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Health Inequalities

Health Inequalities

This enquiry examines the role of design and creative practice in giving voice to older people facing extreme poverty in Sheffield. 

Funded by: Research England

Project lead: Claire Craig, Sarah Smith (Smizz), Helen Fisher

Despite the long-term trends of improvement in life expectancy, infant mortality and rates of premature deaths from cancer and cardiovascular disease in England as a whole, stark inequalities in health remain (Public Health England, 2019). 

According to research undertaken by the Kings Fund ‘long term conditions are 60% higher in people experiencing poverty (DH, 2012). Studies have suggested that the severity of the disease is 30% greater for this population and that multi-morbidity is more prevalent particularly in relation to individuals living with mental health problems. For premature cardiovascular disease mortality considerable inequality by deprivation exists with mortality rates in the most deprived tenth of areas of the UK almost 3.5 times higher than those in the least deprived tenth of areas.

Design has an important role to play in challenging and addressing these inequalities. In 1972 Papanek and Fuller argued that design is imperative to satisfy unmet or underserved needs of marginalised people living in resource limited societies. More recently there has been a diversification of how and where designers are working with greater emphasis on civic responsibility and the value of social design. 

Researchers in Lab4Living engage in a wide-ranging programme of work addressing health inequalities. This current study utilizes a design-led approach to make visible some of the challenges older people living in poverty in Sheffield face. This two year project was undertaken in partnership with REACH as part of the national AgeBetter programme. Inspired by the Life Café (a curated set of materials to enable individuals to have challenging conversations about sensitive topics of end of life), the project lead commissioned the development of a toolkit to support conversations about finances. This was found to be successful and has now been adopted by Age Better in a national roll out of the work.The research culminated in an interactive exhibition where participants were able to share their experiences of social isolation, loneliness and financial hardship. The work has contributed to broader debates regarding he need to create services that are more in-tune with the complex and multiple barriers people living in poverty face.

Occupation Based Social Transformation

The term ‘social transformation through occupation’ is used broadly to refer to various approaches that focus on using occupation as a means to restructure practices, systems and structures, so as to ameliorate occupational and social inequities. 

Project team: Claire Craig / Nicholas Pollard

Funded by: European Network of Occupational Therapists in Higher Education

The social transformation through occupation think-tank has brought together a global multi-sectorial group, which includes professionals, service users, researchers, politicians, members of the public, students and teachers. The enquiry explores how communities draw on collective creativity to come together and build assets to support quality of life.  

Members of the think-tank and its associated network which spans over 30 countries, have been gathering information and creating pathways towards actions to tackle health inequalities through an occupation based perspective. The research team focuses on ways to bring together diverse theoretical perspectives and practices to move social transformation through occupation forward. 

Early research has been manifested in an e-book of Case Studies for Social Transformation through Occupation. The e-book shares exemplar case studies generated throughout the research, providing ideas for how such case studies can be used in education and practice.

Analysis of these case studies identified that participants were drawing upon key principles and practices associated with broader models of social transformations, particularly those associated with participatory, emancipatory and community development approaches. Aligned with these types of approaches, participants emphasized the need to:

  • Span a continuum from individual lives to political systems 
  • Incorporate critical examination of power and positionality 
  • Engage critical theoretical frameworks 
  • Build collaborative partnerships across diverse groups 

Thank you for your work and inspiration on this important topic. Congratulations for this fantastic product. I could see this resource being useful for introducing occupation to students in other disciplines. I would like to use the cases as exemplars for my students’ projects in health entrepreneurship. 

Comment from Educator

GRIP: Promoting exercise after stroke and transient ischaemic attack

This project, funded through the Getting Research into Practice (GRIP) programme, explores ways to promote exercise in stroke survivors living in Sheffield (UK), using co-production workshops.

Funded by:
Getting Research into Practice (GRIP) funding programme through National Institute for Health Research Collaborations for Leadership in Applied Research and Care Yorkshire and Humber (NIHR CLAHRC YH).

Gavin Church – stroke specialist physiotherapist, Sheffield Teaching Hospitals NHS Trust; Ali Ali – stroke consultant, Sheffield Teaching Hospitals NHS Trust.

Lab4Living team:
Remi Bec and Joseph Langley collaborating with Mark Fisher, course tutor,
BA (Hons) Product Design

Stroke is the 4th leading cause of death and the leading cause of adult disability in the UK, affecting 152,000 individuals annually and costing the UK health economy nearly £9 billion.
A quarter of these strokes are recurrent and often preventable if secondary vascular risk is optimised.

