Claudia de Souza Libanio
Design & Covid-19
Blaise Nguendo Yongsi
Editor of the Global Health Little Book Series:
Dr Emmanuel Tsekleves
ImaginationLancaster, Lancaster University
© ImaginationLancaster 2021
All rights reserved
(Editors) Emmanuel Tsekleves, Fatima Ghani, Charles Ebikeme, Claudia
de Souza Libanio, Yonette Thomas, Blaise Nguendo Yongsi, Leigh-Ann
Hepburn, Pablo Hermansen.
1 Design Research Society Special Interest Group on Global Health
Design & Covid-19
This book is an outcome of the collective efforts of the Design Research
Society (DRS) Special Interest Group (SIG) in Global Health1. We thank
the DRS as well as all the members of our SIG and all the contributing
authors to this volume.
What this little book tells you
What does the Global Health SIG stand for?
DRS2020 Conversation: the role of Design in tackling Covid-19
Covid-19 Global Health Design Research Case Studies
1) Global: The good, bad & ugly of Covid-19 communication
2) Africa: Communication Strategies for Combatting Covid-19
3) Canada: Visual communication guidelines
4) Brazil: Public Healthcare access for older people
5) USA: Design thinking and emancipatory public health
6) Mexico: Space adaptation fo social interaction
7) USA: Visualising college students lives during the Pandemic
8) China & USA: Sex, social distancing and the pandemic
What this little book tells you
This Little Book tells you about how the design research community is
tackling Covid-19 across different parts of the world. It explores how and
why design is uniquely positioned to contribute to the global pandemic
relief effort. The rst volume in this series, the Little Look presents the
Global Health Special Interest Group and what it stands for. It then
presents, through eight case studies, different ways in which design
research is addressing some of the challenges posed by Covid-19 to our
individual lifestyles and society.
What does the
SIG stand for?
The term Internet of Things (IoT) can be traced back to a presentation is
Health is a fundamental human right and a key indicator of sustainable
development. Poor health threatens the rights of children to education, limits
economic opportunities for men and women and increases poverty within
communities and countries around the world.
The role of designers in indirectly supporting the promotion of healthy life-
styles or in their contribution to illbeing has emerged. This means designers
now need to consider, both morally and ethically, how they can ensure
that they ‘do no harm’ and that they might deliberately decide to promote
healthy lifestyles and therefore prevent ill health.
Design’s ability to engage real people and communities, understand every-
day problems and implement the ‘right’ solution, not just the ‘newest tech-
nology’, enables it to act as a bridge between other disciplines. Despite this,
research into the role of design in tackling the Sustainable Development
Goals is disparate and detached. As such, there is a need to understand the
role of design and promote a more cohesive strategy to tackle the Sustain-
able Development Goals.
To address this, the Global health SIG was created. Its focus relates to the
UN’s Sustainable Development Goal 3 “ensure healthy lives and promote
well-being for all at all ages”. The new goal for worldwide Good Health
promotes healthy lifestyles, preventive measures and modern, efcient
healthcare for everyone.
To reect the global health ethos this SIG, ensures that DRS members are
recruited and play a key role in the SIG, from across all continents.
Furthermore, emphasis is placed on the development of international events
with a focus on the Global South, where several global health challenges
and opportunities exist.
In the Global Health SIG we aim to:
1. further develop the research area of design for health at a global scale.
2. engage health and design researchers from the Global South in design
3. develop and foster more research collaborations in design for health
between DRS members and other researchers in the Global North and
We will recognise when we are successful when:
• There is recognition of design research by a number of researchers in
international health committees and reported case studies in The Little
Book of Global Health Design.
• There is greater participation and an increase in the number of paper
submissions at DRS and other relevant events from the Global South.
• There are new research collaborations, research proposals, networks
and events involving DRS members in this eld.
One year, since the running of the SIG, we have run a number of activi-
ties. Key highlights include: a Conversation session at the DRS2020 online
conference on ‘Global Health in light of COVID-19: Reframing the Role
of Design’; publication of a chapter in the Handbook of Global health on
‘Urbanisation & Cities as Drivers of Global Health’; development of Global
Repository of Ofcial COVID-19 Public Health Messages and Information;
a series of capacity building webinars, in collaboration with UNU-IIGH, on
Translation of health research to Policy focusing on early career research-
ers; and a web blog on ‘Improving health communication to counter-misin-
formation during the COVID-19 pandemic‘.
The DRS Global Health SIG Committee Members: Emmanuel Tsekleves, Fa-
tima Ghani, Charles Ebikeme, Claudia de Souza Libanio, Yonette Thomas,
Blaise Nguendo Yongsi, Leigh-Ann Hepburn, Pablo Hermansen.
Global Health in light of COVID-19: Reframing the Role of Design – Notes
from Conversation Session in DRS2020 Conference.
By Emmanuel Tsekleves, Claudia de Souza Libanio, Mariana
Fonseca Braga, Badziili Nthubu, Jena Mitkus, Leigh-Ann Hep-
burn, Fatima Ghani.
The COVID-19 pandemic presents an unprecedented challenge, threaten-
ing the lives and livelihoods of millions of people around the world. While
the epicentre of the pandemic was around Europe and the US, a growing
number of cases are reported in Africa, Central, South America and Asia
with potentially serious social, economic and political consequences for
these regions. Some of the poorest societies in the world will be the least
prepared and most vulnerable to the effects of the virus. Working with
other sectors, design research can potentially address and mitigate the
health, social, economic, cultural and environmental impacts of the COV-
ID-19 outbreak in Low- and Middle-Income Countries (LMICs).
Research evidence has demonstrated the propensity of design to contrib-
ute signicantly in health and wellbeing (Ulrich et al., 2008; Tsekleves &
Cooper, 2017). However, the majority of the research tools and methods
are framed for use within a developed country context, with only limited
work starting to emerge in LMIC context (Daudt et al. 2019; Tsekleves et
So, in order to encourage discussion on the topic, an online conversation
session at DRS2020 Online Conference took place on the 14th of August
2020. The overarching question is: Which frameworks, methods and tools
can be used from a systems and design approach to provide evidence for
the social determinants of health in Low Middle Income Countries?
Within this context, the Conversation session explored the following:
1. How can design research help address and mitigate the health, social,
economic impacts of the COVID-19 outbreak in Low- and Middle-In-
come Countries? Which design research methods and tools might be
useful in that context?
2. Which sectors do design researchers need to work with to address?
Which gaps/challenges are they likely to face in working with these
The research community, along with the design community are called
upon to address and mitigate the health, social, economic impacts of the
COVID-19 outbreak across the world and in particular in Low/Middle-In-
come Countries. Design’s ability to engage real people and communities,
understand everyday problems and implement the appropriate solution to
a dened context integrating people’s voices, experience, potential, cre-
ativity and needs into problem solving, sensemaking and decision making
processes, not just the ‘newest technology’, enables it to act as a bridge
between disciplines. It is an important and growing voice in this eld that
helps to bridge the gap between the rapid advancements in science, tech-
nology and engineering with people and contexts on an everyday level.
Thus, design can take a leading role in research that addresses and miti-
gates the health, social, economic impacts of the COVID-19.
Question 1: How can design research help address and mitigate the
health, social, economic impacts of the COVID-19 outbreak in Low/Mid-
Prior to responding to this question, it was discussed that one should rec-
ognise that Low/Middle-Income Countries (LMICs) have very different
contexts, cultures, policies and social practices. Within that context there
are chronic and systemic challenges related to access to education and
the healthcare system. People do not generally trust in government and
Tackling self-isolation in these contexts is very challenging. Sometimes, it
is impossible to do this, due to the accommodation arrangements, public
transport infrastructure, communication barriers, nancial difculties that
force people to work in person, but also people’s scepticism in following
central government-led initiatives. This provides opportunities for design
researchers. Opportunities to work with environmental design to recreate
cities, taking into account where people are, where they live, their com-
mute patterns, etc. Also, design research can work on developing new
ways of communicating and interacting with other people and systems.
