ENRICHED INTAKE PROCESS A redesign of the intake process at Dutch midwife practices with the aim to empower ‘vulnerable’ women in their pregnancy journey

Final bachelor project Noëlle van Glabbeek

Coach: C.C.M. Hummels

In collaboration with Philips DesignPhoto by: ThinkStock

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A redesign of the intake process at Dutch midwife practices with the aim to empower ‘vulnerable’ women in their pregnancy journey Final Bachelor Project Noëlle van Glabbeek Student number: 0938999 E-mail: n.c.v.glabbeek@student.tue.nl Squad: Transformative Inclusive Practices Project Coach: C.C.M. Hummels Teacher Coach: P.J.F. Peters Collaborations: Philips Design, Maxima Medical Center (MMC) Veldhoven, PUUR Verloskundig Centrum Veldhoven

INDEX

Acknowledgements 30 References 31 Appendices 32 Reflection 33 Appendix 1: Scope 34 Appendix 2: Interviews 36 Appendix 3: Intake form 49 Appendix 4: Intake moment 57

Executive summary 4

Introduction 5 Prologue 6 Vision 6 Methodologies 6 Project background 8 Scope 8 Challenges 9

Design Process 10 Steps to iteration 1 13 Iteration 1 14 Steps to iteration 2 15 Iteration 2 16 Validation iteration 2 18 Steps to iteration 3 19 Iteration 3 20 Final proposal 25

Validation Final proposal 26 Discussion 28 Future work 29 Conclusion 29

ENRICHED INTAKE PROCESS

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The Dutch healthcare system is peforming relatively poor when it comes to perinatal care. TU/e, Philips Design, MMC Veldhoven and midwife practice PUUR started a joint initiative aiming towards systemic change of the Dutch healthcare system forperinatalcare.Withinthisinitiative,theyspecificallyfocusonempoweringandguiding ‘vulnerable’ women through the system. As a part of this overarching project, this student project focuses on a smaller part on micro level by re-assessing the intake process at the midwife practice. In this intake process, challenges are present involving sensitivity and trust towards the pregnant women as well as making a holisticriskassessmentwhilebeingtime-efficientasmidwife. Based on interviews with experts, midwives and (pregnant) women, a redesigned intake process is proposed consisting of three tools touching upon these challenges. Instead of a direct, impersonal intake form in paper version, a digital, interactive intake form is proposed. With the interactive, digital intake form, the women are able to get information, note down questions immediately or indicate sensitive subjects. Based on this information, advice for communication is given to the midwives by the midwives’interface.Thisinterfacefurthermoreshowstheprofileofthewoman,anoverviewofrisksandtheoptionssheusedbyfillinginthequestionnaire.Duringthefirstappointments,themidwifecanusethephysicalcommunicationtooltoreallyhave a conversation, gain trust and get the right information of the pregnant woman. By adding the information to the system again by a NFC-reader, all information will go into the midwives’ interface again. Validation with women, a health professional and midwife gave valuable insights that can be used for future iterations. It is recommended to make these next iterations, in order to be able to test the proposed process with a bigger focus on how the tools willfitinthemidwives’workflow.Bygatheringthesenewinsights,adaptingdesigns,collaborating and linking it to other work of students/designers, future designers will come closer towards systemic change of the Dutch healthcare system for perinatal care. However, while doing this, I recommend that these designers do not forget the current thoughts of people in practice and touch upon their (lack of) awareness with their designs as well.

EXECUTIVE SUMMARY

Although the Dutch healthcare system is seen as a wealthy health system in Europe, the perinatal death rate is fairly high in comparison with other European countries (Buitendijk et al, 2014; Mohangoo et al, 2008). When the Netherlands is compared to countries with the same quality of numbers, level of healthcare and population characteristics, for example Finland, Belgium and Germany, recent data shows the poor performance and improvement of the perinatal death rate (Vos et al, 2014). For this reason, promotion of healthy pregnancy is one of the top priorities for the Dutch health care system (Denktas et al, 2011).

When zooming in on this poor performance, it is found that most ethnic minorities even have a larger perinatal death rate than indigenous Dutch women (van Enk et al, 1998). The results of the study done by Bollini et al. (2009) showed inequity for immigrant women in the Dutch healthcare system and for this reason, they highlight the importance of these women to get targeted attention.

To tackle this challenge, Philips, TU/e, Maxima Medical Center (MMC) Veldhoven and midwife practice PUUR have started a joint initiative to set up a project that focuses on improving pregnancy of the ‘vulnerable’ pregnant women in the Dutch healthcare system. With the term ‘vulnerable women’, they target not only at ethnic minorities or migrant women, but also on ‘women with a low-socioeconomic status, low education, low social integration or living in deprived areas and/or affected by language barriers.’ (Philips, 2018). Within their project, they pointed out three innovation streams that eventually aim towards systemic change of the Dutch healthcare system for healthy pregnancy. Philips Design invited four students from theIndustrialDesigndepartmenttoworkonthefirstinnovationstream.

Thefirstinnovationstream(Fig.1) is about empowering and guiding the vulnerable women for a healthier pregnancy. It entails the early access, reliable and tailored information, and approach of services during the overall process to stimulate a healthier pregnancy for these women.

INTRODUCTION

Project divisionDuring this semester, master-student Jing-Cai Lui is doing her design research project on the how to engage the pregnant women to get access to the system. Final Bachelor student Veerle Teigeler is doing her project about how to get reliable and tailored information in an app designed for these women. This project’s main focus will be on the intake process of the pregnant women. The project will look into the approach and services towards the pregnant women during this process, both from the pregnant women’s perspective as the midwives’ perspective. Since these projects are about the access and guidance through the perinatal healthcare system, they canbeseenaspartofthefirstinnovationstream.Thefourthstudent,BrittSmuldersis working on developing a tool to map all the stakeholders involved in this process. Sinceherprojectlooksattheoverallpictureofstakeholdersanddifferentvalueflowswithinthesystem,itcannotbeseenaspartofthefirstinnovationstream,butmoreas an overarching project that touches upon more innovation streams. Fig.1. Innovation stream 1 (Philips, 2018)

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Vision I believe that in society, everybody should have equal rights, equal opportunities and reachable facilities. The place people live, or come from, should not determine the care they are able to receive. My vision as designer is inlinewiththeSustainableDevelopmentGoalsdefinedbytheUnited Nations General Assembly (2015) to reduce inequality and improve health and wellbeing by the year of 2030. Inordertofightthesechallenges,weshouldtakea strong user perspective. How can we design for people if we do not understand them, their view and their thoughts? Most insights for this approach emanate from philosophy. For example, as the Zimbabwean philosopher Joram Tarusarira (2008) ones stated: ‘If you don’t know their software, there will always be this gap in terms of understanding in conversation. If you want aid to be of effect, then you have to engage with the people; if you want sustainability, you have to engage with the people.’ Understanding different cultural values, desires and needs are of high importance here. In the end, by working towards societal change, I think it is important to not only focus on how we as designers can improve situations and make people learn new behaviours or lifestyles, but how we can learn from our users as well. Designing is a process of sharing thoughts, experiences and ideas amongst different perspectives tolearnandreflectonthem.

At last, designers should take into account the value of listening, observing, questioning, associating and experimenting. Dyer et al. (2009) described most of these skills in their article named The Innovator’s DNA. I strongly support these activities, since I believe you must not only value your own thoughts, assumptions and ideas, you need to be critical about them. Listen to others, observe others, question their perspective as well as yours, associate subjects in a creative manner and experiment to validate.

PROLOGUE

Methodologies Transformative practicesThefirstunderlyingapproachofthisprojectiscalled‘DRIving(DesignResearchand InnoVation) framework for Transformative Practices (in short: TP framework)’ (Hummels et al, 2019). This framework (Fig.2) helps to research and design in order to work towards systemic change while facing the societal challenges of today’s world. The framework consists of multiple activities that are encouraged within designing and researching, as well as collaborating and developing. Those activities varyfrompositioningandframingtoreflectandlearning.Theactivitiesarestronglyconnected to each other and can be done more than once, in any order. During this project, this holistic approach has been an underlying driver throughout the design process. Since the whole Philips project aims towards systemic change in the Dutch healthcare system, it seemed a valuable framework as underlying methodology. All design activities, therefore, are positioned in this framework as indicated in this report. Although the aim is to work towards change while doing these activities, it should be remembered that within this project the design activities were executed on a micro scale by involving women and midwife practices from Eindhoven and surroundings. However, with the joint initiative of TU/e, Philips Design, MMC Veldhoven and PUUR, the aim is to work towards societal change on macro level.

First- second- and third perspectives to design Anotherapproachusedinthisprocessisbaseduponfirst-,second-andthirdperspectives to design. As Tomico et al (2012) describe these perspectives as follows: -Thefirst-personperspectiveentails‘designingforoneselfwithinsociety’.Thismeans that designers design in the context itself and including their own experiences when designing. - The second-person perspective entails ‘designing together with a group of people that are part of society’. This means that the designer includes other stakeholders to design in collaboration with them. - The third-person perspective entails ‘designing for people and society in general’. This means that the designer designs without including users, but with thinking about the problem from a distance.

Smeenk et al (2016) highlight the importance of a mixed-perspective approach, since it ‘brings about a novel and deeper understanding of the commonalities in existing design methodologies’. Giving the fact it seems a promising approach and it aligns with my vision as designer to be aware of the difference of your own perspectives in comparison with others, this method has been taken into account during the design process.

The overall project is completely in line with my vision by supporting the pregnancy experience of ‘vulnerable’ pregnant women in the Netherlands. Since I strive for having a strong focus on the users perspective, this has been used as central input. The project is also approached while taking into account the methodologies explained above. However, it must be noted that they all were an underlying approach throughout the design process, not one is used explicitly step-by-step.

Before getting more into depth about my project, I will share my vision as designer. By doing this, my values and approach throughout this project will become more clear. Furthermore, I will elaborate on the underlying method used for the project to briefly explain where different activities of this project are based upon.

Fig. 2. Detailed activities and elements of the TP framework (Hummels et al, to appear in 2019)

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Scope As explained in the introduction, my focus within the Philips project will be on the intake process of the pregnant women. The overall aim is to enrich the process in a way it provides a more comprehensive view of the women’s condition, and eventually supportthemidwives’workflowindetectingrisk.Requirementsinordertodoso,willbe that the eventual solution must be well accepted and appreciated by midwife and pregnant women and improve mutual trust between them during this process.

When looking at this intake process, it can be divided into three parts or steps (Fig. 3). Thefirstpartistheintakeformthatneedstobefilledinbythepregnantwoman.Thisintakeformasksquestionstothepregnantwomanbeforeshehasherfirstmomentwith the midwife.Thesecondpartwillbethefirstriskassessment,whereanestimationisdoneifthiswoman and her unborn child are at risk. Thethirdpartisthefirstintakemomentwiththemidwife.Hereshewillhaveherfirstacquaintance with the midwife practice in a face-to-face moment with a midwife. Due to time limits of this project, the intake form and intake moment will have a bigger priority than how the risk assessment is being made. However, the risk assessment remains an important part of the intake process, so it is not ignored completely: the subjects for risk assessment were researched, however, the whole algorithm behind this risk assessment was left out of scope.

PROJECT BACKGROUND

Fig. 3. Parts of the intake process

Challenges The reason why it is of importance to look into this process is because the Dutch Healthcare system is facing a couple of challenges while providing service to the pregnant women. Those challenges can be described as follows:

Risk profile: As described in the introduction, not all risk is detected which results in a relatively high perinatal death rate. The focus right now is mainly on medical risks, however, non-medical issues as background, negative experiences and environment are left out. It is of importance to take these issues into account as well, sincetheycanhaveaninfluenceonthewomen’shealthaswell(Hellström,1993;HTP, 2014).

Time: Although the midwives need to make a more holistic risk assessment, they only have limited time for each woman. It remains a challenge to take all those risk factors into account, while having not much time to go through all those factors with the women.

Cultural-sensitivity: the way questions are being asked can be very direct due to our Dutch culture. It does not take into account other religions, cultural values or negative experiences of pregnant woman.

Trust: due to cultural differences, the midwives are sometimes taken less seriously than doctors. Furthermore, due to time limits not all questions are being answered for the pregnant woman which can reduce her trust in midwives or healthcare system as well.

To get a more in depth overview of my project focus and scope, see Appendix 1.1. HereyoucanfindmyFinalDesignBrief,abriefthatwasset-upinthebeginningofthe project to make clear requirements, challenges and deliverables of my bachelor project. However, it is important to mention that this supported the project with taking the general aims and challenges into account rather than being a strict format to hold on to.

