1

INDEPENDENT
HEROES
Supporting type 1 diabetic young
adults’ transition to independent
living
Kunal Gupta

INDEPENDENT HEROES
Supporting type 1 diabetic young adults’ transition
to independent living
By
Kunal Gupta
BDes, School of Design, UPES, 2019
Supervisor: Jonathan Aitken
A critical and process documentation thesis paper submitted in partial
fulfillment of the requirements for the degree of
MASTER OF DESIGN
Emily Carr University of Art and Design, 2021

Kunal Gupta © 2021

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Table of contents
ACKNOWLEDGMENT

08

ABSTRACT

09

1 INTRODUCTION

11

1.1 Thesis statement

12

1.2 Project objectives

13

1.3 Project rationale

14

2 SECONDARY RESEARCH

15

2.1 Understanding type 1 diabetes

16

2.2 Managing type 1 diabetes

17

2.3 Hypoglycemia

18

2.4 Glucagon

19

2.5 Young adults in transition

20

2.6 Technological precedents

21

3 CONTEXT & FRAMING

24

3.1 Situating research

25

3.2 Scope of intervention

28

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4 PRIMARY RESEARCH

30

4.1 Methodology

31

4.1.1 Research Methods

32

4.2 Ethical consideration

34

4.3 Analysis and findings

35

4.3.1 Surveys

35

4.3.2 Semi-structured interviews

35

4.3.3 Cultural probe

37

4.3.4 Making connections-Key findings

39

4.4 Design direction

40

4.4.1 Persona & scenario

40

4.4.2 Co-creation

43

4.4.3 Expert interview

46

5 DESIGN OUTCOME

47

5.1 Design criteria

48

5.2 Ideation

50

5.3 The concept

52

5.4 Mock-ups

61

5.5 Digital model and rendering

62

5.6 Prototype

64

5.7 User Feedback

69

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6 REFLECTION & FUTURE DIRECTION

70

6.1 Insights & learning

71

6.2 Barriers and limitations

72

6.3 Contributions and implications for design practice 73
6.4 Future implications

73

7 WORKS CITED

75

8 GLOSSARY OF TERMS

83

9 APPENDIX

84

9.1 REB application

85

9.2 Nasal glucagon

86

9.3 Research activities

87

9.3.1 Surveys

87

9.3.2 Semi-structured interviews

90

9.3.3 Blogs and podcast

92

9.3.4 Cultural probe

93

9.4 Scenarios of use

95

9.5 User Feedback

98

9.6 App Screens

99

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List of Figures
Figure 1: Estimated prevalence and cost of diabetes (Source: Diabetes Canada)......16
Figure 2: Blood glucose monitor (Source: Pikist)......................................................17
Figure 3: Continuous glucose monitor (Source: Wikimedia commons).....................17
Figure 4: Affinity map of challenges faced by young adults in transition: Secondary
research (Mapping by author).................................................................................26
Figure 5: Challenges faced during the transition to the adult service........................35
Figure 6: Cultural probe analysis...........................................................................38
Figure 7: Affinity mapping, Primary research: Qualitative information clusters formed
from primary research insights (Illustration by author)..............................................39
Figure 8: Personas................................................................................................41
Figure 9: Scenario Development with pain points and design opportunity................42
Figure 10: Co-creation activity 1- Partial Consciousness..........................................43
Figure 11: Co-creation activity 2- Unconsciousness................................................44
Figure 12: Concept Diagram wearable(Illustration by author)..................................50
Figure 13: Concept Diagram alert device (Illustration by author)..............................51
Figure 14: Concept Diagram (Illustration by author)...............................................52
Figure 15: System Map (Illustration by author)........................................................54
Figure 16: Wearable device concept sketch............................................................57
Figure 17: Alert device concept sketches.................................................................57
Figure 18: Information architecture showing the user flow for the App (illustration by the
author)..................................................................................................................58
Figure 19: App wireframe.....................................................................................59
Figure 20: Information architecture showing the user flow for the Carrier app (illustration
by the author)........................................................................................................59
Figure 21: Connect app wireframe........................................................................61
Figure 22: Smart wearable mockups......................................................................61
Figure 23: Alert device mockups............................................................................61
Figure 24: (a) Wearable device turned off; (b) Wearable device when activated........62
Figure 25: (a) Alert device turned off; (b) Alert device when activated.......................63
Figure 26: Wearable device prototype....................................................................64
Figure 27: Alert device prototype...........................................................................64
Figure 28: Wearable and alert device prototype.....................................................65
Figure 29: Alert device prototype on hand..............................................................65
Figure 30: Alert device prototype placements .........................................................66