Furthermore, it creates opportunities to explore methods and tools, such
as participatory methods that can help develop more bottom up and
inclusive policy-making by (1) creating enabling infrastructures to build
dialogues between citizens, public ofcials, civil servants and other stake-
holders, (2) enabling reection upon realities, and (3) collaborative ac-
tion upon community needs, bringing their voices into public problem
solving and planning. This is a shift of the designer role from designing for
people to designing with people. This means that designers act as facilita-
tors in these participatory or co-design processes, creating conditions or
‘protected spaces’ for non-experts to deploy their potential and creativity.
The pandemic has created challenges and opportunities regarding the use
of visual communication to design messages and accompanied visuals,
that are culturally, gender and context appropriate in promoting Cov-
id-19 prevention. This is a time critical factor, as information is updated
constantly with misinformation and inappropriate message and visual
communication design confusing the public.
As the Internet becomes even more necessary for everyday activities such
as studying and working during the Covid-19 pandemic, many people
are still excluded from the opportunity to work remotely and to access
education. This is due to the lack of access to technology resources and
sometimes because of the types of jobs that are often available to disad-
vantaged community members (e.g. informal work, low-income activities
such as cleaning, construction work that requires commuting/’being pres-
ent’ etc). Therefore, there is the need to contribute to the eradication of
the technological divide that exacerbates inequalities in LMICs and at the
same time promote policies that enable people to access health, educa-
tion and other diverse citizen services.
In doing so, design researchers and practitioners need to contribute to (1)
ways to eradicate technological divides by understanding these barriers
with communities and informing public policymaking, and (2) to promote
accessible communication targeting Covid-19. Thus how we operate on
communication in an accessible way becomes a key question that the de-
sign research community can address. As is the question on how design
(co-design and participatory design) might help people in LMICs make
better use of their potential and nd potential in their creative languag-
es. Designers could provide a structure to support people to dialogue,
instead of bottom-up or top-down approaches. Therefore, having a struc-
ture to support dialogue may lead to meaningful communication, even in
areas where there is low technology or digital literacy.
The pandemic demonstrated how important it is for everyone to partici-
pate in the prevention of the spread of the virus. However, in most LMICs,
the governments and health professionals mostly worked in isolation to
design and disseminate information on Covid-19 pandemic. Designers
may bridge these disconnections by developing structures to help people
(to empower them) to engage in dialogic processes.
Health is an area where everyone has a contribution to make and this is
the same case for the Covid-19 pandemic. There is disconnection among
many agents and actors working on Covid-19 prevention. Design re-
searchers need to work, engage and integrate all sectors, especially en-
hancing and promoting networks with the private sector. Working better
across and within disciplines is essential too, as schools of architecture,
design and planning can collaborate on some of the challenges posed
by Covid-19. Designers can support multi-stakeholder collaboration and
foster co-creativity by taking on the role as a participant-facilitator in the
design process. Involving key stakeholders and experts from all relevant
sectors and foundational subject areas could bring new perspectives and
narratives to the design process (Venditti et al., 2017), stimulating and
altering the way interventions are imagined, and subsequently designed.
Engaging communities, as one of the main actors, is critical. However,
communities are not, for most of the time, prepared to work with creative
tools, processes and creativity in general. Therefore, demystifying the cre-
ative design process for communities, facilitating them to become more
creative in tackling their own challenges becomes a challenge and an
opportunity for design researchers. Design research is challenged to em-
power people to deploy their potential to create and consume information
that is accessible to communities, underpinning the translation of scientic
knowledge and public health messaging into lay language and practice,
bringing communities and stakeholders together. Governments and health
professionals alone have not succeeded in communicating and to propos-
ing feasible measures particularly for disadvantaged communities. This
demonstrates that success in tackling COVID-19 canNOT be achieved by
the government or health professionals alone. Also the challenge here
is context; how design research may facilitate context-specic creativity.
Question 2: Which sectors do design researchers need to work with to
address and what are the gaps/challenges are they likely to face in work-
ing with these sectors?
It was widely agreed in the discussion that an intersectoral approach to
addressing global health is needed. In doing so, design researchers need
to work with all sectors not just one. How one identies who the key stake-
holders are and how to bring them together were seen as being context
specic and therefore something that cannot be dened from the outset.
The need to engage more with policy makers, recognising a current decit
in engaging effectively was also highlighted. Making it easier for them to
engage with researchers was seen as key for this. Translating the ndings
in a language and format that is more easily understood by policy makers
was also highlighted. Storytelling was proposed as a useful tool for that
purpose. Storytelling is the natural language of persuasion, since any sto-
ry has to involve both a sequence of events and the interpretation of their
meaning. Arts and Humanities researchers are generally very good story-
tellers, but do not often have the numbers to show. For policy and strategy,
you need to have both. Thus, the coupling of design with evidence-based
research provides opportunities for developing evidenced insights that
make convincing arguments around our need to act.
Several approaches were also offered in successfully engaging with com-
munities. Identifying the key actors and or gatekeepers that control ac-
cess to communities is paramount. For example, in Botswana and other
African countries like Kenya, Lesotho, South Africa, most villages have a
local government system (Kgotla system) or Durbar in Ghana and other
West African countries, where the chief is the central actor or gatekeeper
controlling the community in terms of policy formulations and decision
making, i.e. political, economic and the judiciary. The Kgotla is a space for
dialogue where the community debate in a parliamentary way to reach
consensus democratically (Ngwenya & Kgathi, 2011). Therefore, the kgot-
la role may be essential in organising community engagement activities
around health issues. Other roles connected to the kgotla include village
development committees, councillors and primary schools (leaders) who
are often ignored in the health policy design. Design research is important
to help these key roles to recognise their potential. Designers are chal-
lenged to interconnect key community roles with the central government
and health professionals. This is important because village community
leaders inuence how the community perceives, interprets, and consumes
knowledge related to health and wellness.
The importance of identifying key actors is also illustrated in the case of
Brazilian informal settlements, where active community members, who are
recognised and looked up by communities, have played a noteworthy role
in combating COVID-19. There is a community distrust of politicians that
discredits public messaging and public ofcials’ voices and even leads to
disbelief in the virus. In this context, these community inuencers/gate-
keepers have disseminated preventative measures and developed collab-
orative initiatives involving socially responsible companies, NGOs and
the civil society to tackle the immediate effects of the pandemic (Fonseca
Braga et al., 2020). This reinforces the need for communication that is
trusted by communities and will be embedded in their practices, pointing
out the role of ‘who’ is talking for community trust in public messaging.
How other disciplines perceive design research was discussed extensively,
emphasising the misconception that exists within academia, communities
and policy makers on that. For example, design researchers’ interactions
with African countries’ governments show that most of the time they do not
know how design can help address the problems their societies face. De-
sign researchers need to nd new ways of interacting with government of-
cials and local communities. Understanding the government structure from
central to local authorities is key. Avoiding hierarchies, i.e. top-down or
bottom-up approaches to design, may help create a at dialogic process.
Most people in LMICs perceive ‘design’ as a craft subject, associated with
making furniture and other domestic products. Hence, design research
needs to adapt ‘design’ to t the specic context through local systems,
e.g. the kgotla system or using local activities/gatherings that people are
familiar with rather than overly depending on academic conferences and
seminars. This may help reduce the social and cultural barriers between
researchers, government ofcials and community leaders. This makes it
extremely difcult to engage. There is therefore a need to reposition de-
sign in practice. This presents a challenge and an opportunity.
Although those that have been exposed to design research recognise the
value of the design mindset and the way it operates as key assets in design
research, we should make a better job at promoting this to other disciplines.
This is a design research community issue and responsibility, since most of
the time we ‘talk to ourselves’ and are not always outward facing. Partic-
ipating and engaging in conferences, events, public talks outside of the
design research discipline, as well as involvement in projects that improve
international knowledge and educate the next generation of thinkers via
established international organizations (e.g., Engineers without Borders
competitions, etc.) are good ways forward. Most importantly, promoting
the decolonisation of design knowledge to reinvigorate the contents and
context of learning in LMICs is paramount. This is a signicant challenge
in terms of changing people’s mindset. Design curriculum at secondary
and tertiary schools is isolated from the local context. Designers engaging
LMICs may also focus on how their approaches are inclusive, context-spe-
cic, and embodied in the curriculum. This may include translating design
tools and methods into local languages and using locally relevant social
mechanisms (cultures, norms, and traditions) in design.
