Well, howdy, everyone.

It's great to see familiar faces as well as new fans here today.

My name is Joe Major.

I'm a professor in the Department of Architecture at Texas A&M University.

So today, I will be sharing some of my observations about the frontier of design research for improved population health.

So I will start with a initial introduction about how the concept and understanding of health has been evolving over time and how that has shifted in the way the way we approach health care and the public health in general.

And then the second section I will be talking about different approaches of design research for a more traditional, more narrow approach of post occupancy evaluation to a more vigorous research diagram.

And then the third section, I will be sharing some of my own thoughts, looking at the ongoing and new opportunities in design research.

What do we see as opportunities and the new horizon in design research for health?

So as we talk about design for health, I will be referring to general theory that shape this field.

How we link research and practice together inform each other really by working side by side design, professional planning professional, as well as academia and researchers to jointly promote population health.

So before going into the details, I would love to just take you all to a journey.

Okay.

A few nice scenery.

Imagine yourself traveling there and of course, be droning people here.

You'll see a wonderful combination of different colors yellow, green, blue.

Imagine if you are really there what this place will do to you.

Like how you would feel, how you will enjoy in a particular setting.

Or we could venture out to these at the Olympic National Park, imagining like summertime Wildflower is at peak enjoying life.

They are.

And how it would help you to wait for from on this journey or probably you know everyday like with your exam that Samuel.

And if you go to Japan in this case natural form beautiful natural landscape plus magnificent buildings, craftsmanship right next to each other and unique culture.

What these kind of place would really bring to it in a way is almost magical, right?

What it can do to us are totally different scenario if we are going to Mediterranean Sea and here in Greece enjoyed a beautiful island and the deep sea, well, like a whole year already benefiting from the kind of suggest restorative effects here.

Or if we go to visit to Japan again, going to some of the Japanese garden, the green scenery here all during fall time which the beautiful colored what they do us right in the way I'm trying to make point like what a good place good design could bring to art for general health.

Imagine yourself living in this house now.

How would you feel?

How would you enjoy it?

Or may You may also be looking for a bit more refuge protection in this particular setting on do these new homes bring something unusual and comfortable to you in the way?

So they are different places.

Some are more natural, some manmade wait, nice consideration of being in nature in the play.

So the point is, as we go through these, we know a good place really brings out significant health benefit to us.

Now, coming back to reality, if you're going to hospital as a patient, walk into this patient room, you are probably nervous already looking at on the wires equipment, thinking about a procedure that you have to go through or it could be somewhat nicer.

Why some greenery, nice window, family space.

You feel a little bit more support and a little bit more comfort or it could be even better potentially.

So the question is again, like how we design for better house, how we make it possible, how we integrate that into our everyday practice of designing and planning our environment.

So moving into the first section, how we understand health and promote health, we used to see House as a more natural concept of not being ill, but more recently, and here is the concept promoted by World Health Organization, which consider how to be much more than not to be in sick is also a status of complete medical, mental and social well-being.

So in response to that, we are also shifting our health care and public health promotion form, which additional curative approaches are sick care, if you will call it, to a more preventive and a proactive approaches which are just as well care.

This is especially important because nowadays we are dealing with a lot more chronic diseases in like everyday management, health promotion.

So related to that, there's also a increasing understanding about social determinants of health.

So a key concept here is health is not only about individual biological condition, genetic factors, but places we go to where we live, where we learn, walk and play all together, affect our health risks and the health outcome.

So how is it people 2020 as the national objective to improve population, health and well-being over the next decade?

It uses?

These diagram is a place based framework.

If you look out here, you can see our neighborhood and the built environment measures, our social context, our safety or unsafe neighborhood will have impact health care access and the quality, educational, setting, economic stability.

All of these naturally relate to our physical environment.

So if we take obesity, for example, which is one of the leading public health challenge, these social determinants of health could actually account for as much as 70% of the obesity and the related health outcome.

So we are never isolated.

We are constantly influenced by these different socio determinants.

So socio ecological model is a theory that has to be widely used and really helpful for understanding how and how to behavior.

So if you think about your everyday behavior is never completely individual choice is also influenced by interpersonal relationships, organizational factors, policies and many others.

Community aspect, physical involvement, social involvement, as well as public policy.

So if you think about it, what do we do?

Whether we engage in healthier or unhealthy behavior is really influenced by this complex system of nested factors.

They have that dynamic relationship.

They may influence each other if we try to address health problem, if we look into a root causes is often multilevel to come up with really effective solutions.