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Figure 31: App prototype......................................................................................67
Figure 32: Connect app prototype.........................................................................68
Figure 33: REB Application....................................................................................85
Figure 34: Nasal glucagon....................................................................................86
Figure 35: Nasal glucagon delivery (Source BAQSIMI)............................................86
Figure 36: User survey form (1/5)..........................................................................87
Figure 37: User survey form (2/5)..........................................................................88
Figure 38: User survey form (3/5)..........................................................................88
Figure 39: User survey form (4/5)..........................................................................89
Figure 40: User survey form (5/5)..........................................................................89
Figure 41: Screenshot of survey posted on Online blogs.........................................92
Figure 42: Screenshot of podcast from spotify (1/2)................................................92
Figure 43: Screenshot of podcast from spotify (2/2)................................................93
Figure 44: Cultural Probe Activities........................................................................94
Figure 45: System map of scenario from first person(diabetic) perspective................95
Figure 46: System map of scenario from second person (person observing diabetic)
perspective............................................................................................................96
Figure 47: Scenarios of use...................................................................................97
Figure 48: User feedback activity...........................................................................98
Figure 49: Main application screens(1/2)...............................................................99
Figure 50: Main application screens(2/2)...............................................................100
Figure 51: Savr connect application screens(1/2)....................................................101
Figure 52: Savr connect application screens(2/2)....................................................102

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ACKNOWLEDGMENT
Over the course of two years, countless beautiful souls have contributed their best to this
thesis project.
To my supervisor, Jonathan Aitken, thank you for your mentorship and guidance
throughout this challenging process and especially in these unprecedented times of
global pandemic. His vast knowledge and experiences have truly inspired me to work
continuously. I could not thank him enough for his innumerable readings and edits.
To Caylee Raber, for providing a different lens on the project and supporting with
additional resources.
To my research participants, thank you for your trust, passionate contribution, being
always available, and without whom this project would not have been possible.
A special thank you to the incredible professionals from British Columbia Emergency
Health Services (BCEHS), including Ryan Ackerman, David Brown, Nic Hume, Emily
Perrins and Scott Kozol, for providing their valuable insights and field information
regarding the topic.
To all the design faculty at Emily Carr University for the rich, fruitful conversation and
always directing the right path: Helene Day Fraser, Kathrine Gillieson, Gillian Russel,
Chris Jones, Keith Doyle, Sophie Gaur, Craig Badke, Garnet Hertz.
A big hug to all my MDes Cohort for all the inspirational work, critic sessions and preCOVID fun moments during the studio.
To my amazing roommates, Simranbir and Surnoor, for all the countless chai and
conversations at odd hours.
I must acknowledge my Father, a type 2 diabetic, was an inspiration for this project
and continuously provided me with the latest diabetes news worldwide and suggesting
updates on my project.
I am grateful for the encouragement, love and support from my family and friends. My
Mom for frequently sending me meditation-videos, and my twin brother for listening to
my rants.
And lastly, to the University for a plethora of resources and support my journey as a
designer and researcher.

