseases being an issue for their population, they lacked knowledge of disease progression and how they could expect to manage their conditions. The Laotian group in particular noted that community members’ use of traditional medicine might continue without informing Western practitioners, who are perceived as cold and condescending when patients do not understand or receive information about their illnesses. Proper presentation of education was especially heavy on the minds of this group as they recounted how three middle-aged men in their community had recently died from cardiovascular complications after being diagnosed with hypertension. The men had distrusted the advice and prescriptions of Western practitioners and had attempted to procure herbs for their hypertension, which subsequently progressed. This episode demonstrated to the team the importance of culturally sensitive health education for preserving trust in the patient-provider relationship. 3 groups also desired more education on mental health issues, noting generational differences in recognizing and seeking treatment for conditions such as depression and anxiety. The space thus needed to promote trust among the patient population while permitting exhibits and events for health education.

8 groups emphasized their desire for a space that facilitates intergenerational family bonding and cultural education. These groups alerted the team to the need to consider how various details contribute to the space’s suitability as an intergenerational and educational meeting space: particular color combinations could either soothe or evoke unpleasant historical associations, while murals, group exercise activities such as tai chi, and traditional board games like Chinese chess could immediately provide a sense of familiarity as fixtures common to other favored meeting spaces such as parks. (Visitors to parks in many Chinese-American neighborhoods will quickly recognize how all these elements combine to foster a sense of intergenerational community.) 5 groups wanted child services and places for children to learn about different cultures and their own ethnic group, among various services. Participants found child services fitting for a family medicine-run wellness center and expressed that such services would give more peace of mind if they needed to be examined on their own. Furthermore, they raised the idea that having some resources such as legal counsel or food security resources on premises, which could help coordinate strategies on social determinants of health. The seven themes provided ample material for informing design sprint’s prototypes, which were then refined into iterations of the potential space.

The final concept design of the center was selected for its preservation of the building’s central columnar area, expected patient flow, and incorporation of innovative multipurpose spaces (Fig. 3). Spaces were color-coded and categorized according to the primary end user for which the space was designed, with green assigned to spaces for patients, blue for staff, and red for the overall community. The plan was a synthesis of the goals of hospitality, patient orientation to space, and unconventional meeting areas with the distinctive historical details that the building, a former trade school, afforded us.

For the purposes of health services research, we mostly focused on the design process itself and the ways the process elucidated and interacted with multiple stakeholders’ priorities. However, a brief discussion will help demonstrate how the final concept reflected those priorities before returning to comment on the process.

All of the focus group themes were able to be incorporated into the wellness center’s design in some form, which is evident from a walkthrough of the concept from a patient’s perspective. Upon entry, a reception and library area present the wellness center as a more welcoming place than the typical clinic. A library setting meets the need for health and cultural education, and the books and windows provide positive distractions that reduce boredom and anxiety (20). The reception desk is placed sufficiently close to seating to show sufficient attention and preserve quiet during staff and patient interactions. Patients may enter a gallery that exhibits local art and cultural artifacts while letting in natural light from the building’s high windows. Both the gallery and the adjoining community meeting room have a view of the small community garden (not shown in the image) that can be used for health education on nutrition and healthy lifestyles. The meeting room is a flexible space that can be divided several ways and could be used for purposes such as cultural education, vaccination events, group therapy, guided exercise, etc.

Moving from the community to the patient and staff spaces, the exam rooms were planned with enough room for a few family members. With understanding that it would be difficult to have space for multigenerational families, an exam table, and ideal positioning of computers and equipment all together, consult rooms were added to allow family meetings in a less cramped setting while keeping the exam rooms from being too large. In staff areas, spaces for a community organization could make it convenient for patients to address social determinants of health during a visit. Having staff from the community organization present and proximal to the reception area was intended to promote patients’ trust in the wellness center overall.

Creative solutions to challenges

Once focus groups had been conducted, one major challenge was addressing the myriad of community members’ non-clinical requests while prioritizing the primary goal of the center to meet medical needs. Some of these requests were simply unfeasible or mutually exclusive, such as a need for spaces of peace and tranquility but also areas for group exercise and celebrations. Therefore, during the design sprint, several of the groups discussed the option of modular rooms that could be adapted to a variety of purposes just by rearranging some of the furniture, dividers, or accessories. Instead of attempting to fit spaces into the building for mutually exclusive purposes, allowing community members to decide when they want the spaces to fit particular needs eliminated the potential conflict between various priorities. Teams hoping to use design thinking in building clinical spaces must consider how to make the space itself adaptable to the different populations they serve that have disparate interests.

