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An opportunity for inclusive and human-centred
design
Isobel Leason,1 Nicholas Longridge,2 Manu Raj Mathur3 and Farnaz Nickpour*4
Introduction
Oral healthcare is in a period of change, with
shis towards person-centred, preventative
approaches and advancements in technology
transforming current models of care.
Simultaneously, key challenges, such as oral
health inequalities and sociodemographic
shis, are placing increasing and unsustainable
pressures on oral healthcare systems.
Across the wider landscape of design
and innovation, inclusive design (ID) and
human-centred design (HCD) are two core
approaches that are increasingly valued by
and integrated into health and social care
organisations. However, their recognition and
uptake in oral healthcare remains limited.1 We
propose that ID and HCD are highly relevant
and potentially instrumental to oral healthcare
systems. e symbiosis of the two oers robust
and holistic methodologies for design-driven
problem-framing, problem-solving and
innovation. ID and HCD emphasise placing
people at the centre of the design process
while acknowledging their multifaceted needs,
expectations, behaviours and relationships.
They seek to understand and engage with
diverse populations and co-create solutions
with and for them that accommodate all, not
only the mainstream usergroups.
is paper examines how a timely meeting
between these fields could be strategic
in facilitating transformational change;
promoting ID and HCD as a suitable and
eective approach to help understand, address
and innovate key and complex challenges
facing oral healthcare.
Challenges and transitions in oral
healthcare
Person-centred and prevention-oriented
care
The FDI World Dental Federation’s revised
definition of oral health states ‘oral health
is multi-faceted and includes the ability
to speak, smile, smell, taste, touch, chew,
swallow and convey a range of emotions
through facial expressions with confidence
and without pain, discomfort and disease of
the craniofacial complex’.2 This definition
is significant in overcoming the traditional
perspective of oral health simply as the
absence of disease. The definition and
accompanying framework treat oral health as
a fluid state of wellbeing, taking into account
physiological, mental and psychosocial
aspects, while also addressing the demands
of life and daily function.3
This change in perspective is increasingly
evident across the field of oral health.
There is a growing focus on oral health-
related quality of life4,5 and the long-term
Introduces inclusive design and human-centred
design and their signicance to the trends and
challenges in contemporary oral health systems.
Highlights the broad capabilities and potential
contributions of design.
Discusses barriers an d driver s to the adoption
of inclusive and human-centred design in oral
health.
Key points
Abstract
Challenges and trends, such as person-centred care, demographic shifts and technological advancements, are
transforming oral health systems. Inclusive design and human-centred design are disciplines highly relevant and
potentially instrumental to these oral healthcare transformations. This paper provides an overview of the denitions
and characteristics of inclusive and human-centred design which centre on understanding people’s multifaceted
needs, expectations, behaviours and relationships, and engaging with diverse and often excluded populations.
Design’s broad capabilities are outlined across outcome and contribution types and the potential role of inclusive
and human-centred design to oral health is explored by outlining its relevance to key transformational, societal
and technological shifts. Finally, barriers and drivers to the adoption of inclusive and human-centred design in oral
health are discussed around three themes: awareness and understanding of the role and value of design; disciplinary
dierences; and the wider healthcare systems context.
1Division of Industrial Design, University of Liverpool,
Liverpool, UK; 2Clinical Lect urer in Restorat ive Dentistr y
and Speci alist in Endodont ics, Universit y of Liverpool ,
Liverpool, UK; 3Professor in D ental Public Healt h,
Queen Mar y Universit y of London, London , UK; 4Reader
in Inclusive Design and Human-Centred Innovation,
University of Liverpool, Liverpool, UK.
*Corresp ondence to: Farnaz Nic kpour
Email address: Farnaz.Nickpo ur@liverpool.ac.uk
Refere ed Paper.
Submit ted 26 January 2022
Revised 7 July 2022
Accepted 18 Ju ly 2022
https://doi.o rg/10.1038/s41415-022-5101-1
BRITISH DENTAL JOURNAL | VOLUME 233 NO. 8 | OCTOBER 28 2022 607
OPINION
physical and psychosocial impacts that
poor oral health can have. Moving on from
along-established approach focused on the
treatment of established disease, dentistry
is evolving towards a patient-centred,6
prevention-orientated7 system of care.