Similarly, we need to use multilevel approaches to make sure it's really effective.

So with that understanding of how plays matter, we are seeing increasing effort from different discipline in promoting healthy involvement.

So why example is in 2017, multiple professional organizations that include the American Institute of Health, American Planning Association, American Public Health Association, American Society of Landscape Architects, and many others, They released this joint call to Action to promote Healthy Community.

The key idea is if we really as a whole really want to be effective in addressing health challenges and inequity issue, we need a solid partnership and collaboration between build involved professionals and the public health professional.

We need to take a approach that is health focused.

When we look at our landscape, our home, our workplaces and our schools, etc..

So it is a kind of general backbone for understanding design for health.

So moving into the second section, how we could further evolve the research agenda for design research for better health.

So here I like use this analogy in the way if we think about medical research and practice.

Imagine yourself going to your doctors like you would expect whatever he or she gives you, whether it's medication, certain procedure that should be evidence based should have been tested to be effective.

Why?

So the medical community built their practice guideline on top of a series of study where there is case report, case control study cohort study or randomized controlled trial.

These knowledge pyramid really lead to common agreement in practice guideline, and they often use systematic review and meta analysis to arrive at the best knowledge and the solution for certain conditions and the treatment.

And we think about our architecture, research and practice.

Any project we design, we build in the way is wonderful research opportunity, but they are not often utilized.

So we may repeat the same mistake we made in a previous project because we didn't really fully understand how it was not working.

And these really hold back internal job how we can better design for health.

So if you go into design practice, you will see a lot of design firm.

Do you talk a lot about post arguments that evaluation is definite valuable and to use systematic approach to evaluate how a particular design works after it was built.

So the results, whether it is successful experiences or lesson that learn the form of value, could inform either the design of next similar project or feed into the more general design knowledge.

So it's really important and helpful, but to think beyond that, what else are we can do or what limitation does these have?

So if you think about a post, organize a study, say you design is building.

You ask a participant how satisfied they are, how much these they enjoyed a particular space.

Do the arrangement of a furniture work well, etc.

You may get some positive response, but it's a bit difficult to say.

Is it better than before?

Right.

So if they are an opportunity and this is becoming more and more common, we see the use of pre and post occupancy study.

We are the impact of intervention.

Could it be better understood because that's a reference point.

You had a previous condition to check against where you assess the condition after the actual occupancy.

So this is one advancement in the way.

But again, if you think about here, imagining in know made of this process, for example, COVID pandemic then says are all confounded in so many different way and how can you really compare right.

So research design wise, if we could introduce another group that didn't receive that particular intervention, we often call it control group.

What it does here is gave you another reference point by having another group of population that also have pre and post assessment at the same time, but they didn't receive that intervention.

So it allows us to better isolate the potential impact of these involvement or intervention.

So this is what we typically call Quasar Experimental study.

Now, to take it a bit further, if we could, depending on a particular project, we can also make it more rigorous by using random assignment of subjects.

So what it does is it allows us to have these two really comparable groups instead of potentially having one group option that already helps you to study with one group of students who are already doing much better or they have better teacher, etc..

So this random assignment allow us to have those comparable group to better study the impact of the potential change.

So if you look at this whole progression, if you will form post occupancy study all the way to quasi experimental study, you can see the effort or the value of introducing additional data points pre versus post and the higher case versus control and the last experiment of study using random assignment to make sure we have comparable groups.

So in particular project, it could often be limited by what is actually feasible.

But knowing how different research style Gwen and research design would have an impact on quality of evidence is potentially really important.

So I will share a few example I'll use in different study design just as a way to showcase how the different design may potentially affect the value of evidence as well.

So the first one school design for better learning.

So this is a elementary school project in our school district near Dallas.

It's a brand new school with very different design concept compared to more traditional school.

So within the district as well as the local community, do what they were interested in learning, What does this school really allow students to learn better and to perform better?

And because this is important public investment, why does it mean our future school should also be designed in this approach versus the more traditional approach?

So what we did and this is a collaboration with Stantec, the design firm, we looked at these Lee and Amanda.

We buy a new school as well as a more traditional school in the same district called Lakeside, which had the traditional furniture and a traditional school building to start with.

And what is also unique is these lakeside school with our changes to the building, they received brand new furniture during the process of a two year study, and it allowed us to do that, make that comparison as well before and after receiving the new furniture.

And we also compare both to the Lee adamantly the brand new school.

So basically, we did two rounds of survey in 2015 and the 2016.

What do we did it first in 2015.