Constraints of the physical building and limited space were limiters on the details that could be included. Because of the building’s historical and architectural value, we agreed that many of the wall details, columns, and window configuration should be preserved, and rooms could not be as large as initially desired. The medical students served as good communicators to nonclinical staff, architects, and community members of the clinical requirements of the exam rooms, as they could describe the sequence of the physical exam, the typical placement of objects like the table and tools, and points of friction in the flow of the exam. One such point was the use of electronic medical records (EMR) during the exam coupled with placement of the computer facing away from the patient, which inhibited face-to-face rapport between the practitioner and patient. As touched upon, exam rooms were therefore designed with space for adequate computer placement, with the tradeoff of some of the rooms being unsuitable for large families to occupy all at once. To mitigate this, designated family meeting rooms were included, i.e. the consult rooms, and there were slightly fewer exam rooms in total. We learned it was wiser to design each room to solve one or two problems rather than every problem at once.

Strengths, limitations, and future directions

The main strength of our research is documentation of each step in the design process, describing how the theory and principles of design thinking are applied in concrete settings for the benefit of underserved multiethnic populations and resulting in a design that harmonizes the interests of many stakeholders. The use of design thinking principles and methods with trainees to create a clinical space is novel. The methodology of arranging design thinking tools in each stage from the imagine/empathy phase (focus group analysis) to imagine (design sprint with brainstorming HMW statements) to making (journey maps, VR, and final concept) provided a high level of transparency and inclusion for the patient population communities. This process is replicable for any teams needing to harmonize the preferences of all stakeholders. Teams hoping to center the design of clinical space around end user preferences, especially for refugee, immigrant, or low-income populations, could consider holding similar design workshops with community input. Medical students in our case acted as design workshop leaders. Construction of a clinical space can present a rare and valuable opportunity for students to practice design thinking, and academic medical institutions should benefit from their contributions whenever possible. Helpful resources in design thinking included The Field Guide to Human-Centered Design Thinking (21) and Health Design Thinking (9), and our process may be considered a demonstration of those theories in health care for planning a new clinical setting.

Another strength of our research was the use of qualitative methods to gather the input of multiple end users and patient populations. Qualitative methods allowed community members to express how social determinants of health affected them from their own perspectives, and they could communicate what features would encourage them to address those issues and engage in follow-up. Cultural norms such as those about hospitality or different perspectives on alternative and traditional medicine systems versus Western evidence-based medicine only could be considered thanks to the more open structure of the focus groups. Incorporated into design thinking, qualitative methods produce a full account of end user priorities that reinforces the design fundamental of centering the end user’s experience. When addressing needs from underserved or displaced groups such as immigrants and refugees, qualitative methods can help members of those groups feel that their contributions are valued among the considerations of all the stakeholders.

A limitation of this work is the fact that longitudinal data from the community could not be incorporated into our methodology. While we gathered qualitative information from the focus groups to understand patients’ preferences, the Wyss Wellness Center has been operating for too short a period to collect meaningful data on the center’s effect on patients’ continuing health. The center is well positioned to collect and interpret these data in the first few years of operation using EMR and community surveys. Furthermore, having community organizers on site will be helpful for contextualizing these data within the overall needs of the communities. Specific data of interest would include incidence of cardiovascular disease and diabetes in clinic patients versus the general population in the area, typical diet habits before and after nutrition interventions, and patient satisfaction surveys. The center could also use validated measures of patients’ perceptions of quality of the space (e.g. (22)), assessing whether ongoing perceptions correspond to the completed design process. The full implications of using design thinking for planning the wellness center could require another article touching on metrics rather than the design process itself.

Finally, a mixed strength and limitation was collection of qualitative data in a non-clinical setting, which was appropriate for a center serving the general population. We thus benefited from partnerships with other stakeholders and could consider non-clinical priorities that might affect planning. However, we were therefore unable to collect data on some clinical characteristics such as high utilizers or prevalence of specific medical conditions.