Patient-centred care (PCC) is a n
increasingly prominent concept in
dentistry. Several theoretical models for
PCC in dentistry have been proposed
which highlight the importance of providing
humane care and making a connection with
patients.6,8 ,9,10,11
In recent years, person-centred care has
emerged as an expansion of patient-centred
care.12 It is a central goal throughout the
FDI’s Vision 2030 report, where it is defined
as follows: ‘people-centred care is focused
and organised around the health needs and
expectations of people and communities
rather than on diseases. People-centred
care extends the concept of patient-centred
care to individuals, families, communities
and society. Whereas patient-centred care
is commonly understood as focusing on
the individual seeking care – the patient
– people-centred care encompasses these
clinical encounters and also includes
attention to the health of people in their
communities and their crucial role in
shaping health policy and health services’.13
Fostering people-centred services is also an
important strategy to strengthen oral health
services in the World Health Organisation’s
(WHO) Global oral health strategy and a
suggested action in the WHO’s Director-
General’s 2021 report, which informed the
World Health Assembly resolutions on
oral health.14,15 The WHO resolutions are
significant in policy discourse, boosting
people-centred care in national and
international oral health policy agendas.
Despite guidelines, recommendations
and standards at policy level, there is
limited understanding and facilitation, and
subsequently uptake and implementation, of
PCC on an institutional level and in day-to-
day practice.16,17 This gap between policy and
practice of PCC is evident across the wider
healthcare sector,18,19 where it has been noted
that PCC ‘has many evangelists but few
practitioners’.20 However, progress towards
PCC in dentistry lags behind other health
professions.16 This may be due to dentists’
misunderstanding or reluctance towards
PCC,16 as well as current target-driven
contracts and systems not rewarding PCC.
It has been demonstrated that treatments can
be selected based on improved remuneration,
which may not align withPCC.21
Shifts towards prevention-orientated
care are also proposed. Prevention is a
dimension in a number of PCC models22 and
is recommended at an organisational level.
While recommendations of prevention-
focused approaches have been made,
current dental contracts don’t adequately
reward preventative activity.23 Much of
dental care remains treatment-orientated
rather than prevention-orientated24 and
preventable diseases, such as dental caries
and periodontal disease, remain prevalent
across all age groups.25
Societal challenges: health inequalities
and population ageing
e rst pillar of FDI’s Vision 2030 advocacy
strategy stresses on universal coverage for oral
health and states that ‘quality oral healthcare
should become available, accessible and
aordable to all, with special attention paid
to marginalised and vulnerable populations’.13
Tackling oral health inequalities is a
major problem facing public bodies and
policymakers.13,26 A myriad of biological,
physical, psychosocial, sociodemographic
and socioeconomic factors, such as education,
physical and neurocognitive ability and social
class, have been identied as impacting an
individual’s access to and quality of dental
care.27 Furthermore, these factors have
an intersectional and interrelated nature,
potentially leading to compound systemic
disadvantages to those populations at their
convergence. Understanding the factors
involved in health inequalities and their
complex interrelation is necessary to inform
equally complex and eective interventions
to addressthem.28
Population ageing presents an additional
societal challenge which is placing increasing
demands on health and social care systems.29
It is estimated that across England, Wales and
Northern Ireland, the number of people aged
65 or over with an urgent dental condition
could rise by more than 50% by 2040 due
to population growth alone.30 In addition
to increased oral care demand, the nature
of dental services required for older people
is changing. For example, the increasing
percentage of older adults retaining their
natural teeth31 demands more complex dental
management that the profession needs to
address.32
Technological advancement and
adoption
Parallel to these shifts, the advancement
and adoption of technology within
dentistry is rapidly increasing. is can be
observed through examples such as robotic
dental implant placement,33 the use of
computer-aided design and manufacturing
technologies34 and the development of
teledentistry services.35 If implemented
appropriately, such technologies have the
potential to help meet pressures on oral
healthcare systems, improving access to and
quality of dentalcare.
We propose that ID and HCD are highly
relevant to these transformational, societal
and technological shis in oral health. To
frame this relevance, an overview of these
elds and their denitions and capabilities
within the wider design landscape is provided.
Design in the context of health:
denition and capabilities
Design is widely defined as a creative,
problem-framing and problem-solving
activity. It is a set of principles, mindsets (ways
of thinking), practices and processes (ways
of working) and methods and techniques
(toolkits)36 which are used to understand
and dene problems and develop solutions.
It can be adopted as a generative and creative,
as well as an analytical and critical process.