Position and frame

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The design process initiated by looking at the two different parts of the intake process separately (as described above): the intake form as well as the first moment. Since I aim to dive into my user’s values, needs and desires, I took this as central input throughout the design process. In the shown Fig. 4, the whole design process and its iterations are visualized. Descriptions of the major activities are described afterwards. It must be mentioned that although the visual indicates an almost chronological process, not all activities are done after one-another. Various activities were overlapping and influenced each other interchangeably. However, the process is being explained in this manner to clearly show the work done and the decisions made to the final proposal of the intake process and belonging tools. Furthermore, at every design activity it is highlighted what the underlying step is based upon the TP framework to work towards systemic change.

DESIGN PROCESS

Fig. 4. Visualization design process

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Steps to Iteration 1 BenchmarkingWith the aim of designing an enriched the intake process, a requirement was set in thebeginningtohavealookattheintakeform,neededtobefilledinbyapregnantwoman before entering the midwife practice. In such an intake form, mainly questions about medical health are being asked for a midwife to assess if this woman is at risk and needs additional services. As described in challenges, it is assumed that these intake forms can be very direct, meaning that they are not taking into account cultural sensitivity. Furthermore, it was assumed that it does not take into account other risk factors except for medical ones. Non-medical issues will be dealt with later, or not at all. To justify these initial assumptions, it was decided to do benchmarking ofintakeforms.Inadditiontothis,twointakeprocessflowswerealreadytakenintoaccount within this analysis, to see what additional information is asked later on in the process and why. The forms and processes analysed during these benchmark included the following:

- 10 basic intake forms of midwife practices in the Netherlands- R4U,whichisanintakeformspecificallydesignedforvulnerablewomenevolvedfrom Erasmus studies (van Veen et al, 2014)- Mind2Care,whichisadigitalintakeformspecificallydesignedforvulnerablewomen evolved from Erasmus studies (Quispel, 2014)- Intake process designed by Nicky & Minerva (two former TU/e students that already worked on this project)- Intake process midwifery practice PUUR (according to interview)

While analyzing these forms, the different subjects were clustered to get an overview of what is needs to be asked to assess vulnerability and to design a form to detect this vulnerability within a basic intake form of a midwife practice. An overview of these subjects per form can be seen in Appendix 3.1.

The next step in this benchmark was to clarify where the opportunity lies for a new intake form. From both the perspective of the pregnant women, as well as the perspective of the midwives, the analysis of the different intake forms made it possible to make an overview of the forms amongst important factors. Whereas sensitivity and length of the form were indicated to be important for a pregnant woman(basedondesignbrief),timeefficiencyandaholisticriskassessmentwerethe ones for the midwives indicated by the interview with a midwife from PUUR (see Appendix 2.2/2.3). Due to this overview (Fig.5) based on research of Erasmus (Van Veen et al, 2014; Quispel, 2014) and going through them myself, it became clear that the challenge of the intake form relies in making the intake form more sensitive, but not too much time-taking for the pregnant women, but at the same time, providing a holisticriskassessmentaswellasbeingtimeefficientforthemidwife. Pregnant woman’s perspective Midwife’s perspective Fig. 5. Benchmark of intake forms

Position and frame

Fig. 4. Visualization design process

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Steps to Iteration 2

User involvementAlthough interviews were already a focus from the beginning of the project, it began tohaveabiginfluenceontheseconditerationoftheproject.Outofinterviewswitha midwife from PUUR, women at Woensel market, an medical advisor of AZC Budel, aSyrianwomanwhofledhercountryafewyearsago,aTurkishambassador,aMoroccan ambassador and a Montenegrin ambassador came important insights where decisions were based upon for the second iteration. These semi-structured interviews were analyzed using thematic analysis. For the interview questions, analysis, notes and the consent form see Appendix 2.1 to 2.13. In the text box below (Textbox 1) important remarks are being summarized. Textbox 1. Insights interviews

Syrian refugee: She did not mind answering certain questions, although she thought some questions were sensitive in her culture or religion. If she knew WHY those questions are being asked, she wanted to answer it.

Midwife practice PUUR: -Languagebarrierisabigdifficulty.Translatorsneedtobepaidbythepracticesotheyonlyuse it if really necessary. - Guidelines towards cultural differences would be appreciated by midwives: what are sensitive subjects in a culture, how to approach them?

Turkish, Moroccan and Montenegrin ambassadors: - subjects as abortion, drugs or alcohol are sensitive subjects in the Islamic religion, because it is not an option for them.- Pregnancy experiences: women often experienced a language barrier, a partner/family member translated during visits- It would be good to prepare women on the sensitive questions that are coming and to put emphasis on importance for their pregnancy.

AZC medical advisor: ‘I don’t think you can approach everyone in their own manner through one questionnaire. What you can do, is explain why we ask those questions, so they will understand why it is important for us to know.’-Languagebarrierisabigdifficulty- For refugees a lot of simple explanation is needed

Desk researchNext to benchmarking, desk research was done into rules and advices about subjectstoincludewithinanintakeform.ThegovernmentguidelinesoftheKNOV(2005)formulatedaspecificsetofguidelinesmandatoryforamidwifepracticetoask to a pregnant woman to see if she is at risk. These guidelines include general- , obstetric- and family particularities (f.e. age, diabetes or hereditary diseases).Besides these guidelines, a lot of research at Erasmus Rotterdam were already done withintheareaofperinatalcarefor‘vulnerable’women.SpecificallyPhDstudybyQuispel (2014) looked into the forms R4U and Mind2Care and advised the following:

‘’If used as guidance to tailored risk specific care, the instruments seem to provide complementary information and they could be used in addition to each other.’’

Thebenchmarkanddeskresearchtogetherledtothefirstiterationoftheintakeform: a paper version of the questions needed to be asked to the pregnant woman while entering the midwife practice.

Intake formBased upon the balance between the midwives’ perspective and the pregnant women’sperspective(identifiedbythebenchmark)andtheguidelinesandadviceof desk research, it was decided to include the questions of the basic intake forms according to the government guidelines, the questions for vulnerability of R4U and Mind2Care.Thesesubjectswerecolour-codedandorderedtocometothefinalquestions of the intake form (Fig. 6). This total package of questions is validated later on in the process by a midwife from the practice verloskunde040. With her adjustments,afinalversionoftheintakeformwasset-up(see Appendix 3.2).

Intake momentSince the benchmark indicated that the intake form must not be too long for the pregnant women, some questions that assess vulnerability were decided to move to intake moment. The additional subjects of cognition, mental health and lifestyle are needed to be assessed and discussed during this moment with the midwife. For thosespecificquestions,basedonthequestionnaireofMind2Care, see Appendix 3.3. Fig. 6. Ordering subjects and questions for risk assessment

ITERATION 1

Desk research SensitivityFurther desk research into the Erasmus studies showed that sensitive questions were answered by the pregnant women, only explanation of why the questions were asked was needed:

‘’ A minority of women expressed a little embarrassment answering the sensitive questions, or asked for explanation why these items were asked, but none of them actually refused to answer. This may be partly due to the fact that reluctance is usually less than expected among those with serious problems,

and partly because the Dutch “ public is informed on the duty of perinatal caregivers to ask for domestic violence in all women. ‘’ (van Veen et al, 2014)

Desk research intake momentThe cultural dimensions of Geert Hofstede (2005) gave insight in how eventual cultural guidelines can be set up, based on a comparison of cultural differences. Atlast,specificresearchintoTurkishandMoroccanpracticesduringpregnancybySahin (2018) made it clear that some cultures have other ideas and values within pregnancy: something that is good to know for midwives since it was proved to be able to negatively affect the woman.

Benchmarking communication toolsSince language barrier was something that was experienced by all people interviewed until this point, benchmarking into communication tools to overcome this barrier was done. From cultural probing to medical models explaining health issues were researched and pros and cons were eventually formulated in Appendix 4.1.

Collect and analyse Collect and analyseEnvision and create

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Intake formBased upon the conclusion that it is mainly how and why questions are being asked, instead of the subject and sensitivity of the question, an interactive intake form was made (Fig. 8). This interactive intake form consists of a virtual midwife that will introduce you to the midwife practice, guides you through the subjects that are going to be asked and gives you three optionstomakeuseofwhilefillinginthequestionnaire:- An information button (i-button) to get more information about the subject and why this is of importance.- A question button (?-button) to note down additional questions that pop-up during the questionnaire.- A cross button (X-button) to skip the subject in order to discuss the subject only in person with the midwife.

When arriving at the more sensitive questions, the midwife prepares you by explaining that those questions can be experienced sensitive and by remembering the pregnant woman to use the cross button if needed.

Asfirstprototype,avideowasmadewithaEnglishvoice-overguidingyouthroughthefirstquestionsofthefirstiteration.Thisfirstprototype,canbefoundbyscanningtheQR-codebelow: Figure 7. QR-code intake form iteration 2

Figure 8. Screens of interactive intake form (iteration 2)

Intake momentTheinsightsthatlanguagebarrierisadifficultyforwomenspeakinganotherlanguage, that guidelines for cultural differences are appreciated by midwives andthebenchmarkingshowingthatdifferentcommunicationtoolsarebeneficialin different circumstances made it clear that a tool is needed which supports the midwife in communicating with women with various backgrounds. Based on these insights,itwasdecidedtodevelopthefirstdigital communication tool with multiple options for the midwife to communicate with the pregnant woman.

The tool consisted of the following options:→Videoswithexplanationforthewomanaboutcertainsubjects→Termsandpicturestoovercomethelanguagebarrier→Guidelinesforinterculturalcommunicationtopreparebeforehand→TheX-buttonsubjectsskippedbythewomanduringtheintakeform→The?-buttonwiththequestionsaskedbythewoman→Additionalmentalhealthquestions(iteration1)→Additionallifestylequestions(iteration1)→Translatorasgoogle-translate→Drawingtooltocommunicate→Optiontowritedownnotesforthemidwife,indicatedbymidwifePUURasimportant option

Next to this, the profile and important results of the questionnaire will be at the left for the midwife to see is in front of her.

Forthisfirstidea,apaper prototype was made to validate this concept with multiple people. It was decided to already visualize this idea, to show the stakeholders what was envisioned with this concept. This prototype was printed out and put on foam board. The visualization of this prototype, can be seen in Fig. 9.

Fig. 9. Paper prototype communication tool midwives

ITERATION 2 Envision and create

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Validation iteration 2

User/Expert involvementTo validate both the interactive intake form as well as the proposed communication tool,usersandexpertswereaskedtogivefeedbackonthefirsttwolow-fiprototypes.The most important insights are summarized below, however, all notes and conclusions of these validation sessions can be found in Appendix 2.14 to 2.17. For some of these interviews, questions of earlier interviews were re-used to get more general information (for example interview questions for midwife practice PUUR were reused at the interview with verloskunde040). However, since the focus was mainly on getting feedback at the prototypes, it was decided to not formulate any additional questions.

Intake formNicole Sanches, PhD Candidate in Cultural Anthropology at Utrecht University and due to her work expert on cultural differences and intercultural communication, gave valuable feedback on both the intake form as well as the best way of communication. For example, she mentioned to make the stereotype less stereotypical. Furthermore, shestatedthatshefindthetoneandformulationofthequestionsaccessibleandinviting, but that offering it in multiple languages would be even more valuable, because this will increase the accessibility to the category of ‘vulnerable’ women.

Furthermore, a co-founder and social worker of Stichting Ik Wil, a non-profitorganisationbasedinEindhoventohelppeoplewithvariousbackgroundinWoensel with their role in society, gave feedback on the intake form as well. Although she mentioned that this interactive intake form is very inviting and it helps with understanding why certain questions are being asked, it might be challenging for peoplewithoutacomputertofillinthisquestionnaire.Shementionedthatitmightbegoodtolookintowhatisthebestdevicetofillinsuchaquestionnaire,whiletakingaclose look at the women we try to target.

As third, the Syrian woman of a former interview was asked to give feedback on the intake form again. Next to the fact that she mentioned she would prefer the intake form in her own language, she also highlighted the importance of making the form able to give the answers back in speech. This would include a big group of analfabetics as well. At lasts, she recommended to use a lot of pictures with the information page to have it very clear for the pregnant woman. At last,, a midwife of verloskunde040 gave her feedback on this form. The midwifeconfirmedthiswouldbeaneffectiveapproachformigrants,butalsoforyoungpregnantwomen,whoareoftenanxiousabouttheirfirstpregnancy.Furthermore,sheexplainedthatthisintakeformcouldalsobefilledinatoneoftheirtablets in the midwife practice. This will give women who do not have a computer at home,theabilitytofillinthequestionnaireaswell.Atlast,thefactthatthisdigitalquestionnairewouldautomaticallyprocessthedataintotheirsystem,shefindveryvaluable.