It is established that physical inactivity is an independent risk factor for primary and secondary stroke and that exercise limits secondary vascular risk by reducing blood pressure, cholesterol and weight. Yet less than half of adults over the age of 65 years in the UK achieve the recommended levels of activity, and this declines further after stroke and transient ischaemic attack.

This project aims at exploring ways of promoting exercise in stroke survivors living in Sheffield, using co-production workshops. Based on the experiences of Sheffield based service users, we aim to understand the current delivery of exercise after stroke, and the myths and enablers/barriers, and to explore ways in which the service could be improved using co-production methods.

Stakeholders involved

The multidisciplinary core team was composed of two health professionals (consultant and physiotherapist) and two designers who co-facilitated a series of five workshops.

Throughout the duration of the project, 71 people have been involved. At least 15 participants took part in each workshop, gathering together stroke survivors, health care professionals, exercise prescribers, social services, commissioners, medics and the voluntary sector.
A group of 10 final year product design students was involved in the final two workshops.

Methods used

This design-led project used co-creative methods throughout a series of divergent and convergent thinking based onto the double diamond (Design Council, 2005) approach.
Based on the experiences of the services accessed by these people in Sheffield, the team learned about current delivery of exercise after stroke, considered the myths and enablers/barriers, and explored ways in which the service might be improved using co-production methods with all participants.

Participants and students take part in workshop activities

Student engagement

Eight Product Design students on the final year module ‘Graduation Design Project Portfolio’ collaborated in the project, which contributed to their final year portfolio. The students self-select from a range of projects, based on their interests and skillsets.

Participants and students take part in a workshop

We always try to offer final years a live project experience and for the past few years have offered a range of briefs. The briefs range from a live project with a product design company, an enterprise project, through to the GRIP project which offers more of a service design opportunity.

Mark Fisher, BA Hons Product Design course tutor

In the second phase of the project, the students were paired with stroke survivors and healthcare professionals to develop their own brief. While briefs were developed independently for individual student assessment purposes, the briefs needed to be complementary and brought together as a single entity for development in phase three. Phase three is ongoing and focuses on securing funding to create one proof of concept to prototype and test in stroke wards.


Based on the insights gathered throughout the first three workshops, an ideal service was mapped out in a visual way. As part of this service, four touchpoints/briefs were developed by the students:

  • A staff training package to make sure the correct information is delivered by health practitioners at the right time and with the right language – Julian Lee;
  • A Stroke passport for patients that can be customised based on their preferences and goals and that could also be used as a log book – Joe Boniface and Daniel Lomas;
  • An animation video raising the benefits of undertaking exercise – John Williams and Emily Bough;
  • A multifaceted intervention (e.g. at the hospital, at home) – Dayna Booth, Ursula Ankeny and Tyra Spain.

Student Learning

I have learned more about the research process of design. The ways in which you can use the comments from the target market earlier on to shape the direction of the project.

Student participant

For the students, the project offered a rich, live learning experience that challenged them to use the design skills and approaches learned on their product design course and apply them to a complex service scenario.

Joe sharing concepts at workshop

What was particularly interesting was how the students responded to the challenge of developing a range of service touchpoints with strong consideration of complex user requirements instead of focusing on developing a tangible outcome.

Mark Fisher, BA Hons Product Design course tutor

The students worked alongside stroke survivors to co-develop creative ideas in a truly immersive experience. They benefited from the support of the research and healthcare professionals, particularly making use of the invitation to regularly attend the Royal Hallamshire Hospital acute stroke ward to get feedback on their service design concepts from a wider clinical team.

Dayna Booth sharing concepts at stroke ward

When asking questions or using activities to find out information you have to ensure that you facilitate in a way that allows them to respond in a bit more depth if possible e.g. sometimes they may need a few prompts

Final year student participant

From working with the stakeholders, students gained valuable insights including eliciting user experiences and understanding requirements, considering ethics, collaborating with clinicians and facilitating workshops.

Students were able to reflect on working with users, clinicians and reported that the project had broadened their thinking and opened up a whole new area of design.

It’s been the most interesting project across all three years of university as although we’ve have live projects before, this one feels the most ‘real world’ and worthwhile as it’s helping people who seem to appreciate what you are trying to do.

Final year student participant

Work is ongoing; phase three activity is focussed on final development and implementation of the staff training package and patient facing outcomes.