Although everybody can design, it is also a
professional practice in which designers gain
considerable training, skills and knowledge.37
Key skills include the ability to visualise and
conceptualise the intangible; designing with
empathy for people and planet; and making
and testing prototypes.38
Design as a discipline is evolving and
these skills are applied in a growing number
of contexts where design is making a range
of contributions. Figure 1 illustrates the
potential contributions and outcomes of
design, providing examples to show how each
is relevant to oral health. Design outcomes can
be classied by four orders: visuals, products,
interactions, or systems.39 In oral healthcare,
design outcomes could range from tangible
artefacts, such as patient information leaets
or dental tools, to large-scale transformations
and oral health policy. Beyond interventions,
design also oers methodologies, theories
and empirical contributions.40 For example,
HCD principles, or co-design methods, can
be applied to oral healthcare research.
608 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 8 | OCTOBER 28 2022
OPINION
What is human-centred design?
HCD is ‘an approach to systems design and
development that aims to make interactive
systems more usable by focusing on the use
of the system and applying human factors/
ergonomics and usability knowledge and
techniques’.41
HCD aims to produce outcomes which are
useful, usable, desirable and meaningful to
the people using them.42 To do so, it places the
needs and experiences of humans at the centre
of the design process, acknowledging them
as the experts in their lived experience and
co-creating solutions with and for them. HCD
incorporates methods to understand people
holistically (including their multifaceted needs,
expectations, behaviours and relationships),
engages with users and multiple stakeholders
throughout the design process and often
involves transdisciplinary collaboration.43
HCD is distinct from user-centred design as
it emphasises people beyond their role as users
and includes dierent stakeholders’ needs and
broader contexts.44,45
Altiparmakogullari et al. applied HCD to
investigate dental photography; specically,
the eciency of the process and the quality of
images produced.46 While previous work had
focused on equipment, their HCD approach
looked at the whole system of people and
equipment, considering ergonomics and
human factors, as well as emotional inuences
on patients. The outcome was a series of
recommendations to improve the dental
photography equipment and processes for both
clinicians and patients.
What is inclusive design?
ID is ‘the design of mainstream products and/
or services that are accessible to, and usable by,
as many people with the widest range of abilities
within the widest range of situations without
the need for special adaptation or specialised
design’.47
ID centres on designing for human diversity.
It acknowledges the central role of design as an
agent of inclusion or exclusion and that (dis)ability
and exclusion can be thrust upon an individual
in temporary, situational or permanent settings,
through inadequate or inconsiderate design.48
Through identifying ‘extremes’ and
‘mainstreams’, ID involves empathising and
ultimately designing with often ignored,
marginalised or excluded user groups, whose
experiences pose the most extreme and diverse
design challenges and opportunities. By
investigating barriers to inclusion, it aims to
bring those extreme and excluded users into the
mainstream and create innovative solutions that
include and benetall.48
Contemporary ID looks beyond disability,
ageing and physical accessibility,49 considers
psychosocial dimensions of inclusion and
exclusion, and places value on quality of life and
experience.50
An example of ID applied to oral health is
the redesign of Jordan toothbrush packing.51
Rich insights were uncovered through working
with extreme users, including: people with
arthritis; people with low vision; children; and
older people, throughout the redesign process.
e outcome was user-friendly packaging that
is easier to open for a wider range of people,
resulting in increased sales and strengthened
brand positioning.
The relevance of inclusive and
human-centred design to oral
health
The potential for ID and HCD to address
challenges to our society’s health is increasingly
recognised.52,53 Design is being adopted as a
central agent of innovation to rethink healthcare
services and systems and tackle complex
problems.54,55,56 Despite this, there is limited
recognition and adoption of ID and HCD
in oral healthcare.1 We discuss the potential
signicance of ID and HCD, rst as an agent for
transformations in oral healthcare, then to the
specic challenges previously outlined.
Inclusive and human-centred design
as an agent of oral healthcare
transformations
e complex nature of oral healthcare systems,
the diversity of individuals within them and the
social and political environments in which they
are situated, mean that many of the challenges
facing oral healthcare could be described as
‘ w i c k e d ’. 57 Addressing wicked problems requires
a systems perspective, as well as collaborative,
creative, integrative and imaginative
approaches.58,59 rough intentionally embracing
complexity, utilising creative approaches and
centring on human values, ID and HCD oer
alternative and non-clinical perspectives and
radically different strategies for addressing
challenges in oral healthcare.