Based on this information, a third iteration of the intake form was done (see Iteration 3)

Steps to Iteration 3 REFLECTION: Digital vs Physical At this point in the process, by presenting to coaches and talking to others about the project, I realized that my communication tool as digital tool for the midwives would bring some disadvantages to the moments between the midwife and the pregnant woman that could not be ignored. As stated in the Design brief, it is important to support mutual trust between the midwife and the pregnant woman, in order for the pregnant woman to share her story and situation. In this way, a valid risk assessment can be done. However, as stated in literature a health professional constantly behind her computer will not improve the communication and trust with the patient (Haider et al, 2018). By asking around, I found out that a lot of people who had appointments with health professionals (within the hospital or general practitioners for example) experienced this problem of feeling that the health professional does notpayattentiontothemandonlyfillingintheanswersanddataintheircomputersystem. This made me realize that if I want to support the communication during the appointments, a physical tool would be more suitable to create mutual trust than a digital tool would.

Desk researchFor both the intake form as well as the communication tools, it was decided to do a bit more research on the meaning of colours, how the visualization of emoticons differ amongst cultures and what approach to use in a cultural sensitive manner. For example, for the next iteration the cultural wheel for colours of McCandless (2009) was used to determine the colours of little visualizations. For more conclusions on this desk research, see Appendix 4.2.

Intake moment - Communication toolThe four experts/users described above were also asked to shortly give feedback on the concept of the communication tool, visualized by a paper prototype. As Nicole Sanches as well as the social worker of Stichting Ik Wil highlighted the importance of approaching different women in their own, personal manner, the social worker indicated that it would be very valuable for the midwife to already know who is in front of her and what is the best way to approach her. This is something that was very notable in all the previous conversations at Woensel market and the breastfeeding cafe as well: everyone seemed to prefer their own manner of communication and everyone seemed to prefer their own way of being approached. With this idea already in mind, it was proposed to another midwife of verloskunde040. She reacted positively by mentioning that it would be very valuable if they already know beforehand how to communicate and what to use exactly per woman. This will give them the opportunity to really personalize their care for each woman.

All these main insights were taken into consideration with the third iteration of both the intake form as well as the communication tool.

Collect and analyse Reflect and analyse

Collect and analyse

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Intake formBased on the interviews, a new iteration was made for the intake form (Fig. 10).The midwife is visualized less stereotypical, the information button was worked out withpicturesforthefirstsubject.Insteadofavideo,theintakeformwasmadeinaprogramwheretheusercanfillinthequestionsandmoveinteractivelythroughthewhole questionnaire. At this point in the process, all questions of iteration 1 were worked out so the intake form was ready to be validated by (pregnant) women. To view this prototype, please scan the QR-code below (Fig. 11). Fig. 10. Screen interactive intake form iteration 3 Fig. 11. QR-code intake form iteration 3

ITERATION 3

Intake moment: Midwives’ interface + communication toolBasedonthefeedbackoftheusersandexpertsandthemomentofreflection,itwas decided to make a new iteration of the midwife’s interface in combination with a physical communication tool.

The midwives’ interfaceThe midwives’ interface is now proposed with several options (Fig. 12). The interface was programmed in processing, for this code see Appendix 4.3.

Advice in communicationInstead of an interface only guiding as an advice in communication tool (iteration 2), it was now decided to have it only as an option to show what the best approach is in communication towards the pregnant woman. Since the social worker of Stichting ik Wil highlighted the importance of already knowing who is front of the midwife before thefirstappointment,theconceptchanged:basedontheinformationoftheintakeform, several options of the approach in communication as well as important subjects to discuss (for example lifestyle) is given. Since the intake form was made in a program that could not provide data as output, it was decided to take a letters on the keyboard to show how the advices changes with other answers from the intake form.

Risk visualization based on the answered filled in by the pregnant womanSince the whole point of the intake form and intake moment is still to assess if a woman is at risk, a risk visualization was designed to see where high risks are present. In this way, the midwife is able to immediately see what needs higher priority overanothersubject.Withclickingonthebutton‘outstandingdata’shewillfindtheanswers of the intake form, given by the pregnant woman, in a textual format. Having thisspecificinformationintextinonepage,wasindicatedtobevaluablebyoneof the midwives of verloskunde040. Furthermore, an option to see all the results is given, to go through all the answers of the intake form. In this way, the midwife is able to access all the information obtained by the interactive intake form.

X-buttonThis option will show the questions indicated by the pregnant woman as ‘subject movedtoonlydiscusswithmidwifeinperson’.So,thequestionsrelatedtospecificsubjects listed in this option, will give the midwife insight in what could be sensitive subjects, or which subjects need extra attention.

?- buttonThis option will show the questions, noted down already by the pregnant woman herself. In this way, the midwife already has insight in what the woman is thinking about and what information she would like to have.

Important notesThis option gives the midwife the opportunity to note down important information for her and her colleagues. Since this happened to be an important feature of the system they have now according to the interviews with the midwives from PUUR and verloskunde040, it is decided to have it in this interface as well.

Envision and create

Fig. 12. Midwives’ interface

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Physical communication tool Based on the option: advice in communication, the midwife can use the physical communicationtoolduringthefirstmomentswiththepregnantwoman.Thiscommunication tool is based on knowledge from positive health/psychology (Seligman, 2008). Positive health believes health is not just being ill or healthy, but that every person has different positive health assets which contribute to a longer, healthier life. In this sense, health is seen as ‘’the ability to adapt and self manage in the face of social, physical, and emotional challenges’’ (Huber et al, 2011). Since every person has different assets for health, one resource can bring something positively for the one, but negatively for the other.

Inspired by the theories of salutogenesis, which explains people use this assets onacontinuumfromdiseasetoease(health)(Lindströmetal,2005),aplatewitha continuum was made (Fig. 13). This continuum goes from ‘‘reduced health’’ and ‘‘negative feelings’’ towards ‘‘improved health’’ and ‘‘positive feelings’’. The intention with this continuum is that different subjects are being placed at different points in the continuum, to see what assets and stressors towards health are for the pregnant woman. Fig. 13. Continuum of communication tool

For the different advices for communication, the terms and pictures, lifestyle questions,mentalhealthquestionsandgeneralsubjectsweremade.Otheradvices,for example simple explanations, were not worked out due to time limits of the project.

Terms and pictures (Fig. 14)These communication cards were made due to the fact that language barrier seemed a big issue in the appointments between the midwife and the pregnant woman. Fig. 14. Communication cards terms and pictures Lifestyle questions (Fig. 15) These questions were the additional questions needed to be asked if the results of the intake form highlighted outstanding results regarding lifestyle. These questions are about the amount of physical activity, drugs or alcohol. Fig. 15. Communication cards Lifestyle questions

Mental health questions (Figure 16)These questions were also additional questions needed to be asked if the results of the intake form highlighted outstanding results regarding mental health. The additional questions are based upon questions from the benchmark of Mind2Care and R4U. These questions consist of 8 questions from the EDS-questionnaire, which gives an impression of the mental health of the pregnant woman.

Fig. 16. Communication cards mental health General subjects (Fig. 17)With the idea in mind that other subjects could be also important for the woman, especially when it needs to be placed on a continuum next to, for example, the mental health questions, communication cards of general subjects were made in Dutch and English. Fig. 17. Communication cards general subjects

With these pictures, the midwife and pregnant woman can communicate and get into a deeper conversation: what makes the woman feel happy? Why? What makes the woman feel less happy? Why? What are her worries? With having this deeper conversation, the aim is that trust can be improved between the midwife and the pregnant woman. With this trust, more information might come to the table and eventually, the midwife is able to make a better risk assessment based on this information. The midwife will get a holistic picture of the woman by using this physical communication tool (Fig. 20). To get the information back into the midwives’ interface, it was proposed that the midwife can use a NFC-reader to scan these communication cards which appeared to belong important information to and note down the important things discussed into the system (Fig. 18 and 19). This is function is programmed with Arduino in communication with Processing. To see the Arduino code, see Appendix 4.4.

] Fig. 18. NFC-reader with com. card Fig. 19. Pop-up in midwives’ interface Fig. 20. Physical communication box with NFC-reader

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REFLECTION: Midwives’ workflowUntilthispointoftheprocess,thefocuswasreallyonhowthemidwives’workflowneedstobeinthefuture.AlthoughinthefirstinterviewwithPUUR(Appendix 2.2/ 2.3)theirintakeprocesswasbrieflydiscussed,itwasnevermadeveryclearhowitthenwouldbeimprovedusingthesetools.Reflectingonthis,itwasdecidedtovisualizethemidwives’workflowrightnowbasedontheinterviewsofPUURandanadditional interview with a midwife from verloskunde040 (Appendix 2.18). Having thisclear,itiseasiertomakeafinalproposalbyknowingwhichtoolsworkonwhatmomentandhowitworksregardstimeefficiencyofthemidwives’workflow(oneofthe important factors stated in the beginning).

Legend:

FINAL PROPOSAL

Whenknowingtheexactflowforbothpregnantwomenaswellasthemidwives,I am now able to propose the enriched intake process including the three designed tools. By using these tools, the midwives will be supported in making a holistic risk assessment within their time constraints, but most importantly, the pregnant women will be approached in a sensitive manner.

Reflect and analyse Envision and create

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To validate the tools, two focus group were held (Fig. 21-22-23). The main aim for these groups were to get feedback on the proposed tools, with a perspective fromamidwife/healthprofessionalwithfocusontime-efficiencyandaholisticriskassessment, but also from the perspective of the pregnant women with a focus on sensitivity and trust. The semi-structured interview questions, formulated for this session, can be found in Appendix 2.19.Forthefirstfocusgroup,theSyrianrefugeefrom former interviews and the AZC medical advisor was being asked. For the second one, an expat coming from India as well as a midwife from verloskunde040 participated.

Both focus groups were structured in a way the intake form was mostly being discussed with the former pregnant women, the midwives’ interface with the midwife/health professional and the communication tool with both. Although the main focus was on getting feedback, it was attempted to simulate the intake process using these tools as much as possible. However, since the women were not pregnant anymore and not all options were worked out in detail, no strict conclusions can be made from this.

Conclusions focus groupsFrom both sessions, some conclusions can be made about the three tools as well as theimportantchallengesoftimeconstraintsandsensitivity.Toviewallthefindingslisted, see Appendix 2.20.

Intake formThe intake form was well received by both the refugee as the expat. Whereas the button to get more information as well as the button to note down questions seemed valuable for both women, the button to indicate sensitivity was of higher importance for the refugee. She indicated she would like to use that cross button when questions were being asked about family or support. Both women appreciated the visuals and did not think the questionnaire was too long, however, they both indicated that it would be handy if the questionnaire could be paused, or if you could go back to the former question. Furthermore, since the refugee spoke Dutch or English less well as her native language, she would preferred to have it in her own language. At last, the AZC medical advisor mentioned it might be good for illiterate people to have the intake form in speech in the future.

Midwives’ interfaceFor the midwives’ interface, the AZC medical advisor immediately highlighted the importance of the risk assessment visual. She indicated this can quickly give you an impression in order to already provide the pregnant woman with personalized care. Furthermore, both midwife as AZC medical advisor were quite enthusiastic about the data automatically being transferred from the intake form to the system. This would save a lot of administration time. At last, advice in communication would be appreciated and could help a lot, especially when the midwife is not familiar with the culture. If she is, the midwife mentioned that she might approach the women be based on experience instead.

Physical communication toolFor the communication tool, the communication cards were very appreciated by both women as well as AZC medical advisor and the midwife. However, the continuum was not very clear to both: How to use it? Where to place the cards? They both needed to have a lot of guidance in this. Furthermore, the expat indicated placing this cards in a particular order gave her a lot of stress. She mentioned that she wanted the midwife to take the lead in the conversation and to ask questions instead of rating things more importantly for her.

Pregnant woman’s perspective: Length and sensitivity As discussed above, both women did not think the intake form was too long. They stated that they did not mind since the questions seemed important concerning their pregnancy. With a focus on trust and sensitivity towards the pregnant women, the intake form seemed to be more approachable and sensitive than the basic intake forms of the midwife practice. Especially the video’s highlighting that the next question was going to be sensitive and the information about WHY the question was being asked seemed to be very appreciated by the women. Due to the simulation of an intake moment in both focus groups, it became clear that the physical communication tool would allow a deeper conversation between the midwife and the pregnant woman. Both women highlighted the fact that this was pleasurable, however, only if the midwife would take the lead in this.