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ABSTRACT
This Master of Design Thesis project focuses on the condition of severe hypoglycemia
(low blood sugar) in young adults living with type 1 diabetes by carefully understanding
the unique challenges they face in transitioning to adult care. This research surfaces
the needs that often get blurred in the transition process and offers a design for an
appropriate solution to support the identified issues.
Canadian young adults living with type 1 diabetes often find themselves at the risk of
hypoglycemia during emerging adulthood. The concept of emerging adulthood has not
been considered extensively in managing chronic illness and transition from pediatric to
adult care. Yet, this is a critical time when a person may first assume full responsibility for
their diabetes self-care while simultaneously facing all the usual challenges young adults
face. Additionally, the fear of hypoglycemia is strongest in this group.
A review of the literature informs us about previous work done in this field. However,
most current interventions are in the form of bulky printed materials. Another critical
issue with the development of most recent tools is the absence of user involvement in the
creative process leading to unmet user needs.
In this project, participatory design methodologies were introduced in a human-centered
approach, collaborating with young adults to understand and address the transition
process gap. It included actively listening to user narratives and co-creating the solution.
The synthesis of primary and secondary research resulted in the designed outcome of a
smart wearable device that will work in conjunction with the Continuous glucose monitor
(CGM) and alerts the bystander and emergency contacts by turning them into potential
lifesavers. It will inform them of a diabetic emergency and guide them through the lifesaving instructions. Additionally, it will alert the medical emergency services for prompt
assistance if needed.
The solution attempts to provide early intervention during emergency and could also
alleviate the fear of hypoglycemia in young adults. This in turn will reduce the load on the
already burdened healthcare system.

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KEYWORDS
Young adults
Type 1 diabetes
T1D
Transition
Hypoglycemia
Glucagon
Medical emergency
CGM
Blood sugar
Participatory
Human centered
Co-creation
Cultural probe
Affinity diagramming
Early intervention
Smart wearable

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1 INTRODUCTION
1.1 Thesis Statement
1.2 Project Objective
1.3 Project Rationale

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1.1 THESIS STATEMENT
Facilitating type 1 diabetic young adults’ transition to adult
care through a design intervention that helps them navigate
hypoglycemia.

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1.2 PROJECT OBJECTIVES
The objectives of this project include:
1. Understanding and identifying the needs of type 1
diabetic young adults as they transition fully into
adult self-care.
2. Employ participatory design methods that empower
young adults to have a voice in the design process.
3. Integrate research findings to develop a solution.

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1.3 Project Rationale
The transition of young adults living with type 1 diabetes from pediatric to adult care
is fraught with challenges. Current gaps in this process pose some serious health
challenges and add to the cost of diabetes, which was estimated to be $15.36 billion for
1.2 million Canadian living with diabetes (Bilandzic & Rosella, 2017). Ensuring care and
support for people with diabetes will safeguard the patient’s well-being and reduce the
systemic cost associated with diabetes care.
Young adults experience gaps in the care transfer procedure and have additional
transitional issues and challenges apart from diabetic-related complications. Many of
these transitional challenges have been identified; however, very few interventions exist
to assist them through the process. The healthcare system in Canada acknowledges
the challenges young adults face in transition and is facilitated through transitional
programs; however, research indicated that healthcare professionals may not always
conduct a detailed needs assessment and generally tend to lack user participation in
these solutions’ design processes, leading to unmet user needs (Shah, Robinson, &
AlShawi, 2009).
My primary research identifies that the incidence of hypoglycemia (low blood sugar) is
prevalent among the targeted group. At this age, young adults are often moving out
of their parents’ home to start university or join work—a new environment with people
who might be unfamiliar with diabetes. Glucagon, an emergency medication commonly
used to treat severe hypoglycemia, only works if someone knows when to use it, where
it is, how to use it and is motivated to do so. After reviewing precedent literature and
work done in this field, I identified a gap that no treatment plan exists in the market that
addresses the above and provides life-saving assistance to people with diabetes.
There is a need to provide young adults with such a life-saving tool that they can utilize
in emergencies. A secondary outcome would be the confidence this tool might give
young adults and reduce their stress during diabetic situations. My thesis project seeks
to address this gap by developing a solution that aims to provide early assistance by
alerting people when to use it, notifying their location and guiding them to the life-saving
process.