The funder’s report on this Translating Knowledge into Action project is now available from NIHR CLAHRC YH.

Participants and students take part in a workshop

NIHR Knowledge Mobilisation Research Fellowship

Dr Joe Langley’s three year fellowship explored the added value of design and making as a form of facilitating co-produced research, and of sharing, synthesising and activating knowledge within participants, systems and organisations. This work resulted in personal development in co-design and co-production and had a particular focus on the impact activities could have on relationships and systemic power structures.

Funded by:
National Institute of Health Research (NIHR)

NIHR CLAHRC YH, Royal College of Midwives, The University of Sheffield, Bradford Royal Infirmary, Sheffield Children’s Hospital, NIHR Devices for Dignity HTC, TITCH Network

Project team:
Dr Joe Langley

Creativity, Innovation, Design (George Cox)

Background to the NIHR Fellowship programme

£8 billion per year is spent on health-related research and there is increasing pressure to demonstrate a return on this investment. Yet translation of health services research knowledge into everyday practice remains a challenge.

The fellowship programme aims to advance knowledge and understanding about research use, influence and impact. It looks at how research can be blended with other knowledge, such as professional practice and patient experiential knowledge. This opens the door for participatory and co-produced research methods in particular.

Through the Knowledge Mobilisation Research Fellowships, the NIHR enables up to five individuals to explore the mechanisms, barriers and enablers of Knowledge Mobilisation and to mobilise some health services research knowledge into everyday practice.

“Making things together is a great leveller.”

Prof Jo Cooke, mentor
Think with your hands

Joe Langley’s three year Knowledge Mobilisation Research Fellowship was the first to be awarded to a researcher from outside the health disciplines. The fellowship has explored the added value of design and specifically making, within the context of co-produced research; of sharing, synthesising and activating knowledge within participants. Joe’s interest in this is focused on the creative, practical activities of ‘making’ employed by designers and applying them in participatory health research and innovation.

During the course of the fellowship, Joe’s research began to focus in particular on the impact those activities could have on relationships, systemic power structures and hierarchies in health and in wider society. The prevailing mode of communication within many such hierarchies is written and spoken language, a mode of communication associated with knowledge – and therefore power.

“This was an amazing opportunity for me to really get ‘inside’ this complex and, initially, slightly alien field. I have a far greater understanding, met some inspirational people, established great relationships and have been able to open doors to expand the work I do.”

(Dr Joe Langley)

Language is often used (consciously and unconsciously) as a means of excluding different ‘tribes’ of people, creating impenetrable barriers of sounds or ciphers that demonstrate (often academic or intellectual) ‘expertise’ whilst ignoring expertise by lived experience.

Design uses a visual language form of communication to share ideas, knowledge, information and complex concepts. In addition, design practice also uses the activity of making things (prototypes, doodles, mock-ups) as a means of thinking, reflecting and considering specific questions and challenges.

When such practices and techniques are shared with other stakeholders in a co-design initiative, and designers or design researchers take on a facilitating role, it achieves two principal things:

  • practical, making activities enable people to reflect on questions, experiences and complex ideas before they respond to the question or challenge posed. Hence their responses are more considered and they often realise tacit or unconscious knowledge about their experiences that may not have been revealed through other, more direct forms of enquiry
  • the things they make become part of the visual mode of communication that augments their ability to collaborate with others from different backgrounds, creating a more level playing field

Deduction, Induction, Abduction


This fellowship brings together knowledge, understanding and expertise from multiple worlds:

  • clinical practice (healthcare delivery)
  • health services research
  • implementation, knowledge translation or knowledge mobilisation research
  • design practice
  • design research

“I am still challenged and sometimes frustrated by a common academic view of the Journal paper as the end goal; as ‘impact’. Sometimes this view is held because it is just very difficult to translate knowledge (words on paper) into actions. There is no escaping this; it is hard. But this is what designers and engineers do. Their disciplines are translational, and there is an opportunity for more academics to collaborate with designers and engineers in their research from the start, not as an afterthought.”

Dr Joe Langley, Knowledge Mobilsation Fellow

Some of these worlds were less familiar to Joe. Hence, Joe’s methods were aimed at increasing familiarity with the first three areas and then experimentally utilising the design methods within them (in co-design settings) to gain an understanding of what was happening from a Knowledge Mobilisation (KMb) perspective.