Midwife’s perspective: time efficiency and holistic risk assessmentThe fact that the data from the intake form will be automatically received was very appreciated by the midwife. This will save a lot of administration time for her and her colleagues. For the midwives’ interface, the risk visualization would help the midwife in providing more personalized care. The advise in communication potentially will help in getting to know the holistic picture. Regards the communication tool, the midwife indeed indicated that medical questions have priority right now. So for her, talking about these subjects are also of priority later in the pregnancy process.

Fig. 21. The first focus group at the Syrian woman’s home

VALIDATION FINAL PROPOSAL

Fig. 22 and 23. The second focus group with the expat and midwife of verloskunde040

Collect and analyse

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MethodDuring the whole design process, the underlying method of the Transformative Practices Paradigm is being applied. Together with a focus on the involvement of usersandexperts,thismethodallowedtoenvision,createandreflectondesigndecisionstogetherwithpeopleinthefield.Iwouldreallyrecommendusingthismethodology for designers, since it helps in designing with and for people who do not have a design background. Especially in the case of societal challenges, collaboration with multiple stakeholders with various backgrounds is needed to eventually work towards (systemic) change.

Enriched intake processBy using the three ‘tools’ of an intake form, the midwives’ interface as well as the physical communication tool, an enriched intake process is proposed. The feedback gathered on these tools during the two focus groups can be used as valuable insights for future work. Although the focus was on getting feedback on these tools separately, it was tried to simulate an intake process as good as possible. However, due to limitations of the current prototypes and the women not being pregnant anymore, the insights from this are questionable. For example, the communication tool was used during the focus group to stimulate a deeper conversation between the woman and the midwife, however, medical questions about the pregnancy were not asked due to the woman not being pregnant. When these questions were included, using the tool could have been more time-consuming than it was during this focus group.

At next, the project started from the challenges from both midwives- as well as pregnant women’s perspective. The issues of making a holistic risk assessment withintimeconstraintswereconfirmedbymidwivesduringtheproject.However,the challenges of sensitivity and length for the pregnant women showed to be a bit different than assumed in the beginning: women did not mind to answer sensitive subjects, unless they knew why the questions were being asked and in what way. Furthermore, the length of the intake form did not seem a problem for both the expat as the Syrian woman. Although this already might be a valuable insight for future work, additional research has to indicate if this yields for a more general population of women.

Furthermore, it must be noted that since all interviews included women with different (cultural) backgrounds who did not live in the Netherlands for that long, a language barrier was often present. This was, for example, the case with the Syrian woman who was interviewed multiple times. Although she could understand and speak Dutchquitewellnow,googletranslatewassometimesusedwithexplainingdifficultterms. Due to these language barriers, it can be discussable if the right feedback and information was communicated.

Another point important to mention is that this project is executed on mainly a local level.Onlyforthebenchmarkoftheintakeformaswellasthedeskresearch,information was used that applied for the Netherlands in general. For the interviews, mostly people from Eindhoven and surroundings have participated. Since the overall challenge is a general challenge for the Netherlands, it is of importance to have a more representable sample of participants in the future. In this way, information is less biased by local determinants.

Atlast,Iwanttomentionthatoneofthefindingsshowedthatthemidwiveswouldlike to use the communication tool later on in the process. During the focus group, themidwifehighlightedtheimportanceforhertoaskmedicalquestionsfirst,theholistic picture would be good to assess later on in the process. Although this is valuable feedback on the re-designed intake process, it made me realize that it is of importance that these midwives also make a change in thoughts: the holistic picture is valuable, also in the beginning and especially with these women. For future designersworkingwithinthistopic,itisimportanttohavethisinmindto,atfirst,nottake the user’s feedback as only input for the design and, at second, take this need for transformation of mindsets into account with the designs as well.

DISCUSSION

FUTURE WORK

CONCLUSION

For future work, I recommend to make a new iteration on the proposed tools based on the user’s feedback. A new iteration of the intake form, interface and communication tool makes it possible to validate the tools again. For the intake form specifically,Irecommendtodevelopitfurtherintomorelanguagesandpotentiallywith speech in the future. It is also valuable to make the other prototypes more extensive,soeventually,thenewproposedworkflowforthemidwivescanbetestedin a valid manner. Preferably, this would be tested with people from different places in the Netherlands.

Furthermore, I think there can be a lot achieved in making health professionals aware of the importance of taking the holistic picture into account. As stated earlier, they need to make a shift in mindset and it might be interesting to see how this can be stimulated. When redesigning this intake process, the awareness of the midwives for other risk factors other than medical must not be left out. Ideally, future designs respond to this lack of awareness and stimulate midwives to pay attention to that holistic picture.

Since we were working with four design students within this topic of systemic change for perinatal care, our focus had mostly been divided on different parts of the micro level. Although all projects brought forward valuable insights to slowly work towards that systemic change, I think future work has to focus on bringing these insights together and start designing for the overall system on the macro level in order to realize change in society. This start with, for example, linking the app Veerle has worked on, to the intake form of my work. When having this overall re-designed system, transformation of the Dutch healthcare system will potentially lead to reduced numbers of the perinatal mortality.

In this report I described my approach to an enriched intake process at a midwife practices in the Netherlands. This project was part of a bigger project proposed by Philips Design to empower and guide ‘vulnerable’ pregnant women through the Dutch Healthcare system. In a iterative design process based upon the Transformative Practices Framework, three tools were proposed to enrich the intake processinawayitfitsthemidwives’workflowaswellasapproachespregnantwomen in a sensitive manner. The three tools consists of a digital, interactive intake form with options to have more information or to ‘skip’ sensitive subjects, the midwives’ interface which highlights risk and advices in communication and a physical communication tool that allows the midwife to have a deeper conversation with the pregnant woman and to make a holistic risk assessment.

Based on a lot of user- and expert involvement, feedback is gathered on the tools as well as the proposed intake process. These insights, documented in this report, can be used for future iterations to enrich the intake process, but most importantly, it creates insights in how to work towards systemic change of our Dutch healthcare system for perinatal care.

Reflect and analyse Position and frame

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I want to thank the people who guided and supported me throughout this project pastsemester.Atfirst,IwanttothankmycoachCarolineHummelsforprovidingmewithhelpfulinsightsandfeedback.Bythinkingcriticallyandmakingmereflectonmydecisions, she pushed me towards crucial steps in the design process.

Furthermore, I want to thank the team of Philips Design for the intensive coaching, thevaluablefeedbackandreflectionsthroughouttheproject.Byhavingpresentationsessions and (bi)weekly coach meetings, I learned a lot on professional- and design level.Duetothesemomentsofcoachingandreflecting,theprojectwasshapedtowards a better outcome step-by-step. I want to specially thank Aylin, Simona, Partray and Reon for their help and support.

I also want to thank my fellow students Veerle, Jing and Britt who were also working within the bigger scope of this project. By having discussions, peer-reviewing and collaborating I learned a lot from them and their work as well.

At last, I want to thank all the women, experts and midwives who wanted to share their experiences, perspectives and knowledge to support me in my project. Since I value user- and expert involvement a lot, I appreciate that all these people made time to sit down with me and share their opinion on my work. With their knowledge, the project got very valuable in the insights it obtained from all these different stakeholders.

ACKNOWLEDGEMENTS

REFERENCES Bollini, P. , Pampallona ,S., Wanner ,P., Kupelnick,B. (2009).Pregnancy outcome of migrant women and integration policy: A systematic review of the international literature. Social Science & Medicine, Volume 68, Issue 3, 2009, Pages 452-461, ISSN 0277-9536,https://doi.org/10.1016/j.socscimed.2008.10.018.

Buitendijk, S. E., & Nijhuis, J. G. (2004). High perinatal mortality in the Netherlands compared to the rest of Europe. Nederlands tijdschrift voor geneeskunde, 148(38), 1855-1860.

Denktas, S., Bonsel, G.J., Van der Weg, E.J., Voorham, A.J.J., Torij, H.W., De Graaf, J.P., Wildschut, H.I.J., Peters, I.A., Birnie, E., Steegers, E.A.P. (2011). An Urban Perinatal Health Programme of Strat-egiestoImprovePerinatalHealth.MaternalChildHealthJournal(2012)16:1553–1558DOI10.1007/s10995-011-0873-y

Dyer, J., Gregerson, H., & Christensen, C. (2009). The Innovator’s DNA. Harvard Business Review. Retrieved from https://hbr.org/2009/12/the-innovators-dna

Haider A, Tanco K, Epner M, et al. Physicians’ Compassion, Communication Skills, and Profession-alism With and Without Physicians’ Use of an Examination Room Computer: A Randomized Clinical Trial.JAMAOncol.2018;4(6):879–881.doi:10.1001/jamaoncol.2018.0343

Hellström,O.(1993).Theimportanceofaholisticconceptofhealthforhealthcare.Examplesfromthe clinic. Theoretical Medicine, 14(4), 325-342. doi: 10.1007/bf00996340

HTP, J. P. C. H. (2014). Holistic care in high risk pregnancy. International Journal of Childbirth Educa-tion, 29(4), 68.

Hummels, C., Trotto, A., Peters, J., Levy, P., Alves Lino, J. and Klooster, S. (to appear in 2019). Trans-formative Practices Framework. In: Handbook Strategy for Change. Glasgow: Glasgow Caledonian University.

Huber,M., Knottnerus, J.A., Green, L., van der Horst, H., Jadad, A.R., Kromhout, D., Leonard, B., Lorig, K., Loureiro, M.I., van der Meer, J.W.M., Schnabel, P., Smith, R., van Weel, C., Smid, H. (2011). Howshouldwedefinehealth?theBMJ,2011;343:d4163

Kobau, R., Seligman, M., Peterson, C., Diener, E., Zack, M., Chapman, D., & Thompson, W. (2011). Mental Health Promotion in Public Health: Perspectives and Strategies From Positive Psychology. AmericanJournalOfPublicHealth,101(8),e1-e9.doi:10.2105/ajph.2010.300083

Lindström,B.,&Eriksson,M.(2005).Salutogenesis.JournalofEpidemiology&CommunityHealth,59(6), 440-442. McCandless, D. (2019). Colours in Cultures — Information is Beautiful. Retrieved from https://informa-tionisbeautiful.net/visualizations/colours-in-cultures/

Mohangoo, A.D., Buitendijk,S.E.,Hukkelhoven, C.W.P.M.,Ravelli, A.C.J., Rijninks-van Driel, G.C., Tamminga, P. and Nijhuis, J.G. (2008). Hoge perinatale sterfte in Nederland vergeleken met andere Europese landen: de Peristat-II-studie. Nederlands Tijdschrift voor Geneeskunde, 2008;152:2718-27.

Philips(2018).ImprovingCareofVulnerableWomenintheNetherlandsbyearlyidentificationofperinatal and maternal risks: student kick-off meeting.

Smeenk,W.,Tomico,O.,&vanTurnhout,K.(2016).Asystematicanalysisofmixedperspectivesinempathic design: Not one perspective encompasses all. International Journal of Design, 10(2), 31-48.

Tarusarira,J.(2008).EducationforSocialChange.InOpeningeyes:TrainingforTransformationforcommunity empowerment (pp. 33-70).

Tomico,O.,Winthagen,V.O.,&vanHeist,M.M.G.(2012).Designingfor,withorwithin:1st,2ndand3rd person points of view on designing for systems. In Proceedings of the 7th Nordic Conference on Human Computer Interaction: Making Sense Through Design (pp. 180-188). New York, NY: ACM.

United Nations General Assembly (2015). Transforming our world: The 2030 agenda for sus-tainable development. Retrieved from http:// www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E

Van Enk, A., Buitendijk ,S.E., van der Pal, K.M., van Enk, W.J., Schulpen, T.W. (1998). Perinatal death in ethnic minorities in The Netherlands. Journal of Epidemiology & Community Health 1998;52:735-739.

Vos, A.A., Bonsel, G.J., Steegers, E.A.P. (2014). Foetale en neonatale sterfte in Europees perspectief: verbetering van de verloskundige zorg in Nederland blijft nodig. Nederlands Tijdschrift voor Ge-neeskunde, 2014;158: A7594.

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APPENDICES

As Final project of my Bachelor, this project gave me the possibility to put everything I have learned during the bachelor program to practice, as well as develop my design and research skillsevenfurther.Furthermore,thisspecificprojectallowedmetoworkonachallengeIstrive to tackle as designer. Past semester, I have been working on my goals to become an skilledIndustrialdesignerwithanexpertiseinhealth,userandsociety.Inthisreflection,Iwilllook back at the activities done, what I have learned from this and what I could have done differently.