Here we present eight case studies from different parts of the world.
Each case study provides an overview of on-going research on tackling
covid-19 and its effects on society and the individual.
Case studies 1-3 provide global, regional and local perspectives on the
application of communication design, visual communication design and
other communication strategies to understand and improve the infodemic
and mis-communication around Covid-19.
Case studies 4-5 present how different public health systems, namely in
Brazil and the USA are coping with the challenges of the pandemic as
well as the opportunities for change through the application of design
Case studies 6-8 explore the issue of social distancing in the student
community and provide tools for social adaptation as well as maintaining
social relations in light of Covid-19 and future pandemics.
Case Study 1:
The good, bad &
ugly of Covid-19
By Emmanuel Tsekleves
In this unprecedented Covid-19 situation, Governments across the globe
and policy makers are looking at each other for solutions inspiration,
trialled policies and interventions they can implement by their own
national and regional authorities. But have failed to establish international
cooperation and knowledge exchange to cope with this. In this context,
local COVID-19 communication plays a key role in informing citizens.
In response to that, the Design Research Society Special Interest Group
on Global Health, has developed an open access repository containing
crowdsourced information on Covid-19 public health messages and
information set by ofcial national and international bodies. The aim
is twofold. First, to develop an ofcial of data on public messages and
information on Covid-19 that researchers, public health authorities
and policy makers can access and forward to communities globally.
Second, to conduct a multinational and multicultural visual and language
communication analysis of Covid-19 public health messages included in it.
Following a two-stage message/language framing and visual design
analysis of crowdsourced ofcial Covid-19 Public Health material from
46 countries, across ve continents, and more in-depth analysis of 32
material from 17 countries, we present a few examples of good, bad and
ugly covid-19 public health communication design.
In terms of message and language framing, the following example, from
the Rwandan Ministry of Health on ‘The Do’s and Don’ts of face mask
guidelines’, demonstrates several good visual design and communication
features. It features a consistent visual style, with an uncluttered layout that
incorporate an easy path for the eye to follow. Important icons are bigger
in terms of size and use contrasting colours to help readers distinguish
clearly what they can and cannot do. In terms of message framing, the
instructions are very practical and culturally appropriate and specic, as
they provide a useful context on when, how to use, how to wash and
procure, as well as common mistakes people make in all these points.
Fi gu re 1.1. Communication material by the Rwandan Ministry of Health on The Do’s
and Don’ts of face mask guidelines.
In the example below, the poster is too busy in terms of visuals, whilst
several of the clipart used are too small to see as is their corresponding
caption. Some of the advice provided, such as ‘Maintain at least 1 metre
distance in marketplaces, medical stores, hospitals, etc’ are unrealistic
given the high-density population of cities in India. Another issue in this
example, is the use of visuals, where the characters featured in them,
do not represent the country’s population demographics, as they feature
only white persons. This is an element which has been observed in several
materials from several countries from the Global South who seem to
have copied and pasted messages as well as visuals from Global North
Figure 1.2. Communication material by the Indian Ministry of Health on not over-
In relation to the example discussed above, the following one from
South Africa does not include do consider ethnic diversity in its visuals,
illustrating a predominantly all white family. Furthermore, there are no
signposts on where or how to get more information and the text in the
centre in white appears blurry due to incorrect application of antialiasing.
Lastly, the message it provides appears to be distant ‘WHO advise people
to...’ as it does not directly address the population and does not call for
Figure 1.3. Communication material by the South African Department of Health on
C ov i d -19.
By Charles Ebikeme
Disease X was the knowledge that a serious international epidemic could
be caused by a hypothetical unknown pathogen. We knew it would most
likely emerge from an animal to human spill over zoonosis. We knew it
had the potential to spread to all corners of the globe. Disease X was
the name attributed to it by the World Health Organisation (WHO)
in February 2018. Ultimately, Disease X turned out to be COVID-19.
The past decades should have been a dress rehearsal in pandemic
preparedness. Starting with the severe acute respiratory syndrome
(SARS) coronavirus in 2003, H1N1 “swine” inuenza in 2009,
middle east respiratory syndrome (MERS) in 2012, chikungunya
in 2014 and Zika in 2015, as well as Ebola from 2014 to this day.
Case Study 2:
Covid19 in the
The question remains, why were we not better prepared, both at a techni-
cal level, and at a social level. In retrospect, it is unsurprising that a virus
that preyed on our social dynamics would prove difcult to eliminate. In
order to stop transmission, this virus would require the individual to think
about the community, young to think of old, and the vulnerable to depend
on the privileged. To eliminate this virus, it would require behavioural
change on a scale that has so far eluded us. It would require leadership
from national governments, strong policies, and proactive and rapid pub-
lic health communications.
All countries utilize health communications in some capacity – such as
for outbreak response – and these have traditionally been shown to be
an effective way of driving health impact. Public attitudes towards policy
decisions rest, in some part, on how those decisions are communicated to
Many governments traditionally implement a variety of innovations in
communications to increase effectiveness. At times, these communications
may also show they consistently miss a subset of populations (most often
the most vulnerable) resulting in reduced equity of the health intervention.
Public Health communication & previous outbreaks legacy
Public health emergencies involving deadly infectious diseases, such
as the one seen during the West Africa Ebola epidemic, traditionally
involve a complex intersection of behavioural and emotional responses
of the community. These shape, inuence, and contribute signicantly to
disease perception, downstream effectiveness of preventative and control
strategies, and ultimately can determine the course of the epidemic.
For example, In Guinea in 2014, Ebola response teams were prevented
from accessing populations in need due to mistrust, fear and suspicion of
authorities. Alongside this, there was common mistrust and rejection of
western biomedical medicine.
The outbreak in Guinea, Liberia, and Sierra Leone was the largest
epidemic of Ebola ever recorded to date. One of the legacies of the Ebola
epidemic is the further recognition that focused communication strategies
can be effective in changing attitudes and behaviours during an outbreak.
Such insights have been seen with other infectious disease epidemics such
as HIV/AIDS. To combat the Ebola epidemic, communication and subse-
quent messages were entrenched in the consideration of local knowledge
and culture. With recognition from both national and international actors
that communicating with populations needs to be customised and con-
textualised to the unique situation. Moreover, there was also recognition
that communities need to be included in the solutions and messages being
communicated. Epidemic response teams will benet from the perspective
of the recipients of their health messages.
After the SARS outbreak, Taiwan’s Centers for Disease Control (Taiwan
CDC) followed the WHO outbreak communication guidelines on trust,
early announcements, transparency, informing the public, and planning,
in order to reform its risk communication systems. The same risk communi-
cation framework in Taiwan has been used to respond to the 2009-2016
inuenza epidemics, Ebola in West Africa (2014-16), and MERS-CoV in
South Korea (2015) in the years post-SARS. Many communication strate-
gies, ranging from traditional media to social and new media, have been
implemented to improve transparency in public communication and pro-
mote civic engagement.
Public Health communication in the time of Covid-19
When the World Health Organisation declared Sars-Cov-2, the novel
coronavirus, a Public Health Emergency of International Concern (PHEIC)
on the 31 Januar y, Dr Tedros, the Director General of the WHO, urged
collaboration and cooperation among countries. In the months since
then, what we have experienced was far from that - exposing the aws in
national science policy systems.
We are living through a collective realisation of how understanding
science has tangible, practical, and immediate applications for our daily
lives. Not simply the understanding of that science, but its implementation
in managing the risk associated with the disease. The ongoing loss of life
globally, articulated differently within individual nations and institutions,
as well as the virus’s ability to spread rapidly through communities due to
asymptomatic carriers, has generated a need for political response and
action through clear, detailed messaging to global constituencies. Analysis
of a selection of African countries provides insights into the nature of pub-
lic health communication in the early months of the COVID-19 pandemic.