“I come from an engineering background and now use design and co-design practises within my research, working with Health Research Scientists, clinicians and patients. This gives me opportunities to use hybrid methods drawing on all these areas. This fellowship has given me a far broader appreciation of how different disciplines, expertise and world views can be woven together to create holistic knowledge that is pragmatic, relevant and works in-practise-in-context.”

Dr Joe Langley

A literature review, which focused on the area of Implementation and KMb, together with participation at a range of national and international research, clinical and innovation forums in these areas (including Garfield Innovation Center, Kaiser Permanente, San Francisco; Karolinska Institutet Stockholm, Mayo Clinic, Rochester, USA), rapidly increased Joe’s understanding of Knowledge Transfer (KT), Implementation Science and KMb (in the field of healthcare). Immersive experiences in a Metabolic Bone centre in Sheffield Teaching Hospitals NHS Trust, collaborations with YH CLAHRC and undertaking a number of case studies increased Joe’s understanding of clinical practice and health services research.

During the fellowship, Joe was mentored by experts from different fields of expertise

  • Prof Jo Rycroft-Malone (Pro Vice-Chancellor, Research & Impact & Professor of Implementation & Health Services Research, Bangor University) – implementation science
  • Prof Jo Cooke (Deputy Director and Capacity Lead, NIHR CLAHRC Yorkshire and Humber and Honorary Professor of Health and Social Care Research, Sheffield Hallam University) – applied health research
  • Prof Paul Chamberlain (Director of Art and Design Research Centre and Lab4Living) – design research
gamified smart inharler

“When Joe was awarded his knowledge mobilisation fellowship the contribution of design thinking and science to implementation research had not been explored. This has changed significantly, largely due to Joe’s work in raising the profile and potential of design science.

During this time it has been a pleasure to work alongside Joe. His creativity, energy and enthusiasm has brought some much needed fresh thinking to how we can improve health and care services through genuine partnerships and the co-creation of knowledge.”

Professor Jo Rycroft-Malone, Mentor

Case Studies

Five case studies emerged through the collaboration with YH CLAHRC and enabled Joe to apply and ‘play around with’ design and co-design practices in health service and health services research initiatives.

  • Improving midwifery services with and for mid-wives and expectant women – see below
  • Developing a mental capacity assessment support tool (MCAST) with and for speech and language therapists in community and hospital settings – see below
  • Development of a testicular volume assessment tool and training kit – see below
  • Designing gamified smart inhalers with and for school age children – resulting in concepts and working prototypes
  • Designing an emotional support tool with and for patients on an acute cardiac ward – resulting in concepts and working prototypes for a complex support tool that includes peer networks, paper and digital based components for patients and family members.
Developing an emotional support tool for patients on an acute cardiac ward

Case study #1

Better Births by Design: Improving midwifery services with and for mid-wives and expectant women

In this case study, which focused on improving midwifery services, two midwifery teams (one community team in Colchester and one hospital based team in Preston) participated and were trained and mentored in using co-design as a means of improving their services. An evaluation was carried out by an independent academic from Bangor University nine months later with positive outcomes.

2 years on and both teams still tweet about their co-design and improvement activity.

Case study #2

MCAST: Developing a mental capacity assessment support tool

Mental Capacity Tool
Mental Capacity Tool

A toolkit for assessing mental capacity has been developed with and for speech and language therapists in community and hospital settings. The toolkit is currently being tested/evaluated via a clinical trial in Sheffield Teaching Hospitals.

2 years on and both teams still tweet about their co-design and improvement activity.

“I have really enjoyed working with Joe. Using design in health services research has been highly insightful and formative in our thinking about co-production in the CLAHRC, as you can ‘see’ authentic partnership working in action. The process of making things helps to uncover people’s ideas and thoughts, to share them, and provide opportunities for synergy. Making things together is a great leveller and pays attention to power issues in the sharing process. 

Design and design thinking should be an important consideration in the shape of future health service research teams.”

Professor Jo Cooke, Mentor

Case study #3

Testicular Volume Assessment: Development of an assessment tool and training kit

In this case study, a prototype simulation model was designed and built to test the accuracy of paediatric endocrinologists’ volume assessment. Once data was collected and evidence of inaccuracy established, we explored alternative approaches to training, co-designing (with endocrinologists and students) a package that included simulation and physical analogies based on everyday objects.

This was piloted in 2017 with one cohort of trainee Paediatric medics and is currently being revised based on the feedback.


Related research on Sheffield Hallam University’s Research Archive

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