Atfirst,IwanttoreflectonmyPDPgoals,setinthebeginningoftheproject.Oneofmymaingoals was to develop my technical design skills by programming an interactive tool. In the beginning of the project I really wanted to program the intake form providing data for the mid-wives’ interface. Although I did program the interface of the midwives in combination with the physical communication tool, the results of the intake form were not used as input for this in-terface.Thisisbecause,whilereflectingonthis,Irealizedthatforfeedbackpurposesitwasmorebeneficialtoexpandtheintakeformwithallquestionsandmakingitinteractiveratherthanhavingsomedatainfluencethemidwives’interface.Therefore,itwasdecidedtojusttake keys as input for the change in this system. Looking back on this, I think it is good that I madethisdecisionwithacritical,reflectiveeyeonthisgoal,ratherthanjust‘doitbecauseIsaid so’. For future projects or goals, it made me realize that they are not a golden standard, but you can be critical about and to adapt if you see more potential in an alternative.

Another goal was to improve my visualizations. Since my project involved making a lot of these,IthinkImanagedtofulfillthatgoalmorethanintended.IeventooktheleadinmakingthefinalposterforDemoday,whichlearnedmealotaboutcommunicatingonemessagewhile having to deal with work of multiple students with different design identities. Further-more,onegoalwastoreflectondecisionsmadeinthedesignprocess.AlthoughpresentingmyworkatPhilipsmademereflectacoupleoftimes,Ishouldhavedocumenteditbetter.Forfutureprojects,Iwillplanstrictreflectionmoment(bi)weeklyanddocumentthisreflectionproperly. I think by doing this, I will be more aware of (design) decisions and I will be able to argument or explain them better.

Withinthisproject,weworkedverycloselywiththeteamofPhilipsDesign.Atfirst,Ineededto get used to their way of working a lot. At the same time, I think I learned a lot of this way of working: providing critical feedback and question every piece of work made me develop a critical eye. Without these feedback sessions, I am sure I did not came to the end result of the project as it is. This way or working made me realize (more than before) that criticism is theretotakeyoufurther,nottotakeyoudown.Iwilldefinitelytakethiswithmeinmyfuturecareer and stay enthusiastic and carry on ambitiously with my work.

OneofthethingsIdidnotexpecttohavedifficultieswith,wasthewayofworkingwiththis group of ‘vulnerable’ women. As stated in my vision, I am someone who values other perspectives, who wants to listen and observe and engage with the people. In this project, Iexperienceditcanbedifficulttoengagewithpeoplewithotherculturalbackgrounds.Byreflectingonthosedifferentbackgrounds,Ievengotabitstuckfocusingmoreonthose(cul-tural) differences than on the fact we are all human. An expert meeting with Cindy van den Bremen made me realize I have went a bit too far in highlighting those differences. When you pay interest in someone as a human, in their story, these differences should not matter. Reflectingonthis,Iwentfurtherwiththeprojectandgotmoreengagedwiththewomen:I went several times to Stichting Ik Wil, had personal conversations with the women and people working there. This realization will be very valuable for me in my future career, since I aim to work with a lot of other cultures in developing countries.

Atlast,Iwanttoreflectonmyresearchapproach.Althoughthisprojectwasadesignproject,I conducted a lot of interviews with users and experts. I selectively transcribed most inter-viewsanddidathematicanalysisonthefirstones.However,Iwouldliketohavedonethiswith the other interviews as well. By doing this proper analysis, I might have found more valuable insights as well as documented this insights better. This is something I want to take with me for new research projects: analyse and document! In the future, this again will help me to better argue for what I propose as designer/researcher.

REFLECTION

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APPENDIX 1: SCOPE

1.1 Final design brief

Design brief - Noëlle van Glabbeek Supportintakeview&segmentationapproachforvulnerabilityidentification

Inthisprojectweaimtosupporttheintakeprocessforthefirstantenatalvisitandusethefollowing assumptions as a starting point:• Enriched pre-intake and/or intake questions can help to provide a more comprehensive view of the woman’s condition and to provide input for a possible segmentation tool; •Segmentingthelevelofvulnerabilityofpregnantwomencansupporttheworkflowofmidwives. We will reassess the (pre-)intake process to investigate how a segmentation can support midwives in service delivery. We will develop an (interactive) infographic representa-tion.

Deliverables: • Enhanced intake process & graphically represented segmentation tested with midwife practice:Avisual,digitaltoolthatcanbeusedbythemidwivestoflagwomenatrisk• Map/overview illustrating how solution is connected to the wider frame of system change

Student skills/affinity: • Social cultural skills • Data enabled skills • Graphic skills •Dutchlanguage(workingproficiency)• Able to collaborate with potential other students and Philips coaching team

Challenges: • How to analyze the data and how to translate and graphically represent the data in a digital tool • Human oriented approach towards the intake

Linked solution: Make sure the solution (especially the look and feel of the interface) is connected to the next module (i.e. self-reporting and self-monitoring toolkit (that will be developed by Philips professional designers)) so that we can aim for broader systemic changes and the solution’s full potential is shown.

Stakeholders to engage with:• Midwife practices – explore general intake forms • University of Utrecht – culturally sensitive questioning (to be addressed to the pregnant women)• Erasmus Medical Center – explore criteria (e.g. start with scanning previous research reports of Eric Steegers, Hanneke de Graaf)

Requirements:• Explore intake forms from Dutch midwifery practices (both basic forms, e.g. forms used by 040,aswellas,advancedandspecifiedonvulnerablewomen,e.g.R4U/Mind2Care)• Develop criteria to assess vulnerability of pregnant women through – 1) consulting the studies from Erasmus Medical Center and 2)performingextensiveliteratureresearchone.g.stratificationofpregnantwomen,classifi-cationonantenatal/perinatalriskprofiles,andsuggestionsforcarepathfollow-upbasedonriskprofiles• Questions to the vulnerable pregnant women should take sociocultural background and cultural-sensitive aspects into account • Research midwife needs and take into account intuitive, effective, time saving solution to flagwomenatrisk• Developed solution should be well accepted and appreciated bymidwife and pregnant women and improve mutual trust between them.

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APPENDIX 2: INTERVIEWS

2.1 Consent form Informed consent Project mentors: Caroline Hummels, Aylin GroenewoudStudents: Britt Smulders, Veerle Teigeler, Noëlle van Glabbeek, Jing-cai LiuProject: support for healthier pregnancies in the Netherlands

We are Britt, Noëlle, Jing and Veerle; students of the faculty of Industrial Design of the Technical University of Eindhoven. Currently we are doing a project about healthier pregnan-cies in the Netherlands. It is about the experiences pregnant women have with reaching and navigating the Dutch health care system. We will not collect clinical data. During this project we are coached by professionals of Philips Design. The insights gained during this process are part of a research project of Philips design, Maxima Medical Center and Puur. We need your help! We ask for your support with this project through an interview of about an hour. If you have questions during the interview, you can always ask them.· Consent can be withdrawn and the interview can be stopped at any time, without giving a reason.·Theaudiofileswillbetranscribedanonymously.Nameswillbechangedtonumbers.· The data will not be used for commercial purposes.· Audio will be recorded during the interview· Photos for our reports can be taken yes / no.I hereby declare that I, (name participant) ……………………………… understand the procedure and agree to give consent to use information obtained through interviews to the students Britt Smulders, Noëlle van Glabbeek and Jing-cai Liu. ParticipantDate: ……………………..Signature: ……. ResearcherName:………………………………..Date:…………………………Signature:……

2.2 Interview questions PUUR

1. Background informationWhat is your occupation? How long have you been working here? What does a day look like working?

2. This is the intake process a pregnant woman needs to follow according to your website. Is this (still) true? A document will be provided with the steps to take and the subjects to be discussed before and during the intake with the midwife.

3. Please describe what you would like to see differently.- Subjects to be discussed before, or during? Why?- Subjects removed so it saves time? What are priorities?-Subjectsremovedorapproacheddifferently,becauseitisdifficulttocommunicatetothepregnant woman? Why?-Subjectsyouexperiencedtobedifficulttounderstand/talkaboutbythepregnantwoman?Why?- Subjects where you have the feeling the information does not come across the pregnant woman? Why? Example?

4. Please describe where you would like to have extra help with.- Time-managing?- Making the pregnant woman feel comfortable? Trusted? How do you do that right now?- Communicating?- Communicating with other health professionals?

5. Please describe the experience with intercultural communication.- Do you have training for this? What does it look like?-Whatsubjectsaredifficulttocommunicate?Why?- Examples?- When nodding, or being silent, what do you do?-Wouldyouliketohaveguidelinesforthis?Howwouldyoupicturethis(aculturalprofileofthewoman,exactstepstofollowforthatspecificwoman,oradevicethatexplainsittheirway?)

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2.2 Interview PUUR analysis

2.4 Short interviews/conversations Woensel Market 16-3 notes

Person 1 +2: German woman with husband from UK and another German couple as well - She went to the house doctor when she found out she was pregnant. After that, she went to a midwife practice. - She knew some experiences from friends and got information from them - She also got information from the midwife practice’s webpage. - She did not have to put a lotofeffortinfindingthisinformation.-Shewenttopregnancyyoga-Shementionedthatthe Dutch health care system for pregnancy was very different than in Germany In Germany they see a pregnancy more as a disease, so there you will have more scans to check if the pregnancygoeswell.IntheNetherlandstheyaremorerelaxed,theydonothingthefirstthree months. In NL, they will help when something is wrong and intervene at that moment, which is why they are too late sometimes as well. In Germany, they will give you lots of infor-mation, which makes you worried sometimes. It is too much. However, this also depends on what doctor you have, because the other German woman was asked in the beginning of her pregnancy how much she wanted to know. In Germany, 3 scans are done by the doctor, the other ones can be done by the midwife. These midwives change per 8 hours, which differs fromtheNetherlands,whereyouhaveonespecificmidwifethatwillbeatyourdelivery.Inthe Netherlands, they have a more relaxed approach, which she was more used to when giv-ing birth to her second baby. However, she sometimes needed to remind the midwives that she is not aware of the Dutch healthcare system and how it works (the procedures) in NL.

Person 3: (African) woman at Kruidvat with 2 year-old child and 2-month old baby She men-tioned the language barrier. She arranged/got a translator from school that went with her to themeetingswiththeGPormidwife.Atfirst,shewenttotheGP.Shedidnothaveanyfamilyhere,butshedidhavefriends.Communicationwasdifficult,shedidnotspeakDutchfluently.

Person 4: woman with 14-month old child at market with her husband. She did not speak Dutch,sosheimmediatelyreferredtoherhusband.Hetolduseverythingwentfineduringpregnancy. Noëlle: what was interesting here was that the woman looked very open to answer questions but couldn’t answer them. It felt like the husband was not really open to answer our questions.

Person 5: (Indian)woman with child, eventually her husband was there as well. They were from Belgium. She mentioned the system in Belgium also worked with midwives. She did not speak Dutch, her husband did (a little).

Themes:Explanation Dutch Healthcare systemCultural differencesLanguage barrier

2.3 Interview analysis PUUR

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2.5 Interview questions AZC medical advisor

1. Please introduce yourself and your work as medical advisor at AZC Budel.- What do you do? What does your work include?- What does a workday look-like? - How often are you working there?-Areyouworkingwithrefugeesfromdifferentcountries?Orjustwithonespecificback-ground?

2. Please describe what a consult with a refugee looks like.- What needs to be done? - Where is it being done? Can you describe the place?- Could you describe how the situation is set-up? Seats? Who is there?- What equipment do you use? Why?- What is your experience with working this way? What could be improved?

3. Please describe the way you approach the refugees.- Do you approach them differently than for example Dutch people? How?- Where do you pay attention to?-Aretherespecificsubjects/activitiesyouapproachdifferentlybecauseyouknowthattheyhave a different background?- Did you learn this through experience or? - Do you have any help in how you need to approach them?

4. Please describe the way you communicate with the refugees.- Do you use a translator/interpreter? How?- How does this work? What are plus- and downsides?- Would you like to communicate differently? How would you picture this?

5. Please describe your overall feeling during a consult.- Do you feel like you can approach these people in the way you want to? Why?- Do you feel like they trust you as a medical advisor? Why?- Do you feel like they understand you? Why?- What do you think that could improve this?

6. What do you see as opportunities to let these people feel more trusted/comfortable during medical consults?-Culturalprofilingforexample?