From the rst weeks that Sars- Cov-2 was identied, governments had
already begun to communicate on the novel virus and made information
available to the public. In Senegal, the rst public information on
COVID-19 emerged from the Ministry of Health on 22 January (8 days
before PHEIC). Rwanda’s rst press conference on COVID-19 was
held on 23 January (7 days before PHEIC). Countries continued early
communication with sustained messaging through a variety of different
channels. Alongside posters, yers, video and audio spots, Ministries of
Health organised regular press briengs and statements. Governments
also launched public health campaigns early on. Nigeria launched a
public health campaign on March 9 (after registering just 2 cases). Kenya
launched a public health campaign on March 1 in the absence of cases
and deaths. Countries provided dedicated online COVID-19 portals with
case and mortality information at a regional level.
Newly emerging contagious diseases have created a novel chance
to examine how people perceive risk and respond to public health
messaging during an epidemic. As was seen with Ebola, public risk
perception of disease depends on effective government communication
and health messaging. Such messaging also needs to be adaptive and
evolve alongside public reaction and disease progression. For example, in
the early phase of an outbreak, people may experience challenges when
attempting to quantif y the risk, which may lead to an affective reaction.
Researchers have noted that the failure of risk communication about MERS
at the time resulted in a signicant social and economic disturbance.
Increasingly, online communications and social media have become an
important source of health information for users worldwide. In 2020, at the
heigh t of the pandem ic, the WHO be came the UN org anisatio n with the mos t
followers on Instagram. African governments communication messages on
social media employed use of local inuencers and celebrities to transmit
messages on public health prevention and promoting health seeking
behaviours. More than in any previous infectious disease outbreaks, a
digital pandemic was also raging alongside the real pandemic. As the
novel coronavirus caused an increase in search for information with broad
dissemination of false or misleading health information. Social media was
a tool to respond directly to false rumours as well as investigate rumours
on outbreaks in different locations. In the age of social media, information
travels wide and fast, emphasizing a need for accurate data to be
corroborated swiftly and for preventing misleading information from wide
dissemination. Many governments took a proactive stance and spoke
directly to false information. There are wider implications for this ood of
information, termed “infodemic” and the WHO have formalised this pillar
as a strand of ongoing research that needs to be fostered in the wake
of COVID-19. Several practical ways to leverage health communication
strategies to overcome it have already been proposed, from collaborating
with tech companies to having infodemic managers in health ministries
There is a tendency to think of communication only as determining
“what” to say. However, effective communication is a complex process
that requires not only consideration of content, but also consideration
of how, to whom, at what point, and through which channel to deliver
the messaging. Risk communication also considers the nature of risk, the
audience’s characteristics and their risk perceptions, and the complex
media and social environment. Often, communication experts are
involved with health and medical professionals from the very beginning of
the response to a public health crisis.
Over the years and over progressive outbreaks and epidemics, government
public health messaging has evolved to be fully cognisant of the fact that
how they communicate is just as important as what they communicate.
Figure 2.1. Infodemic. Source: WHO/Sam Bradd
Communication design for vulnerable populations during COVID.
By Gillian Harvey
The COVID-19 pandemic has collided with an increased need to provide
clear, concise communication material to diverse audiences. In particular,
this public health emergency has exacerbated the need for messages to
be translated to vulnerable audiences and the public.
This case study discusses one way in which the design of communication
material can help vulnerable populations navigate the uncertainty of
COVID-19. Now more than ever, designers are being called on to provide
information for vulnerable populations where many have limited health
literacy skills (difculty accessing, understanding, and acting on health in-
formation), limited English prociency or physical or cognitive conditions
that impede access to information” (Neuhauser et al., 2009).
In the province of Alberta, a western province within Canada with a pop-
ulation of 4 million people, there were 301 accidental opioid deaths be-
tween April 2020 to June 2020. This was a 97 per cent increase in the 153
deaths over the same period last year. The COVID-19 pandemic has collid-
ed with Canada’s ongoing overdose emergency to exacerbate harms for
people who use opioids. In addition, many high risk populations have little
access to information on how to live safely during a pandemic.
Case Study 3:
Canada - Visual
A small scale public information campaign was designed and distributed
at high risk sites such as Supervised Drug Injection Sites and Community
Centres for high risk adults and youth and for Essential workers that treat
Recent articles in the Guardian have acknowledged how much public
health can be inuenced by the effectiveness of its communication (Sodha,
2020). Historical examples of this include public education campaigns
that were designed by Isotype in the 1920s to educate lay people about
leprosy, and other examples of bold graphics used to raise awareness of
public health issues in the 1980s.
The goal of this case study was to support the development of effective
public health messaging that would lead to informed decision-making.
By quantitative and qualitative evaluation of COVID -19-related visual
communication from around the globe, we assessed: (1) the visual
presentation of information in order to support the underlying message(s)
for harm reduction in high-risk populations; (2) how visual infrastructures
impacts core socio-cognitive factors like self-efcacy involved in
preventative measures. The analysis and design of these materials were
completed over a two-week period.
We used an evidence-based and outcomes-oriented approach based
on evidence available in readability literature available from several
information design sources. Because we were not able to include users in
the design of these instructions, we studied how the visual presentation of
information should be formatted in order to support high risk populations
with low literacy levels. In general, our analysis focused on categorizing
the information within current evidence-based practice literature.
1. Visual infrastructure: This principle applies to the aspect of
presenting the information in such a way that it would support,
and not complicate cognitive load in an emergency. This includes
designing the information in “chunks”. The chunks of a document must
be “segmented into cognitively affordable chunks, clearly labelled
by subtitles and supported by layout” (Noël et al., 2019). Chunking
information allows the information to be digested slowly. This principle
also includes consideration of a type size and style to aid legibility,
and a legible typeface to ensure reading accuracy.
2. Writing: This principle applies to the organization of the text,
sentence structure, plain language and word order; active vs passive
voice including the consideration of cognitive load principles which
state that no more than 7 units of information, plus or minus 2, lists
to highlight and summarize information rather than continuous prose
are effective in memory and retention.
3. Visuals: This principle applies to the syntax, the reference of spatial,
semantic and real-world knowledge, using representational rather
than abstract images recognition and semantic unity in the imagery.
Images should not be contained within boxes as they are interpreted
as stories in themselves, 3D drawings should be favoured over icons,
and that images should be different from each other so as not to be
4. Health Communication: This principle is that information for a
high risk audience often requires understanding that communication
barriers are great and will result in limited health literacy skills such as
difculty accessing, understanding, and acting on health information.
These categories of evidence-based design principles are evident in
an analysis of current COVID-19 communication materials created in
the last 9 months. Despite many evidence based principles, there is no
visual or theoretical framework for understanding visual infrastructure
for emergency instructions for public health messages. This work has
highlighted the importance of creating a framework for evaluating the
role of public health messages within human centred design, emergency
medicine, public health as well as visual analysis.
Based on this analysis, stakeholders, advisors in harm reduction team and
researchers redesigned a set of materials that included these evidence-
based principles. These materials included an information materials on
how to prepare for the spread of COVID-19. Information materials include
Preparing for Covid, How to Use more Safely During Covid and How to
Clean and Disinfect During Covid. These prototypes were designed to
be printed and distributed as necessary to Community based programs,
Opioid Dependency Programs and Supervised Consumption Services.
There are several challenges to the development and mobilization of
communication materials this quickly, as a response to an emergency. First,
the evaluation and development of public documents, however, needs
to consider literature and a framework from public health, emergency
medicine, and human centred design, in addition to just visual analysis.
Second, working with users in development of materials for COVID-19
prevention would be a more robust way to approach the ideation and
development process. Co-design methods of working have proven to be
the most effective way in the development of communication materials for
Third, the challenge that lies is not in the development but in the evaluation,
monitoring and testing of these documents. The next steps for this work are
to gather feedback from high risk or vulnerable populations. We have
developed a paper survey that will be used to gather the effectiveness
and efcacy of these materials. Testing these new guidelines with a high
risk population is one way to maintain the long term effectiveness of
this communication in an emergency situation and will lead to long term
communication standards and guidelines. Just as we have seen in literature
about tsunami and re evacuation procedures as well as in symbol design,
continuing to assess the effectiveness of these materials will allow us to
develop sets of procedures for emergency response across a variety of
medium, languages and cultures.