Cultural considerations are as important as clinical priorities when designing a clinical space for underserved populations like refugees and immigrants. Organizations may elicit these considerations and harmonize them with the priorities of all stakeholders using design thinking. In this case, barriers of language, health education, and generational differences inspired a design thinking approach that saw the clinical space as a ritual space that needs to inspire trust, incorporating welcoming features such as family meeting rooms, a gallery, reimagined exam and waiting rooms, and on-site community organizations.

A team of diverse stakeholders is critical to the design of a clinical space that meets the needs of patients, clinicians, and community members in a quickly changing health care landscape with many data sources. Health design thinking methods are adaptable for transparently engaging and harmonizing the varied interests of these stakeholders. The methods we demonstrated can be employed in a variety of projects to improve an organization’s resilience, anticipating and understanding the needs of patient populations such as refugees and immigrants that have already overcome many challenges.

Focus group

SEAMAAC

Southeast Asian Mutual Assistance Association Coalition

HMW

“How Might We” statements

Virtual reality

EMR

Electronic medical record

Ethics approval

Research material consisted of secondary focus group data collected by the nonprofit social services organization SEAMAAC (Southeast Asian Mutual Assistance Association Coalition) and de-identified prior to analysis by researchers. SEAMAAC obtained written consent from all participants prior to conducting focus groups and approved the use of the data by the authors for this study.

Consent for publication

Not applicable.

Availability of data and materials

The data analyzed in this study are not publicly available as they are proprietary to local community organizations, but they are available upon reasonable request to the corresponding author given appropriate ethical and community approval.

Competing interests

The authors declare that they have no competing interests.

Funding

The Wyss foundation funded the design and construction of the wellness center by Thomas Jefferson University’s Department of Family and Community Medicine. The funding body played no role in the design of the study, collection, analysis, and interpretation of data, and in the writing of the manuscript. Publication was made possible by the Jefferson open access fund.

Authors’ contributions

Staff from Jefferson’s Department of Family and Community Medicine overseen by MA led the project and established the vision for the center, coordinating the various partners. Working under the leadership of family medicine staff, our team consisted of medical students ES, BJ, and SC and faculty, BK, from Jefferson’s Health Design Lab who liaised between the family medicine, architects at KieranTimberlake (principally BF), and staff at SEAMAAC. Using insights from the design sprint and the virtual reality experience, KieranTimberlake architects developed the final concept design for the center. ES, BJ, and SC collected data from the community focus groups, worked with BK to facilitate the design sprint with partners, and drafted the manuscript.

Acknowledgements

The authors would like to thank the SEAMAAC staff and Thomas Jefferson University’s digital health team for their collaborative efforts and ongoing work at the wellness center.

Authors’ information

BK is professor of emergency medicine and design at Thomas Jefferson University, director of the Health Design Lab, and co-author of Health Design Thinking (Cooper Hewitt Smithsonian Design Museum and MIT Press). BJ is a scholar of religion and culture and is an officer in the U.S. Navy Medical Corps; his views are his own. BF is a partner at KieranTimberlake and has taught architecture and design at numerous institutions including Harvard and the University of Pennsylvania. MA is director of the Jefferson Center for Refugee Health.