We compare the new school with the Lakeside traditional school weights, traditional furniture.

And one year later, we went back with the same survey.

It allowed us to compare for Lakeside before and after receiving the new furniture.

Did anything change?

And also for the new school and the lakeside.

What new furniture do they perform on?

Similarly, in terms of student engagement and the satisfaction, or are they still quite different?

So it is a kind of unique opportunity because of the project that are happening in the district.

So the first comparison that you see here, the Orange line at the New School, Lea Elementary, and what I'm showing, it's the result for each major domain on a scale of 1 to 5.

And the blue line is one, a lakeside but traditional school.

So what are you can see here is for satisfaction with specific domains like acoustic lighting.

So more comfort views, etc., as well as student engagement outcomes.

So here you see the domain of behavior, engagement, emotional engagement, behavior, disaffection and emotional disaffection.

And across the board, you can see Lea and among her school perform better than the lakeside at the traditional school with traditional furniture.

So this is back in 2015 and one year later we went back where the lakeside received a new furniture for one year.

And of new furniture is a comparable to what's available in LEA and a monopoly.

So here things get a bit more interesting in the complex, right?

So first, if you look at the two orange line Lea and Harmony in 2015 and the dashed orange line is the same school in 2016.

What do you notice here?

Somehow change after little bit follows 18.

Right.

And that very typical because imagine yourself walk into a new building like it looks new, even if it's relative to average.

You feel better in general.

So Sam and I joke about it like I call it honeymoon effect, like the nice honeymoon vacation time.

You'll get to enjoy each other a lot while you go back to your home is a lot of new problem.

And coming up night who cooks their lunch, who cleans dishes, who controls remote, etc.

Those are realistic problem, right?

That pops up.

So that's very typical.

And if you think back about any new project you work on your research on using push argument.

Evaluation is a potential pitfall as well when you are trying to showcase your new design is performing better, you may well be capturing that honeymoon effect that could be wearing off pretty soon.

So think about a timeline.

Or do you want to try the second wave of assessment?

So that's what alignment we.

So then if you look at the two blue line, the solid line is 2015 for Lakeside, the dash line proven it for one year later.

What you see here is some other aspect.

You can change much about a building because the building didn't change, but you see a big jump in satisfaction with the furniture to the extent that's almost matched the elementary.

So it makes perfect sense again for the school district, for whoever make the investment is a really reassuring message here.

And if you look at the engagement item, what you can see is in terms of behavior, disaffection and emotional disaffection, we see improvement in student, our student outcome as well.

So if we think about reality of a lot of public school, they may not a lot of them probably would not really get a chance to rebuild a new school, But they may have the chance to replace furniture, etc..

So this is really giving us some useful information about how these different approaches of renovation or replacement would potentially work for the students here.

So that's one example.

And the second, moving into a larger scale study, let's look at active living, the idea of encouraging physical activity like walking and biking into data routine.

So this is a project funded by in the National Institute of Health.

We are looking at a mixed use, walkable community in City of Austin, Texas.

We are interested in understanding both short term and long term changes in physical activity among residents as well as understanding what led to these positive changes, if any.

So in this case, we use a natural experiment to study which longitudinal case comparison design page participants are those adults who moved to this new community.

And the comparison participants were paired weights, paces and they have similar like age range, the same gender weight, the particular matching pace and living in similar pre move community.

We are moving to a new place.

So these allow us to make a comparison before and after.

So data correction wise we identified a future Muro residence, invited them to join in a survey as well as a one week optional measure.

Well we invited them to well GP's and accelerometer to capture a physical activity and after a move we invited them to repeat the same measure for multiple time at the same time while comparison participant They completed the same measure at multiple time.

So these allow us to do that pre and post and the case and control comparison.

So data collection why because these are larger scale project we have a diverse set of data collection methods for both human data and the involvement of data which allowed us to better understand our behavioral pattern as well as our environmental exposure and the travel pattern as well.

So here is like a snapshot of the key features of the environment in terms of being walkable, higher density with connected street networks, complete sidewalk coverage.

And also rather diverse housing types ranging from higher density apartment living to larger single family housing, resulting wise, though, we did see between pace and the control, pace is improving our physical activity up from before to after.

And the more importantly among comparison participants.

So if you focus on these like matched comparison between case and control, what do we see here?

And if you think back about research design, if we only did the post occupancy evaluation, we have one data point for these residents after the move.

But how can we tell if it's an improvement?

It was a better than others community, but by having pre and post, we see that improvement and at the same time the control group became valuable because what it's telling us is this is matched control group.