Acknowledgements: Thank you to the Harm Reduction Team at Alberta Health
Services, in particular Sara Gill, Nurse Educator and Amy Woroniuk, Director of
Harm Reduction for the opportunity to guide this work.
Accessibility of the Public Healthcare Services to the Brazilian Elderly
Population During the COVID -19 Pandemic.
By Cláudia de Souza Libânio, Emilene Zitkus, André Pimenta
The Brazilian Public Healthcare System (SUS) was designed to cover
primary and clinical care in all regions of the country. Although the history
of SUS is recent, being institutionalised in 1990, it serves around 162
million people of 209 million Brazilians. Among the challenges faced by
SUS is to accommodate the needs of an ageing society. In Brazil the older
adult population has doubled in the last 40 years, and life expectancy
has increased 40% during the same period (Paim et al., 2011). Most of the
elderly population (75% - 23,5 million) relies on the services provided by
SUS only. This shift has signicantly affected healthcare service in Brazil.
Since the establishment of SUS, a lot has been discussed by users,
researchers, and healthcare professionals in order to improve the
accessibility of the services provided to accommodate the diversity of
Case Study 4:
Brazil - Public
Accessibility of the elderly population to the Brazilian health system poses
a great challenge (Travassos & Viacasa, 2007). Difculty in accessing
quality public health services are related to the geographical distribution
of health services in Brazil, as the current distribution does not meet the
needs of the Brazilian population (Rocha et al. 2017). Other factors related
to social discrimination also contribute to lack of access, such as: gender,
race, educational level, social class and income level of the population.
Digital Accessibility in Brazil During COVID-19
The COVID-19 pandemic led to the digitization of the public health ser vice
in user care. In March 2020, the Federal Council of Medicine released
online consultations (CFM - CFM Resolution No. 1,643/2002) covering
teleorientation, teleconsultation and telemonitoring. Digital accessibility
has become a key need, especially considering how it could benet risk
groups. Thus, teleconsultation can be an instrument for the diffusion of
SUS services, as well as private health services, meeting citizens needs,
without exposing them to the risk of contagion.
Recent research has also revealed an increased demand of digital health
services by elderly people (Sun et al., 2020). In this way, studies can be
developed to generate design strategies that aim to promote quality of
life and wellbeing for elderly people in the Brazilian Public Health System.
Through design strategies, they can study how to promote quality of life
and wellbeing in the Brazilian health system through products, services,
environments, processes and information that take into account diversity
and that include all people, without restrictions. In addition, studies can
be aligned with Goal 3 and Goal 16 of the United Nations Goals that deal
with ensuring healthy lives, promoting wellbeing for all and promoting
It is important that the design of digital healthcare services is appropriate
and accessible to the elderly population, allowing them to take advantage
of these resources. Thus, exploring design strategies (system design;
user-centred design, inclusive design and user experience research) can
improve user experience, enhance community impact in terms of changing
mind-sets and promote quality of life and wellbeing for elderly people in
the Brazilian Public health system. A case study on the accessibility of
some of the SUS services design has shown several areas where design
could improve the elderly patients’ experience (Zitkus and Libânio, 2019).
Another study explored design opportunities and developed design
guidelines in a specic SUS service context (Daudt, et al, 2019).
Designing Accessible Services for Elderly Users
There are several considerations that should be taken into acount to make
SUS digital services more accessible, some are infrastructural, and others
are related to how the service is designed. For example, according to
surveys conducted by IBGE (PNAD 2018), although in Brazil about 79%
of households have an internet connection, there is a great disparity
between urban areas (83.8%) and rural areas (49.2%). Also, the internet
availability varies signicantly among the ve regions of the country. For
example, the unavailability of the internet service in the Northern region
is the main reason for the its lack of use, despite the region having the
highest mortality rates due to COVID-19 in Brazil.
The IBGE survey also shows that, in 2018, only 38.7% of people aged 60
years or older used the internet in the three months prior to the survey.
The proportion of elderly people using the internet also varies widely
from region to region, with the lowest in the country being 27.8% of the
elderly population in the North, and the highest 46.9% of the elderly in
the Southeast (PNAD 2018). Therefore, considering that one of the risk
groups in this pandemic are the elderly and they would be the ones who
would benet the most from the teleconsultation, they are also the ones
who are mostly affected by digital exclusion.
When comparing the Brazilian context to the other countries’ examples,
we can see that there is still a long way to go, which can be a result of the
challenges SUS has been facing (Daudt, et al. 2019). Therefore, in order
to maximize the adoption of technology in healthcare for the inclusion
of the Brazilian population, several factors related to current and the
potential exclusion of a digital system need to be investigated, including
digital illiteracy, low level of education and lack of interest. Identifying
and understanding the problems surrounding digital exclusion in Brazil
and planning design strategies for containing and eradicating exclusion
are extremely important, which became evident in the current pandemic
with the possibility of teleconsultation.
Case Study 5:
USA - Design
Creating patient-centred and equitable health research through design-
based research methodsc.
By Lesley-Ann Noel
Who determines research priorities in public health? What if ordinary
citizens could dictate what gets researched in the eld of public health.
In this study, researchers at Tulane University sought to use design
thinking and qualitative research methods to understand the experience
of the COVID -19 pandemic of residents of New Orleans. These methods
would help these resi-dents create research priorities to guide public
health organizations. The aim of the ongoing re-search project is to
develop research methods and tools that could be used by public health
practitioners to create patient-centred research by using human-centred
design methods. During this initial phase of the study, the researchers
aimed to create the tools, test them with different participants groups and
then create clear guidelines on how to use and adapt these methods to
understand patient priorities. The general theme that was used to ‘test’ the
methods was ‘how had patient/public behaviour has changed due to the
COVID-19 pandemic?’. Ultimately it is expected that the methods could
be used to understand public health issues in more general contexts. The
research was undertaken remotely due to social distancing requirements
during the COVID-19 pandemic, thus creating an additional constraint to
using the methods.
When using design thinking, people are borrowing both the design
process and the ways of thinking of designers to solve problems. The
project began with an interest in using methods that would help public
health practitioners to empathize with patients or members of the public,
even during short workshops. Several design and qualitative research
methods were selected for this project such as:
• Photo elicitation
• Cultural Probes
• Critical Utopian Action Research
• Narrative and Storytelling.
While all of the methods were not explicitly design methods, as a design-
focused team, they were used through a design lens, using remote
platforms that designers use and through a design understanding. A
mixed team of professors and graduate assistants from design and public
health backgrounds adapted the methods to see how they could be used
in a public health context to understand the experience of the pandemic,
in particular in a remote context. A series of ve public workshops was
created to explain and test the methods with interested participants who
generally already had some familiarity with design, design thinking and
research. Some of the methods were further tested with a small group of
residents in New Orleans who did not have a background in design, design
thinking or public health. The public workshops were led by graduate
assistants from the School of Public Health, while the private workshops
were led by a professor in design thinking. The workshops were held
remotely via Zoom meetings and the online whiteboard platform Mural
was used to support the discussion.
In the rst workshop, participants were invited to share a photograph
demonstrating how their residences or surroundings had changed during
the pandemic to protect their health. The photographs ranged from
predictable such as packs of PPE, and signs reminding people to wear
masks, to more unexpected self-care items, newly acquired pets and
plants and nally items that suggested a concern about health such as
roller skates and tennis shoes. The photographs were then used to spark
conversations about the pandemic. After which participants identied the
themes that were discussed.
Figure 5.1. A participant shared a photograph of her new roller skates as an
example of health-related changes she had made in her behaviour during
the pandemic. Other participants analysed what they thought this image
meant during a discussion.
The second workshop focused on using poetry to share the emotions of the
pandemic. Participants were introduced to techniques to write and analyse
poetry. The poetry that they wrote revealed their anxiety, frustrations and
exhaustion, despite their cheerful responses at the start of the workshop,
when they were asked how they were doing.