Andrade C, Lima ML, Fornara F, Bonaiuto M. Users’ views of hospital environmental quality: Validation of the Perceived Hospital Environment Quality Indicators (PHEQIs). Journal of Environmental Psychology. 2012 Jun 1;32(2):97–111.
Bishop D, Altshuler M, Scott K, Panzer J, Mills G, Mcmanus P. The refugee medical exam: What you need to do. The Journal of family practice. 2012 Dec 1;61:E1–10.
Brickhill-Atkinson M, Hauck FR. Impact of COVID-19 on Resettled Refugees. Prim Care. 2021 Mar;48(1):57–66.
Clarke SK, Kumar GS, Sutton J, Atem J, Banerji A, Brindamour M, et al. Potential Impact of COVID-19 on Recently Resettled Refugee Populations in the United States and Canada: Perspectives of Refugee Healthcare Providers. J Immigr Minor Health. 2021 Feb;23(1):184–9.
Colenberg S, Jylhä T, Arkesteijn M. The relationship between interior office space and employee health and well-being – a literature review. Building Research & Information. 2021 Apr 3;49(3):352–66.
Collins L, Klasko SK, Sicks S. Equipping the Workforce for Complex Care: How Jefferson University Trains Medical Students in Hotspotting. NEJM Catalyst [Internet]. 2019 [cited 2022 Jul 7];1(1). Available from: https://catalyst.nejm.org/doi/full/10.1056/CAT.19.1087
Douglas CH, Douglas MR. Patient-centred improvements in health-care built environments: perspectives and design indicators. Health Expect. 2005 Sep;8(3):264–76.
Faltermeier T. Why public health research needs qualitative approaches: Subjects and methods in change. European Journal of Public Health. 1997 Dec 1;7(4):357–63.
IDEO.org. The Field Guide to Human-Centered Design. 1st edition. San Francisco, Calif.: IDEO.org / Design Kit; 2015. 192 p.
Jiang S, Powers M, Allison D, Vincent E. Informing Healthcare Waiting Area Design Using Transparency Attributes: A Comparative Preference Study. HERD: Health Environments Research & Design Journal. 2016 Nov 14;10.
Ku B, Lupton E. Health Design Thinking, second edition: Creating Products and Services for Better Health. Expanded edition. Cambridge: The MIT Press; 2022. 228 p.
Link BG, Phelan J. Social Conditions As Fundamental Causes of Disease. Journal of Health and Social Behavior. 1995;80–94.
Nguyen LT, Kaptchuk TJ, Davis RB, Nguyen G, Pham V, Tringale SM, et al. The Use of Traditional Vietnamese Medicine Among Vietnamese Immigrants Attending an Urban Community Health Center in the United States. J Altern Complement Med. 2016 Feb;22(2):145–53.
Nowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis: Striving to Meet the Trustworthiness Criteria. International Journal of Qualitative Methods. 2017 Dec 1;16(1):1609406917733847.
Okonkwo NE, Aguwa UT, Jang M, Barré IA, Page KR, Sullivan PS, et al. COVID-19 and the US response: accelerating health inequities. BMJ Evid Based Med. 2020 Jun 1;bmjebm-2020-111426.
Payne SR, Mackrill J, Cain R, Strelitz J, Gate L. Developing interior design briefs for health-care and well-being centres through public participation. Architectural Engineering and Design Management. 2015 Jul 4;11(4):264–79.
Shultz J, Jha R. Using Virtual Reality (VR) Mock-Ups for Evidence-Based Healthcare Facility Design Decisions. Int J Environ Res Public Health. 2021 Oct 26;18(21):11250.
WHO Regional Office for the Eastern Mediterranean. Health promotion and disease prevention through population-based interventions, including action to address social determinants and health inequity [Internet]. World Health Organization - Regional Office for the Eastern Mediterranean. 2017 [cited 2022 Jul 7]. Available from: http://www.emro.who.int/about-who/public-health-functions/health-promotion-disease-prevention.html
Woodall C. How many refugees are in Pa. and where are they? [Internet]. Penn Live. 2015 [cited 2022 Jul 7]. Available from: https://www.pennlive.com/news/2015/12/how_many_refugees_are_in_pa_an.html
Zhang D. Courtyard Housing in China: Chinese Quest for Harmony. Journal of Contemporary Urban Affairs. 2017 Dec 1;1(2):38–56.
d.school Starter Kit [Internet]. Stanford d.school. [cited 2022 Jul 7]. Available from: https://dschool.stanford.edu/resources/dschool-starter-kit
Health Access Program [Internet]. Nationalities Service Center. 2015 [cited 2022 Jul 7]. Available from: https://nscphila.org/health-access-program
Regional Community Health Needs Assessment 2022 | Department of Public Health [Internet]. City of Philadelphia. 2022 [cited 2022 Jul 7]. Available from: https://www.phila.gov/documents/regional-community-health-needs-assessment/

The Supplementary Material is not available with this version

Download PDF

Journal Publication

published 09 Nov, 2023

Read the published version in BMC Health Services Research →

Editorial decision: Major revision
12 Apr, 2023
Reviewers agreed at journal
01 Feb, 2023
Reviewers invited by journal
11 Jan, 2023
Editor invited by journal
25 Nov, 2022
Editor assigned by journal
28 Sep, 2022
First submitted to journal
28 Sep, 2022

You are reading this latest preprint version

Designing for trust: user-friendly refugee wellness center planning process and concept, a health design case study

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background: The Design Challenge

Methods: The Design Process

Stakeholder engagement focus groups

Design sprint

Results

Access

Resources

Discussion

Creative solutions to challenges

Strengths, limitations, and future directions

Conclusions

Abbreviations

Declarations

References

Supplementary Material

Status:

Journal Publication

Version 1