Now physical activity decreased over time and that's actually very typical.

If we think about as we become older, we typically get less active over time.

So these really allow us to be able to see the tab between pace and the control point after the move.

Is that different?

What do we call difference in difference?

That's an actual effect that we are seeing from these particular walkable community.

If we use a more limited occupancy study, we are not going to be able to detect that actual impact in this case.

So this is a second example.

And so the one is a relatively small study, but it kind of gave us some good idea about how we test certain element in design while controlling others.

So this was actually a dissertation study by one of our former students, Adele.

She's interested in how healthcare involvement could affect employee stress and change is a relatively small scale dissertation study.

She didn't really have the resources to build in a changing environment, but here she used photo simulation and utilized that flexibility to simulate different type of intervention.

So you can see from left to right from a power like conference room to introducing some plans, large painting of nature, window open into nature, plus window and balcony opening.

So you can see it's relatively easy to create these simulation.

And then she asked employees how effectively these place will help them believe.

That's just because we know stress at a workplace is a huge challenge among healthcare workers.

So this is one example.

You can see how the differences that are showing up across different scenario.

And she had multiple comparison scenario to triangulate result.

So here is another kind of lounge area, but with the similar same simulation scenario repeated and you are seeing similar results here.

So it's not ideal like it could be when you're working on a design project, you're thinking about what do we do in this particular space?

What kind of additional amenity would be most helpful.

So here the consistent message you're seeing is not knowing.

Not having any natural elements is performing.

Watch them having indoor plan.

But that is not as good as in a large landscape artwork here.

But that's not as good as window view.

And for that, the best scenario here is having vertical access to outdoors in addition to the visual access to nature.

So it's kind of effective way to test these particular variation while controlling other animals in a space.

So it is another angle to think about how design research can help.

And last one is employ quite different angle.

So this one is a in Sweden actually a chronomat like critical care unit.

What I did here is because of the Challenger, they had always acoustic involvement in this particular space isn't very noisy.

They decided to test how higher acoustic performance seen want to work in this particular unit and the change to like quit that appliance study environment where the participants don't really know which to know where they are in.

They switch is seen in tile overnight and the scene in whether it's better or worse performing in terms of like acoustic performance, they look exactly the same.

So basically others have windows walkers who switch them out.

They don't know which one they are exposed to.

So what they found it all is interestingly, because it's well controlled, a study here, they are able to tell during good acoustics patient had better sleep, which is really important for patient recovery.

They had less physiological stress by different indicators and also they have lower incidence of rehospitalization.

So these are pretty bit thinking about it's just see, the inhale is not about different medication, different procedure and medical wise.

Right.

And what's even more important and encouraging, they calculated a payback time.

So for this particular seating high, because that's oftentimes a concern for your client.

Why?

Well, it sounds good, but we just don't have the money to do it.

Right.

That's very typical kind of counter argument.

So here what they found is the payback time by referring to improved outcome, it's really only one month.

So beyond that, you'll have additional cumulative saving by better performing for these better performing scene.

And so it's actually being more financial income revenue here because of a better performance here.

So a very kind of a smart idea to think about how we can test a particular element while creating an environment that is well controlled for our study purpose.

So that's the last example I want to share.

And the next few slides are what we talking a little bit about, what at least I personally see and also our research team looking ahead, what do we see as gap of knowledge?

Because in the past we have heavily will really rely on correlation or study.

Well we can say well a is associated ways of be but the next natural question is like really is it really because of a down we have bad outcome, bad health, etc..

So that seemed to be a major gap that is being more and more emphasized.

And a related to that, there's really a strong demand for us to better understand how it happened.

So if this design option helps student learn better, if that particular workplace help empower you to stay healthier, how exactly that happened?

So knowing that underlying mechanism really help us to better understand better design for that.

And the third one, how much is related those respond to relationship.

So example of like nature years is helpful.

But if I say to you for community, how much nature, how many parks, open spaces they need to really be beneficial for the larger population, for example, and also cost effectiveness because is always going to be about resources that are available which you get priority.

So if we could have better understand that, we could make better decision as a whole, like by walking way to policymakers, etc., because of the fact human being in a way we cannot isolate them for particular really controlled experiments study.

In most cases we are seeing the potential and the need to use more natural experiment to study.

So because those involved changes are happening our everyday life, if we could use data where there is a major project, major infrastructure that in the city is bringing in, we study the impact of those investment to see how it is really affecting the population health.

So like referring to this gap of knowledge, if we take nature of voices, how to example, like do we need more research around it to we fully understand it.