In the Introduction to Cultural Probes workshop, participants were
introduced to the journaling and analysing the reections for themes,
as well as a more quantitative method of responding to questions using
Figure 5.2 Some of the themes that were revealed in an exercise to elicit a
one-word response to the reading of a poem and the viewing of an image.
Critical Utopian Action Research
In this workshop, participants were introduced to Critical Utopian Action
research, a future focused method in which participants reect on what is
wrong, imagine where they want to go, and then design a way to get there.
In the rst activity, after a discussion about the pandemic, participants
‘time-travelled’ to the year 2050, and reected on the wonderful
healthcare that exists in the future. They sent messages to people back in
2020, telling them what they could look forward to. Their reections on
the future helped uncover that the lack of equity in the healthcare system
was deemed the main challenge among participants. They referred to
a future where they would not worry about the cost of insurance or the
cost of care. They would not have to choose between their jobs and their
health. All doctors would accept all health plans, and these plans would
probably not even be necessary, since there might be universal health
care. They then designed ways in which they could reach the future they
desired in 2050, making recommendations such as equity education for
medical staff, actuaries and underwriters.
Narrative and Storytelling
In the nal workshop of the series, participants learnt several techniques
about using storytelling to map their experience of the pandemic. In one
of the activities, they used the Narrative Arc, a literary device used to
teach writers how to compose a story, to create their own story about a
high or low point of the pandemic.
Figure 5.3 The participants used the Narrative arc to tell their stories about
Conclusions and recommendations for implementation
The public workshops were attended by people with a specic interest in
design or research. These participants had good access to reliable internet
via their computers or phones. They participated actively and use of the
various methods sparked deep discussions about the experience of the
pandemic, uncovering themes like anxiety, depression, a sense of loss, but
also positive themes like gratitude, growth and hope. The conversations
uncovered the impact of increased workloads and the lack of childcare
on women, even women who did not have young children, as they, in
their roles as grandparents and alternative caregivers, assumed greater
responsibilities. The conversations provided rich data for public health
practitioners to analyse on what is signicant to members of the public.
The preliminary trials also demonstrated how the ‘digital divide’ could
impact the use of these methods remotely. When the methods were used
with the smaller group of New Orleans residents, the researchers were
able to see the difculty in conducting this type of research remotely,
as participants used a variety of platforms to log in, such as phones,
tablets and computers. Participants had uctuating internet speeds and
conversations were impeded by bad sound on some connections. There
was also a high learning curve to understand the online whiteboard
The initial analysis of the experience of using these methods has led the
researchers to consider some additional remote engagement approaches
for the implementation of the second half of the study.
This study was conducted to support the work of Social Entrepreneurship / Public
Health professor, Dr. Alessandra Bazzano as part of the Eugene Washington
PCORI Engagement Award to use equity-focused design to improve community
participation in public health research against COVID-19.
The workshops were developed by Dr. Noel with the support of design thinking
graduate assistants: Natalie Hudanick, Sneha Rout, Niesha Ford, Dr. Shaymaa
Abdalal and Michaeline Anglemire.
Case Study 6:
Mexico - Space
Proposal for inter vention and adapt ation of spaces with health p arameters,
in the face of COVID-19.
By Leobardo Armando Ceja Bravo, Judith Montaño Hernández,
Miguel Ángel Rojas Sánchez
The De La Salle Bajío University is located in the city of León, Guanajuato,
Mexico. It has a population of approximately 10 thousand people,
including students, teachers, administrators and support and maintenance
personnel. Such a quantity of population in transit and movement within
their campuses, is extremely complex and at the same time, it can be
considered a space with a high probability of contagion. Within this
context, since the middle of March and to this day, the operational
functions that were usually carried out continue to be suspended, as a
result of the moment in which we nd ourselves in relation to the pandemic
that aficts us worldwide, and in the Mexican national context, seeking in
this way “to guarantee services and assistance, are planned and adopted
based on their opinion and local contexts.”(OMS, 2020, p. 6). One way to
achieve the reduction of infections by COVID-19 is oriented to the distance
that can be established between people. For this, the suggestion in the
indication of various measures that contribute to regulation in circulation,
socialization and interaction, can be considered as a good tool. From a
design approach, this can be done.
One of the fundamental elements to keep in mind and for which it is
committed within the design process, is centered on the idea of citizenship.
Therefore, thinking in the sense of design oriented towards the citizen is
central, for this, signage is one of the central resources for this purpose.
It has the power, clarity and subtlety in the organization, orientation and
regulation of the interactions that can be established between different
groups of people. The design through the use of signage fundamentally
has the purpose of guiding, distributing and redirecting people, without
making them feel restricted or unable to carry out an activity.
Within the health contingency that is currently being experienced
worldwide. Thinking about the ways that people were socializing and
what is required now is critical. For this, proposing effective strategies
of social behavior implies a profound change in their habits, for which
it is necessary to investigate in each context the way in which people
previously behaved and the way in which they socialize, likewise, It is
important to identify and relate the type of activities associated with
the various congured spaces. Once taking into account these spatial
conditions, it is necessary to understand some of the general guidelines
suggested by various international bodies such as the WHO (2020). In this
sense, the search for distancing alternatives turns out to be an important
alternative, which must be mediated through signage indications that
contribute to the expected social action in controlled sites.
Research in design will be essential to understand the actions, behaviors,
habits and ways of life of people in social contexts, in that sense, it will
be essential to propose alternatives for socialization and interaction in
the midst of a context of uncertainty such as the one that we are today
and where the search for well-being is paramount. In this sense, design
as a project activity is positioned as an activity through which it is
possible to reestablish, modify, adapt and, above all, project possibilities
of adjustments, inviting people to be aware of themselves and their
environment. Through their own acts or actions, without being invasive,
restrictive or normative. Perhaps that is precisely where the preventive
power associated with the design and type of messages that it emits in
a given site resides. It is in the midst of this context that it is important to
emphasize the preventive, formative and regulatory nature that design
can provide to people within determined social contexts.
Figure 6.1 Example of marking personal distance indoors (upper part images) and outdoor spaces (lower part
images). Preparation of the research team, 2020
In the case to which we refer, it is vitally important to be able to clearly
inform and instruct the correct distance, the type of routes that people
can do and the best way to do it safely, all without losing the objective of
fullling the activities that they are destined to carry out, and above all,
it is very useful to follow the health instructions, which both at a personal
and group level emphasis has been placed on following.
In the case to which we refer, it is vitally important to be able to clearly
inform and instruct the correct distance, the type of routes that people
can do and the best way to do it safely, all without losing the objective of
fullling the activities that they are destined to carry out, and above all,
it is very useful to follow the health instructions, which both at a personal
and group level emphasis has been placed on following.
Understanding the prevailing problems is essential to be able to make any
design proposal, in this case, the biggest challenge was understanding
what is associated with COVID-19, and the ofcial recommendations that
have been emerging over time are decisive. The knowledge of the different
spaces and the actions that need to be carried out provide guidelines for
the development and visualization of intervention proposals. (See Figure
6.1). Therefore, the proposed design is given as an application framework
to the various spaces and campuses that the University has, starting with
common areas and outdoor spaces for socialization and is oriented
towards the delimitation, signaling and orientation of the circulation of
people. In this way, the contribution of the design is clear, subtle guiding
We reiterate that from the design point of view, researching to consider
the greatest of these implications is constituted as one more element
of assessment, interaction and reduction of risk factors so that people
in general and each of those involved in particular can synchronously
contribute to an institutional dynamics oriented towards the awareness of
Case Study 7:
USA - Visualising
Visualizing One Week of College Students’ Lives During the Pandemic.
By Yvette Shen
COVID-19 has signicantly changed nearly every aspect of college life
since its outbreak. Students’ daily routines, from how they learn to how
they live, are altered in a way no one anticipated. As one of the largest
institutions in the nation, the Ohio State University has set up a number of
guidelines and requirements in order to keep the campus safe and healthy.