2.6 Interview AZC medical advisor

Selected transcription (translated):‘I am a Medical nurse at Forensisch Medisch Maatschappij Utrecht.She sees the refugees that just entered the country to see if they are physically and mentally able to go through the asylum procedure’

‘I always use a translator, via the ‘tolkentelefoon’. I talk to this telephone, this translator talks to the refugee, and the refugee back to the telephone. The translator explains the answer to me.’

‘I get to know the translator, the translator and the refugee are introducing each other to see if the language is the right one to communicate. This is very short. I just look into the refugee. When they do not look back, I will note this down in the dossier.’

‘They give a hand when they enter the room, this is mostly not a problem.’

‘I have to use very simple language. For example the word ‘beperking’, they do not know what I mean, even if translated.’

‘I sometimes see that they try to come across as healthy as possible, however, I stress the importance of being honest at that moment. If they are not being honest, the immigratiedi-enst will notice this anyway. Then they are being honest most of the time.’

‘The IND is looking after their story, I just do the medical part.’

‘I make notes of the condition of the refugee that can be entered by the midwife practices if they asked for it, and with permission of the client.’

‘When I talk about non-medical stuff I ask: Do you experienced anything horrible? Do you miss your family? Are you experiencing disadvantages of this? How do you deal with this?Some people will start crying then. I just keep the conversation going. I don’t touch them most of the time. I do have a box with tissues.’

‘Based on feeling I decide if they are mentally not okay. This isn’t black and white. We only have nurses older than 50, because they have experience in this. However, our doctor is always checking our decisions.’

‘An example: a young girl got pregnant, when she was drunk. She began crying when I

askedheraboutthis.ButthereisalwayssomeonefromNIDOS(minorshavethisguardianwhen entering the Netherlands). This guardian is a social worker, who help with this conver-sation and such situations. I told the guardian what the best thing was to do: do a pregnancy test and visit the midwife practice.’

‘Oftenrefugeesneverhadabloodpressuretest.Theyfinditfunnyortheypanic.Iquietlytellwhat it does, in a simple language and with a lot of gestures and by acting out.’‘I have as an advantage that I also work with young children in the MMC, so I know how to makequestionreallysimple,althoughtheyareformulatedverydifficultonthisformIhavetofillin.’

‘Languagebarrierisarealdifficulty.SometimesthetranslationisjustapartofwhatIamsaying and it remains questionable if they understand it in that language.’

‘Youhavesomanycultures,desires,preferences,Idon’tthinkyoucandesign1toolthatfitsall.’

‘Ithinkitisvaluabletousealotofvisualsforthisspecifictargetgroup.’

‘I think explanations help, this also saves time (me explaining a blood pressure test for example).’

‘What I now have in the hospital MMC, is a digital platform that also allows insights in the self-monitoring of the patient via their app. This is very valuable for me, because I can imme-diately see how the patient is doing.’

‘You can look into the arabic communication card. This is something a refugee brought to me during a consult.’

‘You cannot cover all the cultural differences and desires. You have to explain how we do it in the Netherlands, and most importantly: why. This information has to be clear for the target group. They then can decide what they want to do with it.’

‘Cultural guidelines would be appreciated. A lot of practices can differ regard using vitamins, medicines. General practices or beliefs can be communicated to the midwife, so they know what possible ideas the target group has.’

Themes:Language barrier: disadvantages translatorCultural differences: guidelines, communicationExplanations: simplicity, visual 2.7 Interview questions (pregnant) women

At first, I am really interested in how you experience living in the Netherlands. Could you describe this? (- Why did you move to the Netherlands?) - How do you experience living in the Netherlands? What surprised you? Positively or negatively? - What do(n’t) you like here? Why? - What do you miss from your home country? Why? - The behavior/approach/communication of Dutch people, is it different than what you are used to? Why? What do you think of it?

I am interested in what it would look like if you went through this pregnancy process in your home country. Could you describe this process? - Intake form? Midwives? - What do you think of this process? (Dis)advantages?

This is a rough sketch of what a pregnant woman in the Netherlands is going through for the intake process during pregnancy. - What do you think of it in general? How did you experience the intake process in general?- What did you think of the intake form? Difficultsubjectstofillin? Didyouthink/feellikeyouwereabletofillintheformcorrectlybyyourself? Why(not)?Did you feel like the midwife would have a clear picture of you as a person and your pregnancy by filling in this form? Why (not)?-Whatdidyouthinkofthefirstintakemomentwiththemidwife? How did you experience the communication/approach? Did you feel trusted? Anything that you would like to have seen differently? Could you ask questions?

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Please describe(or to recap) what you see as outstanding differences that you experi-ence in the Netherlands with regards to the pregnancy process - What was different than you expected/are used to? - What do you see as advantages and disadvantages of the process here in comparison to your home-country? What would you like to see differently?-Didyouthinkitwasdifficulttogetusedtothewayofworkinghere?Why?

2.8 Interview Syrian woman

Iteration 1 (intake form)- She didn’t mind answering certain questions, but she did thinksome subjects were sensitive. F.e. abortion, she thought this a weirdquestion, because in her culture this is not an option at all.- Language barrier is a thing, would prefer it in own language.

Intake moment- Language barrier- Information lacking-Nottakenseriouslybythemidwife→wantedmoreattentionforherquestionsandworries.

2.9 Interview questions ambassadors

Please introduce yourself- Where are you from?- Where have you been living past and present?- What do you do? Study? Work?

Please describe your culture and how it differs with the Dutch/Western culture- What do you value? And how does this differ? Can you name examples (school, work)? Does this differ per gender?

If I am correct, you had collected some experiences of pregnant women in the Dutch Healthcare system. Can you share/describe them? -Whataredifficultieswithinthesystem?Why?- What do they think of the overall process? Is it easy to get access, is there enough informa-tion? How is the approach of the midwives?

I will go through an intake form with you. I want to know what you think about the subjects being asked, how they are asked, how they need to be answered. I would like you to like at this from your cultural background and through the eyes of a pregnant woman with this same background.- What do you think of the subjects? Which ones are too direct/sensitive and why?- Are they easy to answer?-Doyouthinkthisisagoodwayofapproachingthepregnantwomanforthefirsttime?Whatdo you think that could be improved?

There will also be an intake process for the pregnant women, where these subjects are more deeply discussed with the midwives. - Do you think it is easier to discuss with the midwife? Why (not)?-Whatdoyouthinkwillbedifficulttodiscusswithher?Why?- What do you think they would like to discuss with the midwife? Why?- How do you think they need to be approached? How does it need to differ from approach-ing a Dutch woman?- How do you think the optimal way of communicating will be?

2.10 Interview Turkish ambassador

Important notes:-Turkishculture→accordingtotheIslamicreligion,itisasthefollowing:Allahdecideswhen you come to life and why you will die. Suicide is a big sin, because you are a creation of Allah. So the same yields for abortion, because you are getting a baby, which Allah decid-ed for you. It is Allah’s plan (God’s plan). If you decide to have an abortion, you will murder a creation of yourself and Allah. That is not done in our religion.- Direct questions does not really matter, however, there are some subjects as abortion and alcohol,whicharenotallowedwithinthereligion.Turkish,religiouspeople,willfindthesequestions weird.-SOA’sisalsosuchasubject- We do not think negatively about other cultures or religions, we are for diversity in cul-ture.SoIcanimaginethatifyouexplainwhyyouwanttoknowthesesubjects,specificallymentioning the medical reasons, they will answer. The medical reasons will hopefully push towards a honest answer.- Family is very important in our culture and religion.- The partner will only come along if the woman does not speak the language.

Themes:- Religion

- Abortion-Seks/SOA’s- Lifestyle- Cultural differences

2.11 Interview Moroccan ambassador

Summary of experiences of Moroccan pregnant women in the Netherlands:- The women spoke poor Dutch, so often their partner or family in law went with them to the midwife practices to communicate-Thewomendidconfirmthattheyweremissinginformation,becausethingswerenotex-plained in detail by this inbetween communicator, or they just did not understand.- The women often listened a lot to certain wisdoms of women out of their family.-Womenfounditdifficulttoaskquestions,becausetheythoughttheywerebeingdifficultordisrespectful.- The women see the midwife as a doctor, so she knows what to do.- The women indicated that they wanted to be more involved, without that in between com-munication person.- The women wished that the midwife visited their home, because they felt more comfortable here.- The women would like to have to lists where they can indicate how they experienced the care.- They liked the midwifes

Themes: - Language barrier- Family- Information- Cultural differences- Questions/feedback on care

2.12 Interview Montenegrin ambassador

Important notes:- Abortion is not done in the Islamic religion.-Seksbeforemarriageisalsonotdone.SoaquestionaboutSOA’smightbeoffending.- People who are extreme believers do also not use birth control.- You have a lot of differences in how someone views their religion. Some do drink alcohol, some think it is not done. Some have seks before marriage, some do not. It is also about

howmuchwesternsinfluencespeopleembrace.- Even if people use alcohol, but they see it as not done due to their religion, they will not admit that they use it.-Maybeifthereisanoptiontofillitinmoreanonymously,onlineandbyherself,theywilltellit.- If you say to the women: ‘We understand that. We understand you.’ This highlights the cultural differences. That is not something you really want, it shows that ‘they’ are different.’

Themes:- Religion- Abortion-Seks/SOA’s- Lifestyle- Cultural differences

2.13 Collecting data from analysis

MedicalPUUR:→Thishasthemainfocusofthemidwivesandgynaecologists→Basicdataaboutthecaseisbeingaskedintheintakeform→Roughoverviewofrisksisneededfromthisintakeform→SugartestandbloodpressuretesthavehigherpriorityVerloskunde040:→Sugartestissometimesmandatoryforothercultures→Thefocusisstillonmedicalrisks

KNOV:→Weareworkingtowardsmorepositivehealth:whatdoesthepatientwantregardscare,in order to provide care in a personal way. They are maybe at risk, but it is how they cope with it, what assets they have and we can provide. Example: someone can cope good with not having a lot of money, but not with having no moral support. How to make this personal care?→Amoreholisticriskprofileisneeded

Non-medical issuesPUUR:→Memotoregisteradditionalstand-outs(feelingtheyarenotbeinghonest,notesaboutmental state or worries)

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→Forotherappointmentsthereisaopportunitytowritedownfeelingsandnotes

Verloskunde040:→Alotofnon-medicalquestionsarebeingaskedintheintakemomentrightnow.Butthathas lower priority than an echo or medical risks.

Language barrierPUUR:→Languagebarrierisoneofthemostdifficultthingstoworkwith→Translatorsarenotreallypersonal,itisnoteasytogaintrust→FamilymembersoftenspeakpoorDutch.Arethequestionsbeingunderstood?Dothemidwives understand the answers?

AZC medical advisor:→Disadvantagestranslator:thetranslationisjustapartofwhatIamsayinganditremainsquestionable if they understand it in that language.→WhatIusetoovercomethelanguagebarrier:visuals,arabiccommunicationcard,ges-tures (next to translator)

Verloskunde040:→Wehavetopaytranslatorsbyourselves,sowedonotusethemoften→FamilymembersoftentranslateonesentenceofawholestoryIhavebeentelling

Woensel market:→Experiencedourselvesthelanguagebarrierwith4morewoman(didnotspeakDutchorEnglish)

Sensitivity → religion, abortion, seks, soa’s, lifestyle, cultural differences

Syrian woman:She didn’t mind answering certain questions, but she did think some subjects were sensitive. F.e. abortion, she nd this a weird question, because in her culture this is not an option at all.

Turkish ambassador:Subjects as abortion, alcohol or drugs are sensitive subjects in the islamic religion. He thinks Turkishwomenwillfinditoffendingifanurseaskthemthis,becausethesesubjectsareseen as not an option in there religion.

Montenegrin ambassador:Abortion is not done in the Islamic religion.People who are extreme believers do not use birth control.Maybeifthereisanoptiontofillitinmoreanonymously,onlineandbyherself,theywilltellthe real story about these subjects.

Cultural differences

Nicole Sanches:‘Different groups have different desires of how they want to communicate, how much infor-mation they want.’

AZC medical advisor:‘I don’t think you can approach everyone in their own manner through one questionnaire. What you can do, is explain why we ask those questions, so they will understand why it is important for us to know.’

Moroccan ambassador:→Familyisveryimportant,womanlistentothewisdomsofotherwomeninthefamily.→Theyseethemidwifeasadoctor,sosheknowswhattodo.Theydonotwanttoaskstupid questions.→Theywouldlikedifthemidwifecametotheirhomes,theyfeltmorecomfortablethere.