So I'm referring to a literature review article here.

I think it does a really nice job in summarizing some of the key gaps we could and should explore more.

So one is a mechanism like I was discussing earlier, how the portable pathways are working form nature exposure, a certain type of nature exposure to improve outcome, how the exposure science, the dose response relationship really work, how we can really understand the for epidemiology for a whole population wide like data exposure, virtual population health, how they are improving over time.

If we introduce major intervention and for nature aspect, that's always a question of diversity and equity because we know there are a lot of like nature desert in the way, just like food desert for low income community in a population.

So how we can better adjust that equity issue and how technology come into play here.

So it could be in certain places now, it could be extremely ill patient who could move up, all who couldn't really access nature, how we can bring nature to them, possible ASU technology like a VR, etc.

and also the bottom line economic and policy study how to make such successful business case to make sure the policy would work.

And the implementation sounds wide like how it actually works.

Sometimes we push out a major intervention program, but it didn't succeed because of cultural barrier or other reason.

So we need to better understand how to better implement it.

So it is a kind of example about how those different gaps could tie into a particular design research issue.

And the second new opportunities.

So these are more exciting one, right?

So we are seeing a lot of new technology, artificial intelligence, virtual reality, augmented reality.

We used to like trapping small sensors, etc..

So they are really affecting, for example, healthcare, directly changing the landscape of healthcare.

They are also affecting professional directly by, for example, in the middle image, you see how VR could provide direct video feedback.

It could be for designers as well as for potential users who will utilize the space and the feedback from the users or the direct perception of the designer.

Could help improve the design in return.

So that's just one example.

And another important angle and the new opportunity is what is called just in time intervention is the idea of like, if we want to be effective in promoting health behavior, we could really benefit for new technology by smart sensors, knowing for stress prevention or mental health crises.

If the smart sensors is indicating extreme stress at that particular moment or even suicide to prevention, the CMOS sensor could alert the weather.

It's research team on how professional community health workers and that could trigger more effective intervention in real time because otherwise often behind like, for example, suicide prevention is going to be too late.

So it's really offering new opportunities in the way.

So kind of we are not into some of our ongoing work.

So this is some of the conceptual diagram we have been drafting for workplace study.

And the idea is no workers with a mobile ecological momentary assessment app on their phone wait could be synched with smartwatch like Garmin Watch, which could give us accurate reading about by like suggesting.

No, that's doubtful.

If these worker is working on computer, the software could generate performance measures like is the what employee and make a lot of mistake.

Having to rewrite a lot of things are not an indicator of performance and it could also be sync ways our quality monitor in a particular workplace.

So we know in general when CO2 levels become higher, I'm not sure how these will perform now.

And we tend to get Josie for example, our performance will go down.

So weight to these mobile app, the synched device is smart sensor.

We could potentially, for example, push out a question to the employees when we read a high stress signal, like why are you just out?

What has happening?

All When we send the high, the CO2 level is reaching a level that is relatively potentially harmful to performance.

We can ask them, Do you feel your performance is like or we can check.

They are computer metrics based performance to see if there is actually actual relationship now.

So it really allow us to be able to much better do a much better job in detecting that relationship between exposure and health and a performance outcome.

So to bring it back to the more complex contact, if you recall the socio ecological framework, these it's just one example of the conceptual framework we are developing for working from home environment.

We are interested in promoting employees health, internal physical activity, work relating to stress and work performance, and we are looking at that involved to exposure of on different level micro-level employees, individual characteristics, macro level organization in the community, influences as well as macro level home and neighborhood involvement, which could be physical environment like workstation home furniture, home spacing, neighborhood amenity, as well as technology and social involvement.

Because we know these different layers of factors affect our health and performance together and potentially information for And such a study could inform future policy like a building code or organizational workplace policy as well.

So this is kind of circling back to the beginning.

If we think about the general goal of promoting health, think about easier way research and practice around it and how they can all work together to inform design in planning professional as well as probably how is professional to develop healthier community housing or workplaces and housing in school because we know those different places, our health as a whole in the way we can, really cannot really take them apart.

So from the research perspective, looking at how I think like for the research community, it's important to stay up to date with those.

Methodological advancement is also important for both designer and researchers to know contextual differences.

Because each project is different, each community is different.

We always need to be sensitive to that local context.

We know policy support is going to be really important and the research community could provide more evidence, support for more informed public policy making.

And all in all, we need that collaboration of different disciplines to work together to jointly and more effectively promote population health so that national all.