Most classes are moved online, masks are required along with strict social
distancing measures. Large communal student life events are non-existent,
and student centers and other facilities are either closed or opened with
safety protocols in place. The “traditional” college experience is being
stripped down to only the bare essentials.
Adapting is not easy. All these changes are profoundly affecting students’
physical and mental well-being. In an Information Design class (DESIGN
5505) at the Ohio State University, eleven 3rd year undergraduate
students of Data Analytics major collected one week of data in the Autumn
of 2020, and counted the lifestyle changes they have experienced
intentionally or unintentionally during this unusual time. This information
design project requests students to use their personal activity data as
empathy-based opportunities to provide better insights into their current
status of physical and mental health. The recorded data include: the
frequency of handwashing and mask wearing moments; the amount of
time spent indoor vs. outdoor and the activities involved; the frequency of
socializing with people; the amount of time spent in virtual space and the
distances traveled in the physical world; and any activities taken for their
mental, emotional, and physical health. Students then used information
structure and visual design methods to communicate their data through
the expressions of graphs, charts, icons, and diagrams. The following
examples of the information design outcomes show how different pieces
of data were collected, analyzed, categorized, and presented in visual
Figure 7.1. Number of steps taken before and during the pandemic visual-
In Number of Steps Taken Before and During COVID-19, the step counting
data recorded by the smart phone App were used. Comparison of weekly
average steps before and during COVID-19 shows the decline of walking
opportunities. Because most classes have moved to virtual set-tings,
students have been losing the normal exercise for walking to different
buildings and strolling to places around campus (Figure 7.1). Staying active
regularly has become challenging because of the limited exercise options.
One student used data from her exercise tracking App and calendar App
to compare her physical activities before and during COVID-19. She was
able to reach her daily exercise goal of 30 minutes in only four out of
twenty-six days in the time of COVID-19 (Figure 7.2).
Mask-wearing, handwashing, and social distancing are highly effective in
preventing or slowing down the spread of the virus. By arranging data into
24-hour time sequences in spiral form, One Week in a Pandemic lays out
how these prevention measures become part of our daily routines (Figure
8.3). All safety protocols, well-intentioned as they are, leave students
feeling cooped up in their rooms all day long with fewer chances to
Figure 7.2. Exercise app data visualisation during the pandemic.
interact with others. Home has become the center of nearly everything:
it’s the classroom, the library, the cafeteria, the cinema, and the social
club. To cope with the feeling of loneliness, students have been exploring
social-distancing ways to connect with their friends through phones,
virtual meetings, and virtual watch parties (Figure 8.4). One student was
astonished to see his daily phone usage took up more than 50% of his
awaken time. The lack of social activi-ties also results in an increased
amount of sleep hours and naps during the daytime (Figure 8.5). From
cooking to painting and more, some students have also picked up old
hobbies or learned new skills amid the time spent with their roommates.
Figure 7.3. Routine adoption during the pandemic visualisation.
Research has shown that self-awareness and self-reection is in direct
correlation to physical and mental well-being (Harrington & Loffredo,
2010). The information design projects demon-strated in this case study
are aimed to help students process what they are experiencing and
understand their needs during the Pandemic. Data visualization tasks are
used to cultivate stu-dents’ abilities of taking notice of their behaviors and
thoughts as they unfold. Design principles and visualization techniques are
applied to achieve information visual hierarchy and reveal the patterns,
trends, and outliers in students’ daily life data.
Figure 7.4. Social-distancing ways to connect with friends visualisation
By identifying these patterns and trends, students then can reect on the
current situation, integrate learnings, and assess their well-being goals.
The visualized data results also highlight some of the rising physical and
mental health concerns during these unprecedented times. Therefore, in
this case study, Information design practice functions both as a design
artifact and a research method to provide more insights into the situation.
Although many things feel beyond our control right now, we must take
charge of what we can do to build our emotional resilience and strengthen
our physical health.
Figure 7.5. Sleep data visualisation during the pandemic visualisation.
Case Study 8:
China & USA:
Casual Sex During the COVID-19 Pandemic: Risks, Recommendations and
Spaces for Design Intervention.
By Isabel Prochner, Zhiru Chen, Ting Kang and Hao Lu
“Sex is the opposite of social distancing” said Dr. Kimberly Langdon in
an interview with Cosmopolitan magazine (Hsieh, 2020, para. 19). The
article—in the normally risqué American women’s magazine—stressed the
dangers of casual sex during the pandemic and debunked wishful thinking
that wearing a mask or facing away from each other during sex would
For the most part, research has shown that many people are limiting
contact with sexual partners outside their social bubbles (e.g. Ko et al.,
2020; Lehmiller et al., 2020). However, sex is a reality; as an article title
in The Washington Post read “Yes, some people are still having one-night
stands” (Bonos, 2020). An interviewee in the article noted “I would risk
my health a lot sooner for a sexual experience than I would for a haircut”
(Krista interviewed in Bonos, 2020, para. 6). This scenario was the starting
po int for a seme ste r-lo ng desi gn rese arc h project in an MFA Design co urse
at Syracuse University in the USA. From September-December 2020,
Professor Isabel Prochner and graduate students Zhiru Chen, Ting Kang
and Hao Lu have been exploring how sex and intimate contact might
be safely supported during a long-term pandemic. The project has a
multinational perspective—focusing on the USA and China—as Chen
and Lu are studying from their homes in China and have explored local
perspectives toward the issue.
There are different virus prevention measures and levels of adherence to
virus guidelines in the USA and China, and both countries are experiencing
different realities at the end of 2020. While virus cases are spiking
in the USA, life has mostly returned to normal in China. On the other
hand, discussions about casual sex are more familiar and comfortable
in an American context. It is difcult to nd pandemic guidelines for
casual sex in China. This case study highlights existing research on risks
and recommendations for sex during COVID-19 and presents design
explorations by Chen, Kang and Lu.
Risks and Recommendations for Sex during COVID-19
Casual sex is one of the highest-risk activities during the COVID-19
pandemic. Research suggests that the virus might be present in semen
and other excretions. Though, as authors of “Sexual Health in the SARS-
CoV-2 Era” write, “these data are moot, given that any in-person contact
results in substantial risk for disease transmission” (Turban et al., 2020, p.
1). Consider the exchange of air and saliva and all the surfaces the virus
When public health guidelines exist, the suggestions are fairly consistent:
‘solo sex’ and sex with a housemate (spouse, roommate, etc.) are safest
and masks and disinfection (hand washing, shower, etc.) are essential
for sex with a partner outside your social bubble. Even outside the USA,
the New York City guidelines are often cited and commended for their
realistic and sex positive attitude. As they note, “[d]uring this extended
public health emergency, people will and should have sex” (NYC Health,
2020, p. 1). Historically, abstinence programs and messaging have not
been successful (Santelli et al., 2006) and they become decreasingly
realistic as the pandemic continues. Sex is a natural part of life, motivated
by attraction, pleasure and the expression of affection, among many
things (Meston & Buss, 2007). As Chantelle Otten, director of the
Australian Institute of Sexology and Sexual Medicine wrote, “[s]ex has
always been a great stress reliever and mood booster … it can anchor
us to the present, making us feel stable and secure in the now (which is a
rarity at the moment)” (Otten in Dewitte et al., 2020, p. 549).
Chen, Kang and Lu have been exploring how design can positively
contribute to this difcult situation. Each student is looking at a different
aspect of the problem. To begin, a lot of sex is moving online, with people
trying sexting and cybersex sometimes for the rst time (Lehmiller et al.,
2020). Kang argues that this is positive: while it doesn’t enable physical
touch, it provides intimacy and a way of having sex without risk of
COVID-19 infection. However, she is deeply concerned by internet safety
and the risks of hacking and non-authorized recordings by a partner.
There is also the issue of using platforms like Zoom and Google Meet for
private and intimate activities. After potentially spending hours in video
calls for school or work, these business platforms could feel misaligned
with sex. There’s also risk in blurring boundaries between work and play,
where an off-colour screen name from the night before or misuse of a
work account could mean big trouble. Kang sees potential in the design of
more secure online platforms, and trustworthy mainstream video calling
platforms specially designed for sex and intimacy.