Montenegrin ambassador:→Youdonotwanttoapproachthemlike:‘Weunderstandyou.’Thishighlightsculturaldifferences. That is something you do not want, it shows that ‘they’ are different.

ExplanationWoensel market german woman:‘’I needed to remind the midwives a few times that I amnot aware of how it works within the Dutch healthcare system.’’

AZC medical advisor:Refugees: a lot of simple explanation is needed, preferably visual

2.14 Validation Nicole Sanches (cultural anthropologist at Utrecht University)

Iteration 1 (intake form and intake moment):-Interculturalcommunication→everythingbutmyownisanothercultures.Soeveryonehas different desires, beliefs, values. The target group has this also. - ‘Different groups have different desires of how they want to communicate, how much infor-mation they want.’- Embrace cultural diversity.- Tool to embrace cultural differences amongst university students:

Iteration 2 (intake form):Suggestions and questions (Dutch):-inhetfilmpjegevenjullieaandathetvanbelangisomeencompleetbeeldtekrijgenendaarom sensitieve info wordt gevraagd. Kan je in de uitleg ook iets meegeven aan de vrouw waarom die info van belang voor het medische beeld en de voortgang van de zwanger-schap? Het lijkt me dat de drempel om die informatie te delen daarmee kan worden verlaa-gd.-deknopjesi,?enxlijkenmeeenheelgoedeaanvulling.Specifiekrondomhet‘x’knopjevraag ik me af: op welke locatie zal de vrouw de lijst invullen, heeft ze daar mogelijkheid tot privacy om ook echt voor ‘x’ te kiezen? Kunnen jullie aan de vrouw verduidelijken wat er wordt bedoeld met “only discuss it with us” (bijv. wie is die “us”, zijn dat alleen de verloskun-digen in de betreffende praktijk/ of incl stagiaires/ echoscopiste/ wordt de info gedeeld met huisarts/gynaecoloog etc)?- in het geval dat de vrouw heeft aangegeven iets alleen met de VK te willen bespreken, wat gebeurt er met de info als er toch steeds een partner bij de controles aanwezig is?-hetaanbiedenvanditfilmpje/interactiefformulierinmeerderetalenlijktmeabsoluuteenmeerwaarde hebben waarmee ook de toegankelijkheid naar de categorie vrouwen die je noemt toeneemt.- de toon van het formuleren van de uitleg en vragen vind ik tot zover ook toegankelijk en uitnodigend.- hebben jullie binnen de doelgroep ook vrouwen die om dergelijke redenen niet/minder goed kunnen lezen (bijv. analfabeet/slechtziend)? In dat geval, zou je kunnen overwegen hoe de intake dan kan worden gedaan adhv jullie product (audio-optie/ mondeling?).- De visuals zien er uitstekend uit, mijn complimenten daarop! Wellicht is het in het kader van diverse doelgroepen nog interessant om te overwegen het poppetje te ontdoen van haar culturele/etnische/gendered kenmerken zoals huidskleur en een (kort) rokje, hak schoenen etc. Je kan er ook voor kiezen juist hierin te variëren, zodat de vrouw (wie zij ook is) zich kanherkennenindebeeldvorming.Specifiekinsituatieswaarinereenvermeendecultureledrempel is kan een inclusieve beeldvorming veiligheid bieden. Ik zou dan wel vasthouden

aan1inclusiefogendfilmpjeendusnietvoorelketaaleenanderfilmpjegebruiken.- wellicht is het nog interessant om in het eindproduct een optie tot het stellen van vragen aan te bieden. Daarmee zou de vrouw dan zelf ook de ruimte krijgen om bepaalde punten te benoemen die van belang kunnen zijn voor haar/de zwangerschap/het contact met de verloskundige.

2.15 Interview/validation social worker Stichting ik wil

Iteration 2 (intake form):-Shesaidthatforaspecificgroupthiswouldwork(f.e.writingskillsandcomputerskills).- Buttons are good because it gives the option for multiple women with different background, also Dutch woman who do not need more information.-Itneedstobeintheownlanguageofthewoman→buttontochangelanguage?- Some women do need more explanation, maybe even about the Dutch Healthcare system.-Whereisshegoingtofillinthisintakeform?Atmidwiferypracticealone?Thenshecanaskforhelpandisthepartnernotinfluencingtheanswersperhaps.-Turkishculture→partnerdoesnotevenwanttobeinvolvedintheprocess.Withhavingit in her own language, the process can be according to our cultural values. However, the midwifedoesnothavetolooksurprisedthatthisisthecase→guidelines?

Iteration 2 (intake moment):- She mentioned it might be good that the midwives already have an idea of the background/story/cognition of the woman before the intake moment, so they know how to communicate.- For example: she is often approached as if she is fully Turkish, based on what people think of Turkish people, but since she lived in the Netherlands for all her life, she is very western andfinditoffendingifpeopleasksquestionsasifsheistraditionalTurkish.

2.16 Interview/validation Syrian woman (2)

Iteration 2 (intake form)- She said this intake form would be very valuable to have in your own language. -SheappreciatedtheX-button,itgivestheopportunitytostresssomethingyoufindveryimportant.- For the information button: here could be a lot of pictures, so it is very clear. Maybe link to the app of Veerle?- She liked the visuals, the midwife looks like a traditional midwife here.- She appreciated the question button, if the midwife has the opportunity to really take this into account.

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- Maybe also with voice recognizer, so also people who can’t write can answer the questions.

Iteration 2 (intake moment)- She liked the different ways to communicate, but it should not be to much and misleading.- Translator is very important. And pictures and terms helps a lot.

2.17 Interview/validation midwife verloskunde040 (1)

General→Theydonotknowifthereisgoingtobealanguagebarrierbeforehand.Sometimestheybringapartnerwiththemfromthefirstmomenton,whohelpsasatranslator.Butsometimesthis is not the case. →Notesforoutstandingdataisveryimportantforus.Withthisdata,anothermidwifealsoknows where to pay attention to.→Thecommunicationbetweenthemidwifepracticeandthehospitalisverydifficult.Theyshould have one system that communicates.→Languageandethnicityissomethingveryimportanttoknowasmidwife,forexample,Turkish and Moroccan cultures have higher risk in certain diseases (diabetes, f.e.)

Iteration 2 intake form→Forexpatsthequestionbuttonwouldbeveryhelpful:theyoftenhavealotofquestions.Furthermore, it would be helpful for the midwife to prepare information based on these ques-tions already→Forteenmomsitwouldbeveryvaluable:theintakeformseemsapproachableandsensi-tive to unexperienced moms→Theformbeingdigitalwouldnotbeaproblem.Therecanbeatabletinthewaitingroom,wheretheycanfillitinatthemidwifepractice.Intermsofadministrationtasksforthemid-wives it would be very valuable, since it reduces time spent on these tasks.→Itwouldbethebestifthepregnantwomanfillsitinasearlyaspossibleintheprocess,sothemidwivescangivespecificcareearlyintheprocess.→Itisverygoodthatquestionsabouttheenvironmentaretakenintoaccount.Therewerecases where they found out really late about a woman’s situation at home. It is better to knowthisduringthepregnancyregardingriskidentification.

Iteration 2 intake moment→Visualizationrisk:textwithoutstandingresultsshouldbethere.Alsoallresultsshouldbein there. →Thereismuchtoimprovewithincommunication,soitisgoodthatthisisatoolthathelpsthe midwives.

→Culturaldifferencesmightbesomethingthatismainlydoneonexperiencerightnow.Itmight be handy if there is someone from another culture we don’t know. However, this is not often the case, mostly Moroccan or Turkish women. By experience, we kind of know how to approach them.→Termsandpictures→wedouseTriginuarightnow.Otherlanguageswouldbeappreci-ated, maybe less communicating via partner could happen then.→Theintakemomentisforthingsthatmatter,theintakeformistoalreadyhavethatinfor-mation.→Importantthingsarealsonotedonthe‘zwangerschapskaart’ofthepregnantwoman.

2.18 Interview midwife verloskunde040 (2)

Flow→Apregnantwomanregistersatthewebsite,wecallherforanappointmentandwesentanemailwiththeintakeform.Shehastoprintitout,fillitinandtakeittothefirstmomentwith the midwife. Then this form is not discussed, because it needs to be processed by the midwifefirst,afterthisfirstappointment.Whenallthedataisprocessedmanually,theinfor-mation can be discussed in the second appointment (10-14 weeks).→Forpreparationwewilltake5min.Justtohaveinformationfoldersready.Wedonotknow anything beforehand about the woman.→Becausemostofthetime,thewomanwilltaketheintakeformwithherduringthefirstappointment, we can manually process it afterwards. This will take 10 min per form. →Duringthefirstmoment,wewillhave15minforgeneralinformationaboutthepracticeandpregnancy.Theother15minareforthefirstecho.→Fortheintakemoment,wequicklygothroughthedataoftheintakeform.Ifweseeanoutstanding result, we already take information folders. We also make things ready for the second echo. This will take 10 min also.→Duringtheintakemoment,wehave30minutestoasksadditionalquestions,aboutsensi-tivesubjectsaswell.Orifwethinkthereisrisk(basedonintakeform),wegofurtheronthat.Also during this appointment, we have an echo that takes 15 min.→Additionaldatacanbefilledintothesystem.Thiswilltake10min,mostofthetime.

2.19 Focus group questions

1. Intake form expat- Are the buttons clear? For which question you want to use which button? Why?-Whichquestionsyouthoughtweredifficultorsensitive?Why?- Were there questions that were unclear? Why?- What did you think of the overall intake form? The experience?

- What did you think of the visuals?-Wherewouldyouliketofillinthisquestionnaire?Telephone,computer,tablet?Athomeorat midwifery practice?-Didyouthinkittooktolongtofillinallquestions?Didyoumind?

2. Together with midwifeForthemidwifeIhavedesignedaninterfacewhichshowstheprofileoftheclient,thedatareceived by the intake form directly, advice for communication, the options of the intake form filledinbythepregnantwoman,andanoptionforimportantnotes. - If you have this interface in front of you, where do you directly pay attention to? What do you think is important?- What do you think of all options?-Whatdoyouthinkofthewaydataisautomaticallyfilledininthisinterface?- What do you think of the risk assessment visualisation? Does it add value? How would you use it?- What do you think of the advice in communicating? Do you think this is of importance to knowbeforehand?(Alreadyatthefirstappointmentwiththeecho)?

3. Together with midwife and expatInstruction: I would like to discuss with you the additional subjects that need to be discussed, while you make use of the communication tool. For instance, mental health problems are really at stake. I hope that you will have a real conversation, using the blocks of the commu-nication tool.

Expat:- What did you think of this conversation? When you compare to what you are used to?Midwife:- What did you think of having such a conversation? In comparison with how you are used to?- What did you think of the continuüm? Did it have additional value?- What did you think of the various cards/blocks? Useful? Too many?Expat:-Didyouthinkitwasgoodtodiscusssubjectsthisway?Orwouldyouratherseeitdifferent-ly?Midwife:- Did you think you can come to a holistic risk assessment this way? The whole picture? In comparison with how you are used to?-Whatdoyouthinkofthisprocesswhentakingtime-efficiencyintoaccount?

2.20 Focus group conclusions

Intake form:→Thebuttonswereclearforbothwomen→Informationwouldbeusedespeciallyformedicalquestions(whentermswerenotclear)by refugee→Thevideo’sindicatingsensitivequestionswerehighlyappreciatedbybothwomen.→X-buttonwouldbeusedbyrefugeewhenquestionsarebeingaskedaboutfamilyorsupport→Thereshouldbeanoptiontogobackinthequestionnaire,thiscouldbeplacesattheleft.The cross button could therefore be in the middle, between the ‘back’ and ‘next’ option.→Theintakeformshouldreallycomeinotherlanguages,soalltermsareclearinnativelanguage for everyone→Itisnottoolong,sinceyouwanttomakesureyourpregnancygoeswell.Furthermore,the hospital has way longer forms. It might be good to have an option to pause the question-naire so you can resume at a later point of time.→Thevisualswereclearandthemidwifelooksgood.→Theintakeformshouldbeonlywithspeechaswellinthefuture→Havingtheformdigitallyisfine.Theexpatevenappreciatesitsinceshedoesalotdigital-ly.Therefugeethoughtitwasmostconvenienttofillintheformatyourphoneathome.

Midwives’ interface:→Theriskassessmentvisualseemstogiveaquickoverviewofwheretherisksare.TheAZC medical advisor appreciated this. The midwife missed details here: what were the spe-cificrisks?Shewantedtoseethatimmediately.→Automaticallyfilledindatahelpsalot,itsavesalotofadministrationtime.→Adviceincommunicationwouldbeappreciatedandcouldhelpalot,especiallywhenthemidwife is not familiar with the culture. If she is, her approach might be based on experience instead.