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2 SECONDARY RESEARCH
2.1 Understanding type 1 diabetes
2.2 Managing type 1 diabetes
2.3 Hypoglycemia
2.4 Glucagon
2.5 Young adults in transition
2.6 Technological precedents

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2 SECONDARY RESEARCH
To ground the design firmly in its context, secondary research was initiated to understand
the existing knowledge base of the problem space.

2.1 Understanding Type 1 Diabetes
Roughly 10% of people living with diabetes in Canada have type 1 diabetes (“Type 1 diabetes,” 2020). The increase in diabetes is expected to grow by 30% from 2020 to 2030
(Diabetes in Canada: Backgrounder. Ottawa: Diabetes Canada; 2020).
Type 1 Diabetes (TID) is neither preventable nor curable. Living with T1D requires constant attention to avoid acute, life-threatening hypoglycemia (low blood sugar) or the
long- term damage done by hyperglycemia (high blood sugar). People with diabetes check their blood sugar levels either with blood glucose testing devices or with
a Continuous glucose monitor (CGM). One must carefully calculate insulin doses
based upon activity and stress levels, food intake, illness, and additional factors. These
calculations are rarely perfect; both patients and caregivers experience a tremendous
emotional and mental burden. Blood sugar regulation is necessary because, over a long
period, high glucose levels in your blood can seriously damage the heart, eyes, feet, and
kidneys (“What is Type 1 diabetes?” 2020).

Figure 1: Estimated prevalence and cost of diabetes (Source: Diabetes Canada)

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2.2 Managing type 1 diabetes
Managing and treating T1D is a two-part process: measuring blood glucose and
delivering insulin. There are many ways in which glucose monitoring processes can be
performed.

BLOOD GLUCOSE MONITORING
Glucose monitoring is a vital process for glycemic control. Regular monitoring makes
it easier for patients to make daily management decisions related to food intake,
insulin dose, and physical exercise. It enables patients to avoid potentially dangerous
hypoglycemia and hyperglycemia episodes. There are different ways in which one can
execute this task (“My Site - Chapter 9: Monitoring Glycemic Control,” 2018).

Blood glucose monitors are the most
commonly used and traditional glucose
monitoring methods, including a test strip
that inserts into a meter. A special needle
called a lancet is used to prick the finger
and touch the drop of blood to the test
strip, which the meter starts processing
and gives a blood glucose reading (Center for Devices and Radiological Health,
2019).

Figure 2: Blood glucose monitor (Source: Pixabay)

Figure 3: Continuous glucose monitor. 2016. Wikimedia
commons, licensed under CC BY-SA 4.0

A continuous glucose monitor (CGM)
is a small wearable device that tracks
the person’s glucose throughout the day
and night. While not as common as the
glucose monitors, it is becoming the new
norm. It notifies the user of any highs or
lows to give individuals a clearer picture
of fluctuating blood sugar levels in realtime. The continuous glucose monitor
automatically checks your blood sugar at
regular intervals and displays the blood
glucose reading on a screen (Diabetes
Daily Staff, 2019).

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2.3 Hypoglycemia
Hypoglycemia is the state of low blood sugar caused by too much insulin or too
little sugar in the body. It is defined as blood sugar below 70 milligrams per deciliter
(mg/dL), or 3.9 millimoles per litre (mmol/L). If left untreated, it may result in
seizures, unconsciousness and sometimes death, so it is not surprising that fear of
hypoglycemia is common among adults and children with T1D (Seaquist & Clark, 2013,
as cited in Peters & Laffel, 2013, p. 348).
Symptoms of hypoglycemia include anxiety, behaviour changes that seem similar
to being intoxicated, confusion, difficulty in concentrating, drowsiness, fast heartbeat,
shakiness, slurred speech, unusual tiredness, or weakness.
There are two situations in which hypoglycemic reactions can be treated—awake or
unconscious (Hamdy, 2020).
Treatment
If a person is awake, they should be ingested simple carbohydrates (15 grams*) such
as glucose tabs, glucose gel, regular soda or juice or sugar.
If a person is unconscious, they should be treated with a glucagon and emergency
services should be called.