Chen is focusing on trust and dating, especially during the move from an
online connection to an in-person meetup. She is exploring how Soul—the
popular Chinese dating app—could help build trust and ensure greater
safety for users. This project has potential applications to other dating
apps and explores important ethical questions: What is the responsibility
of dating platforms to keep users safe during the pandemic? What amount
of health information should be collected and how might it be shared with
new partners? Whose responsibility is it to share potentially stigmatizing
information? Finally, Lu is exploring how we might design new forms of
physical touch. Moving away from a pure focus on sex, Lu points out that
some people have not experienced any form of touch since the beginning
of the pandemic. There is also a signicant reduction in handshakes, kisses,
hugs, and other contact. Touch is an indispensable social language with
a multitude of purposes like building bonds, communicating relationships,
showing affection, and offering reassurance. Lu argues that design can
help identify low-risk forms of touch during COVID-19. He provocatively
asks: What would it take for elbow bump greetings to become more
popular? How might we learn a new form of physical contact? How might
we embody meaning in new forms of touch? This exploration could also be
extended to simulations of touch through AR/VR and/or physical artefacts.
Despite the risks associated with casual sex during the pandemic, this
taboo topic is underexplored and underaddressed in both American and
Chinese contexts. It was a rich and challenging topic for our MFA Design
class, and new territory for design. The summer 2020 cover of Innovation
magazine read: “A pandemic grips the world. What can designers do
about it? As it turns out, a lot.” This applies to design interventions for sex
during the pandemic. Chen, Kang and Lu’s design explorations addressed
the online world, in-person interactions, and the move between online and
in-person. While the application of this research must be context-specic,
cybersex, online dating and the need for physical touch are common
experiences across borders. There are many more design and design
research needs in each of these areas. There are also signicant related
issues like access to medication (e.g. birth control and Pre-Exposure
Prophylaxis for HIV), pregnancy care, and support for sex workers during
the continuing pandemic.
Figure 8.1. New forms of touch during the pandemic.
This Little Book has outlined the role design research is currently playing
in tackling Covid-19 and its associated challenges on people globally.
Through eight case studies it has shown the propensity of design research
in tackling the current pandemics as well as ways of strengthening public
health and other government institutions to better address future pandem-
ics. Lastly it has demonstrated the commitment of the design research com-
munity to lead initiatives and projects that contribute towards the goal of
Bonos, L. (2020, August 24). Yes, some people are still having one-night stands. The
Washington Post. https://www.washingtonpost.com/lifestyle/2020/08/24/hookup-casual-
Daudt, F.; Tonetto, L.M.; Rosa, V.M.; Renck, P.B.; Libânio, C.S.; Fontanella, L.L. Opportunities
to design for the wellbeing of children undergoing c ancer treatment at a Brazilian Hospital.
International Association of Societies of Design Research Conference. Manchester: IASDR,
Dewit te, M., Otten, C ., & Walker, L. (2020). Making love in the time of corona—Considering
re- lationships in lockdown. Nature Reviews Urology, 17, 547-553.
Fonseca Braga, M., Romeiro Filho, E., Mendonça, R. M. L. O., Oliveira, R. G. L. & Pereira, H.
G. G. (2020). Design for Resilience: Mapping the Needs of Brazilian Communities to Tackle
COVID-19 Challenges. Strategic Design Research Journal, 13, (03).
Harrington, R., & Loff redo, D. A. (2010). Insight, Rumination, and Self -Reection as Predictors
of Well-Being. The Journal of Psychology, 145(1), 39–57
Hsieh, C. (2020, July 7). Sorry, but doggy-style sex isn’t really safer than missionary when
it comes to spreading COVID-19: And all your other questions about whether safe sex is
possible while social distancing, answered. Cosmopolitan. https://www.cosmopolitan.com/
Ko N.-Y., et al. (2020). Changes in sex life among people in Taiwan during the COVID-19
pandemic: The roles of risk perception, general anxiety, and demographic characteristics.
International Journal of Environmental Research and Public Health, 17(16).
Lehmiller, J. L., Garcia, J. R., Gesselman, A . N., & Mark, K. P. (2020). Less sex, but more
sexual diversity: Changes in sexual behavior during the COVID-19 coronavirus pandemic.
Meston, C. M., & Buss, D. M. (2007). Why humans have sex. Archives of Sexual Behavior,
NYC Health. (2020, June 8). Safer sex and COVID -19. https://ww w1.nyc.gov/assets/doh/
Neuhauser, L, et al. 2009. Partic ipatory design of mass health communic ation in three
languages for seniors and people with disabilities on Medicaid. http s://doi.org/10.2105/
Ngwenya, B.N. and Kga thi, D.L., 2011. Traditional public assembly (Kgotla) and natural
resources management in Ngamiland, Botswana. Rural Livelihoods, Risk and Political
Economy of Access to Natural Resources in the Okavango Delta. Nova Science Publishers,
Noël, G. 2019. Designing bowel preparation patient instructions to improve colon cancer
detection: Evidence-based design criteria for patients’ documents. htt ps://doi.org/10.1075/
Paim, J., Travas sos, C., Almeida, C., Bahia, L ., & Macinko, J. (2011). The Brazilian health
system: histor y, advances, and challenges. The Lancet, 377(9779), 1778-1797.
PNAD. (2018) Internet and television access and possession of mobile phone for personal use
- National Continuous Household Sample Survey - Annual disclosure. Available at: https://
www.ibge.gov.br/busca.html?searchword=internet Access on: July 14th, 2020.
Rocha, T. A. H., da Silva, N. C., Amaral, P. V., Barbosa, A. C. Q., Rocha, J. V. M., Alvares,
V., ... & Facchini, L. A. (2017). Addressing geographic access barriers to emergency care
services: a na tional ecologic study of hospitals in Brazil. International Journal for Equity in
Health, 16(1), 1-10.
OMS, (2020) Actualización de la estrategia frente a la COVID-19, 14 de abril de 2020.
Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (20 06). Abstinence
and abstinenc e-only education: A review of U.S. policies and programs. The Journal of
Adolescent Health, 38(1), 72–81.
Sodha, S. (2020, March 26) Media experts despair at Boris Johnson’s coronavirus campaign.
The Guardian; https://www.theguardian.com/commentisfree/2020/mar/26/media-experts-
Sun, X., Yan, W., Zhou, H., Wang, Z., Zhang, X., Huang, S., & Li, L. (2020). Internet use and
need for digital health technology among the elderly: a cross -sectional survey in China. BMC
public health, 20(1), 1-8.
Travassos, C., & Viacava, F. (2007). Acesso e uso de serviços de saúde em idosos residentes
em áreas rurais, Brasil, 1998 e 2003. Cadernos de Saúde Pública, 23(10), 2490-2502.
Tsekleves, E., & Cooper, R. (Eds.) (2017). Design for Health. (Design for Social Responsibility).
Tsekleves, E., Darby, A., Ahorlu, C ., De Souza, D., Pickup, R., & Boakye, D. (2019). Combining
design research with microbiology to tackle drug-resistant infections in different home
environments in Ghana: Challenging the boundaries of design thinking. The Design Journal,
Turban, J. L., Keuroghlian, A. S., & Mayer, K. H. (2020). Sexual Health in the SARS -CoV-2
Era. Annals of Internal Medicine, 1-4.
Ulrich, R.S., Zimring, C., Zhu, X., DuBose, J., Seo, H., Choi,Y., Quan, X. and Joseph,A . (2008)
A review of the research literature on evidence-based healthcare design. Health Environments
Research and Design Journal, 1(3): 61–125.
Venditti, S., Piredda, F. & Mattana, W. (2017). Micronarratives as the form of contemporary
communication. The Design Journal, 20, Pp. 273-282.
Zitkus, E., & Libanio, C. (2019). User Experienc e of Brazilian Public Healthcare System. A
case study on the accessibility of the information provided. The Design Journal, 22(sup1),
The Little Book of Global Health
Volume 1: Design & Covid-19