ContributionDefinitionExample
Theoretical
Methodological
Empirical
Interventional
Abstract Knowledge type Specific
Tangible artefactsDesign outcomes Intangible transformations
Models,
frameworks,
principles
Methodologies,
methods,
techniques
Experiments,
data, findings
Application of
inclusive design
principles
Use of
co-design
methods
Usability testing and
evaluation of a
clinical interface
Visuals
Communications,
graphics
Patient infonnation
leaflets, children's
oral health
animation
Products
Objects, artefacts
Dental chair, dental
handpiece,
toothbrush
Interactions
Interfaces, services,
experiences
Teledentistry
services, virtual
reality training tools
Systems
Organisations,
ecosystems
Re-organised care
systems, oral health
policy and
commissioning
Fig. 1 Design contributions and outcomes canvas
BRITISH DENTAL JOURNAL | VOLUME 233 NO. 8 | OCTOBER 28 2022 609
OPINION
Systems approaches are central to HCD,
which considers people, their experiences
and contexts, and how these interact within
systems.60 Brocklehurst et al. promoted systems
thinking in oral health research, highlighting the
importance of understanding the complexity
and contextual knowledge of the system in order
to successfully implement interventions.61
Non-clinical perspectives could both oer
new ideas to oral health research and lessen
challenges arising through the dual clinician-
researcher role. Particularly in qualitative
research, a clinician’s professional status can
present issues, such as maintaining a duty of
care while ensuring methodological integrity,
or aect participants’ responses due to power
imbalences.62
Design’s creative methods, such as
visualisations and prototypes, could aid oral
healthcare transformations through facilitating
shared communication and understanding.61,63
Lievesley and Wassall demonstrate the value of
design for describing and reframing complex
problems in their development of a person-
centred view of community dental health
services.64 ey produced two visual models
which were key in facilitating collaboration
across stakeholders and highlighting the value in
taking a person-centred perspective to reframe
systemic challenges. Such creative collaboration
and shared reframing is relevant to the move
to integrated care systems outlined in the
Health and care bill65 and NHS long term plan,66
which requires partnerships between health
providers and reorganised health systems.
Design approaches might aid the integration of
dental practices and their services into the wider
healthcaresystem.
Facilitating person-centred and
prevention-oriented care
e principles and values of ID and HCD are
closely aligned to PCC and the prevention-
orientated approaches being proposed in oral
healthcare.
Apelian et al.’s PCC model is based on
humility, hospitality and mindfulness11 and
Scambler and Asimakopoulou include ‘feeling
empathy and compassion’ as one of four
foundational components in their hierarchy
of PCC.10 is theme of empathy is echoed
in ID and HCD, where empathising and
understanding users is a central concept.42
Grasp live is an example of a product
designed to support a trusting and empathic
relationship between dentist and patient.67
Grasp is a handheld device which the patient
can squeeze to communicate during treatment.
It is connected to a smartphone, as well as
an Apple Watch worn by the dentist, which
provides haptic feedback. is communication
during treatment allows cooperation between
dentist and patient, for example, feedback can be
used for quick conrmation of cavities without
excessive pain. While Grasp was designed with
dental anxiety in mind, it could also be of benet
to a range of patients, including those with
communication diculties.
Other PCC dimensions such as ‘the patient
as a whole person’10 and ‘treated as a person,
recognised as an individual’,9 relate to the FDI’s
definition of person-centred care and echo
HCD’s principle of considering people beyond
their role asusers.
Another key component of PCC is
empowering patients and involving them in
treatment decisions. Mills et al.’s model i ncludes
shared decision making9 and Apelian et al.’s
model includes ‘sharing power’ and ‘creativity’
as key attitudes in co-determining problems
and co-authoring treatment plans.11 Scambler
and Asimakopoulou’s hierarchy of PCC intends
to aid reection on the level to which patients
are involved in decision-making.10 These
concepts encourage participatory approaches,
something which is a key skill of designers who
commonly apply methods such as co-design.
Brocklehurst et al. have promoted the use of
design’s participatory methods in oral health,
particularly in implementation research61 and
special care dentistry.68
Whole Mouth Health is an example of a
project using co-design to explore oral health
literacy and behaviour change.69 A range of
participants across multiple countries and
life stages are involved in a series of problem-
framing and problem-solving activities, with
the aim of co-producing an oral health literacy
platform. The project demonstrates how
participatory design approaches can facilitate
the delivery of preventative and personalised
health information and drive transformations
towardsPCC.
Reframing and tackling societal
challenges
ID is highly relevant to the FDI’s vision of oral
healthcare that is ‘available, accessible, and
aordable to all, with special attention paid
to marginalised and vulnerable populations’.13
Such populations could be considered ‘extreme
users’ which are central to an ID approach.