Communication tool: →Thetoolseemstogivedeeperinformationabout(sensitive)subjects,however,itisthequestionifitfitsintimeconstraintsofthemidwife.→Thecommunicationtoolworksverydifferentthanhealthprofessionalsareusedtorightnow: they use a protocol and have strict questions to come to this risk assessment. Howev-er, based on the visual of risk assessment out of the questionnaire, you can give way more personal care and have a personal conversation. You already know where you have to pay attention to. →Themidwifeindeedindicatedthatmedicalquestionshavepriorityrightnow.Soforher,

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talking about this subjects are also of priority later in the pregnancy process. Especially at a moment where they have time.→Midwivesshouldgetusedtohowthecontinuumworks,howtouseitinpractice→Forpregnantwomenthecontinuumseemednotreallyclearoritgavepressuretoplacesubjects on a continuum→Thecommunicationcardsseemveryhelpful,especiallywhenthereisalanguagebarrier.→Thementalhealthvisualizationsaregoodsinceeverywomancanrecognizethemselvesin it.

APPENDIX 3: INTAKE FORM

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3.2 Iteration 1 Intake form

Intake formWelcome to the midwife practice verloskunde040. This intake form will go through 4 sub-jects, namely personal information, medical history, non-medical questions and environment/socialsituation.Everythingyoufillinherewillbedealtwithconfidentiality.Pleasebringthisform to your next appointment.

Personal InformationFirst, we want to know more of you as a person.1.Name_________________________________2.Date of Birth____________________________3.Country of Birth__________________________

4.Mother’s Country of Birth__________________5.Father’s Country of Birth__________________

Study6.What is the highest education you have completed?0 Primary school0 Secondary school0 Special schooling0 High school0 College0 University

Job7.Do you have a paid job?0 Yes0 No(If No, go to question 10) 8. What do you do for a living?________________________

9. For how many hours per week?________________________

Medical informationNow, we want to know more of your medical history.

Pregnancy10. How long have you been pregnant?0 ___ weeks0 I don’t know

11.Whatwasthefirstdayofyourlastperiod?____________________________________0 I don’t know

10. How many pregnancies have you experienced?__________________________________(If answer is 1, go to question 12 )

11. How many times have you given birth?_________________________________

12. Which argument applies best for you?0 I was consciously trying to conceive0 I was not consciously trying to conceive, but I am happy to be pregnant0 I wanted to become pregnant in the future, but not at this moment in my life0 I did not want to become pregnant at this moment of my life, neither in the future

Medical history13. Did you use medication to get pregnant?0 Yes, namely _________________0 No

14. Do or did you use vitamins or folic acid?0 Yes, namely ________________0 No

15. Have you ever experienced a serious disease? (i.e. heart, liver, lungs, kidneys, bladder, brain, gallbladder, stomach, thyroid, spine, bowels)0 Yes, namely ________________0 No

16. Have you ever seen a specialist?0 Yes, namely ________________0 No

17. Have you ever had blood transfusion?0 Yes0 No

18. Have you ever seen a gynaecologist?0 Yes0 No

19. Have you ever suffered from Varicose veins?0 Yes0 No

20. Have you ever suffered from haemorrhoids?0 Yes0 No

21. Have you ever had cystitis?0 Yes0 No

22. Have you ever had a cold sore?0 Yes0 No

23. Have you ever chicken pox?0 Yes0 No

24. Did you join in the national vaccination program?0 Yes0 No

25. Have you ever a sexual transmitted disease?0 Yes0 No

26. Please identify below if this is present in your family:

0 High blood pressure0 Abnormal thyroid function0 Hereditary diseases

Lifestyle27. Have you been smoking before or during your pregnancy?0 Yes, until I discovered that I was pregnant0 Yes, I still do0 Nowas pregnant 28. Have you been drinking any alcohol before or during your pregnancy?0 Yes, until I discovered that I 0 Yes, I still do0 No 29. Have you been using any recreational drugs before or during your pregnancy?0 Yes, until I discovered that I was pregnant0 Yes, I still do0 No

The questions were are going to ask now, will be about how you are feeling and your situ-ation. We realize that these questions can be sensitive or personal. However, we do want to ask them to get an insight in your situation. In this way, we can provide you with optimal care. If you would rather discuss these subjects only in person with us, feel free to use the X-button.

Non-medical questions30. Are you experiencing any problems with relationships at the moment? (e.g. partner, family, friends?)0 Yes0 No

31. Have you experienced any sexual abuse or domestic violence in the past?0 Yes0 No

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(ifNo→gotoquestion)

32. Do you still experience any disadvantages?0 Yes0 No

33. Have you ever been treated by a psychologists, psychiatrist or supported by a social worker?0 Yes0 No

34. If yes, would you like to tell more about this?

(Based on this answer, midwife could decide to do EDS questionnaire at intake moment)

Environment/Social situation35. Do you have a partner at this moment?0 Yes, my partner and I are living together0 Yes, we are living apart0 No, I do not have a partner

(If No, go to question 37)

36. What is his/her name?_________________

37. Does he/she smoke?0 Yes0 No

38. Do you have the feeling you get enough moral support?0 Yes0 No

39. Do you have the feeling you have enough moral support from family and friends?0 Yes0 No

40.Doyou,ordidyouhaveanyfinancialproblemsordebts?0 Yes0 No

41. Do you have a stable housing?0 Yes0 No

42. Feel free to leave any questions below:SPEECHorTEXTBOXorX

3.3. Iteration 1 Intake moment Thesequestions,identifiedoftheMind2Care-questionnaireasquestionstoassessvulner-ability,arenotinthefirstiterationoftheintakeform.Therefore,theyneedtobetakenintoaccountduringthefirstintakemoment.Thequestionsinitalicfontarealreadyintheques-tionnaire, but they are there to indicate why an additional questions needs to be asked.

27. Have you been smoking before or during your pregnancy?0 Yes, until I discovered that I was pregnant0 Yes, I still do0 No

If yes,1. How many cigarettes do/did you smoke?20 or more a day, 10-19 a day, 5-9 a day, 3-4 a day, 1-2 a day, less than one a day.

28. Have you been drinking any alcohol before or during your pregnancy?0 Yes, until I discovered that I was pregnant0 Yes, I still do0 No

If yes:1. How much alcohol do/did you drink?More than 3 glasses a day, 1-3 glasses a day, 1 glass a day, 4-6 glasses a week, 1-3 glass-es a week, less than one glass a week

29. Have you been using any recreational drugs during your pregnancy?0 Yes, until I discovered that I was pregnant0 Yes, I still do0 No

If yes:1. Which type of recreational drugs do/did you use?Marihuana/hash,Cocaine,Heroin,XTC,Other

33. Have you ever been treated by a psychologists, psychiatrist or supported by a social worker?0 Yes0 No

34. If yes, would you like to tell more about this?SPEECH OR TEXT OR X

(Based on this answer, midwife could decide to do EDS questionnaire at intake moment)

42. EDS introduction The next 10 questions are about how you have felt IN THE PAST 7 DAYS. Click the answer which describes best how you felt.

43. EDS (1) I have been able to laugh and see the funny side of things□AsmuchasIalwayscould□Notquitesomuchnow□Definitelynotsomuchnow□Notatall

44. EDS (2) I have looked forward with enjoyment to things. □AsmuchasIeverdid□RatherlessthanIusedto□DefinitelylessthanIusedto□Hardlyatall

45. EDS (3) I have blamed myself unnecessarily when things went wrong.

□Yes,mostofthetime□Yes,someofthetime

□Notveryoften□No,never

46. EDS (4) I have been anxious or worried for no good reason. □No,notatall□Hardlyever□Yes,sometimes□Yes,veryoften

47. EDS (5) I have felt scared or panicky for no very good reason.□Yes,quitealot□Yes,sometimes□No,notmuch□No,notatall

48. EDS (6) Things have been getting on top of me. □Yes,mostofthetimeIhaven’tbeenabletocopeatall□Yes,sometimesIhaven’tbeencopingaswellasusual□No,mostofthetimeIhavecopedquitewell□No,Ihavebeencopingaswellasever

49.EDS(7)IhavebeensounhappythatIhavehaddifficultysleeping.□Yes,mostofthetime□Yes,sometimes□Notveryoften□No,notatall

50. EDS (8) I have felt sad or miserable. □Yes,mostofthetime□Yes,quiteoften□Notveryoften□No,notatall

51. EDS (9) I have been so unhappy that I have been crying. □Yes,mostofthetime□Yes,quiteoften□Onlyoccasionally□No,never

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52. EDS (10) The thought of harming myself has occurred to me. □Yes,quiteoften□Sometimes□Hardlynever□Never

APPENDIX 4: INTAKE MOMENT

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4.1: Benchmark communication tools

1. Cultural probingPros: They give us a feel for people, mingling observable facts with emotional reactions (Walker et al, 2004)Cons:Nottimeefficient(Nicky&Minerva),Probescoulddifferperperson,group(Walkeretal, 2004)2. Communication cards (AAC/PEC)Pros: They are visual, can be tangible, can be pointed at (Mayer-Johnsen, n.d.)Cons: Communication limitation: not every subject is there, not into depth (Mayer-Johnsen, n.d.)3. Explanation video’sPros: simple way of explanation, can be in own language, can be with stories to relate to , timeefficient(medicaladvisorinterview)Cons: not very personal 4. Translator:Pros: you can transfer the information and get answers back (interview PUUR, medical advisor)Cons: no trust, control and power (Brisset et al, 2013)5. Medical modelsPros: you can point, explain by acting out (interview medical advisor)Cons: not sensitive in some situations (interview ambassadors)6. Drawing apps no data

References:Gaver, W., Boucher, A., Pennington, S., & Walker, B. (2004). Cultural probes and the value of uncertainty. Interactions, 11(5), 53. doi: 10.1145/1015530.1015555

Mayer-Johnsen (2015). Communication Series: What is a Communications Board? Re-trieved via https://books-on-autism.com/2015/10/17/communication-series-what-is-a-commu-nications-board/

Brisset, C., Leanza, Y., & Laforest, K. (2013). Working with interpreters in health care: A systematic review and meta-ethnography of qualitative studies. Patient Education And Coun-seling, 91(2), 131-140. doi: 10.1016/j.pec.2012.11.008

4.2 Research visual communication

→ Meaning of colors (De Bortoli & Jesús Maroto, 2001; McCandless, 2009)

De Bortoli & Jesus Maroto, 2001

Green/Blue/White = Calming, cold, peacefulSo intake form: midwife’s shirt = green, and stick with the green/blue/white visual identity.

De Bortoli, M., & Maroto, J. (2001, November). Colours across cultures: Translating col-ours in interactive marketing communications. In Elicit 2001: Proceedings of the European Languages and the Implementation of Communication and Information Technologies (Elicit) conference (pp. 3-4). UK: Paisley University Language Press.

→ Vertical and horizontal emoticons (Park et al, 2014) ‘’. Interestingly, the emoticons used by people vary by geography and culture. Easterners, for example employ a vertical style like ˆ ˆ, while westerners employ a horizontal style like :-). This difference may be due to cultural reasons since easterners are known to interpret facial expressions from the eyes, while westerners favor the mouth (Yuki, Maddux, and Masuda 2007; Mai et al. 2011; Jack et al. 2012).’’

Park, J., Barash, V., Fink, C., & Cha, M. (2013, June). Emoticon style: Interpreting differenc-es in emoticons across cultures. In Seventh International AAAI Conference on Weblogs and Social Media.

→ Interviews Syrian woman, Nicole Sanches, short conversations different women, Turkish and Montenegrin ambassadors

‘’Ithinkalotofmuslimpeoplewouldfinditoffendingifitisclearthatyoutreatthemdiffer-ently than Dutch people. You don’t want to highlight the cultural difference.’’ (Montenegrin ambassador)

‘’We, as Turkish people, respect the Dutch culture. We are not against other cultures, so we do respect the way Dutch healthcare provides care.’’ (Turkish ambassador)

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4.3 Processing code midwives’ interface

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4.4 Arduino Code NFC-reader communication processing

ThiscodeisanadjustedformofanexamplecodeoftheArduinoRFIDLibraryforMFRC522.Thiscodeisdownloadedfromhttps://github.com/miguelbalboa/rfid. The scheme used to connect the NFC-reader to Arduino can be found here: https://www.youtube.com/watch?v=KQiVLEhzzV0