Design has been applied to facilitate access
to typically excluded groups, for example,
through the design of dental chairs for people
in wheelchairs,70 a communication aid for
people with an intellectual disability71 and a
device for nurses brushing hospital patients’
teeth.72
Beyond this, there is potential for ID and
HCD to help reframe societal challenges and
investigate oral health experiences across
diverse populations. This is particularly
relevant to the area of Inclusion Oral Health;73
advances in which discuss the complexities
of oral health inequalities and call for
‘multidisciplinary research collaborations to
meet the methodological challenges of this
urgent new frontier in oral health inequity
research’.74 ID and HCD offer alternative
perspectives and creative participatory
approaches which would be valuable in such
collaborations.
Limitations of the evidence-based paradigm
in oral health are increasingly recognised.61
Traditional quantitative approaches don’t
always suit wicked problems, such as societal
challenges, which have numerous variables
that can’t be separated and investigated in
isolation. Moreover, sometimes evidence on
impact, measured through lived experience,
is of value. Design could contribute to
complementary ‘thick data’ and ‘big data’
approaches.75 For example, combined with big
data that indicates what people do, HCD might
uncover in-depth, human-centred insights that
are vital to understand why people adopt a
certain behaviour.
Human-centred technology and
innovation
e application of technology to oral healthcare
equipment, environment and systems has
the potential to help meet pressures on oral
healthcare systems and could play a key role
in delivering PCC. However, poorly designed
technology can exacerbate exclusion. The
integration of ID and HCD in the development
and implementation of technologies ensures
that they t the needs of users and stakeholders
and are developed with consideration for the
specic environments and contexts of use.
In oral healthcare, such approaches could
seek to enhance eectiveness and eciency;
improve human wellbeing, user satisfaction,
accessibility, and sustainability; and counteract
possible adverse effects of use on human
health, safety and performance.
Consultation Room 2030 is an example
of a project looking at how technology can
facilitate changing approaches to care.76
610 BRITISH DENTAL JOURNAL | VOLUME 233 NO. 8 | OCTOBER 28 2022
OPINION
e project explores trends in transferring
healthcare experiences from the consultation
room to home and how this can be done in
a human-centred way. Examining the process
from before a consultation to a patient arriving
back at home, they are identifying what could
be innovated through the help of technology,
helping doctors to improve their work and
ultimately enhancing patient experience.
Barriers to adopting inclusive and
human-centred design in oral
health
While recognition of design is growing, it is oen
poorly understood by healthcare practitioners
and poorly integrated into healthcare systems.
Design is predominantly seen and implemented
as an agent of problem solving and hence is
only engaged with if or when that stage applies.
Awareness and understanding of ID and HCD is
particularly limited and there is a need to build
understanding around their potential role and
value so that oral health can engage with and
utilise themfully.
Beyond awareness of ID and HCD, there
is a need to negotiate disciplinary dierences
in approaches to data, rigour, evidence and
impact. For instance, there is discussion around
the nature and hierarchy of evidence in design
versus health.77 Also, where health focuses on
peer-reviewed publications, design takes a more
varied approach to disseminations, including
areas such as exhibition, performance and
making. Future work will have to navigate
these dierences, seeking to bring approaches
together in an eective and complementaryway.
e context of oral and wider healthcare
systems and their political backdrop is another
consideration. e adoption of ID and HCD
within these may require culture change, which
can be dicult to manage. Additionally, design
strategies must be able to adapt to political
and societal changes on local, regional and
nationalscales.
Conclusion
is paper examines the relevance of ID and
HCD to the transformational, societal and
technological shis occurring in oral health.
e denitions and capabilities of ID and HCD
are described and illustrated through practical
examples.
We suggest that there is an opportunity for
oral health to engage with ID and HCD and that
designers could be of value to oral health policy,
research and practice, across issues such as
person-centred practice, Inclusion Oral Health
and accessible technological advancement. To
progress and enhance collaborations between
the fields, barriers, including awareness of
the role and value of design, disciplinary
dierences, and the wider healthcare systems
context, should be considered and addressed.
Ethics declaration
e authors declare no conicts of interest.
Author contributions
Isobel Leason, Nicholas Longridge and Farnaz
Nickpour conceived the paper. Isobel Leason wrote the
rst dra. Isobel Leason, Nicholas Longridge, Manu
Raj Mathur and Farnaz Nickpour provided feedback,
participated in the editing process and approved the
nal version.
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