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2.4 Glucagon
Glucagon is a hormone produced naturally within the body. It is also an emergency
medication used when a person with diabetes is experiencing hypoglycemia, and
sugar cannot be taken orally.
It comes in powder form and is usually added to a solution to administer it. Once
glucagon is injected, it raises the blood sugar by sending a signal to the muscles and
liver (where glucose is stored in the body). The effect of glucagon is the opposite of
insulin, raising blood glucose instead of lowering it. As well as the injectable glucagon,
Nasal glucagon called BAQSIMI is also used to treat hypoglycemia. This powder form of
glucagon is administered into the nose and comes in a single-use dispenser.
When a person is conscious but cannot consume sugar orally, then glucagon can be
self-administered. If the person is unconscious or has an altered level of consciousness,
someone else will need to inject the glucagon into the muscle or administer BAQSIMI
(nasal glucagon) to the nostril. If hospitalized, an injection may be given intravenously
(“Glucagon,” 2020).
The standard glucagon (injectable) requires cumbersome reconstitution and could be
intimidating for caregivers during an emergency (Suico et al., 2020). The nasal glucagon
offers a promising alternative to the transitional ones as it is needle-free, easy to use, as
effective as the standard one (Sherr et al., 2016). This option provides a more reliable
opportunity for treating diabetic emergencies.

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2.5 Young Adults in Transition
Health care transition is defined as the “purposeful, planned movement of young
adults with chronic medical conditions from pediatric care to the adult health care
system” (Kaufman & Pinzon, 2007). The change is often a challenging process and
becomes a significant challenge for healthcare providers. The transition for young people
with diabetes means increasing their diabetes knowledge and enhancing their selfmanagement skills. However, this is influenced by multiple parallel changes in holistic
personal development during emerging adulthood. Several studies claim that ineffective
or broken healthcare transitions may increase diabetic-related complications.
The period of emerging adulthood is focused on exploring one’s identity and
experiencing many social, emotional, educational, occupational, and financial concerns
during this stage. With new responsibilities and reduced parental management, young
adults may struggle, and their glycemic control may suffer (Nakhla M, Daneman D,
Frank M, Guttmann A, 2016; Insabella, Grey, Knafl, & Tamborlane, 2007). Maintaining
a near-normal glycemic level is essential in reducing future complications from diabetes.
A study states that suboptimal glycemic levels established during this age group may be
challenging to change later (Rausch et al., 2012).
Along with regular developmental changes that the age transition offers, youth are
loaded with tangled daily necessities of diabetes care, such as monitoring blood glucose
levels, administering insulin, regulating food and exercise, and have appropriate access
to medical care and diabetes supplies (Weissberg-Benchell, Wolpert, & Anderson, 2007).
At this stage, they often struggle with these demands and may feel unsupported and
vulnerable.
Several barriers are reported to self-care and standard glycemic control in the targeted
demographic. In a small survey, irregular schedules, diet, hypoglycemia, and finances
were also reported as barriers to glycemic control, along with peer pressure and lack of
parental involvement (Ramchandani et al., 2000).
Young adults have unique needs that usually do not fit into the typical pediatric or adult
diabetes care agenda. These needs must be woven into the transition process to ensure a
connected and sophisticated health care transition.

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2.6 Technological Precedents
In order to develop a potential solution to address hypoglycemia, several existing
technology precedents were explored, which acts as the base for the design.

VOICE ACTIVATION
Voice activation technology has evolved for years but is relatively new in this area. Several
health apps, including Covert Alert and Safe, use this technology to alert SOS contacts
through a chosen phrase (“The #1 voice-activated personal safety app is now available
on both Android and iOS.,” 2019) (MobileSoftware AS. 2020). These are personal safety
apps intended for the general public, including children, family members, employees etc.
As well, a voice-activated medical alert system like a medical guardian allows seniors
who want to send medical alerts and summons for help (“The Best Voice Activated
Medical Alert Devices - Caring.com,” 2021).
However, there are ongoing issues, not least of which is the challenge of slurred patient
speech in an emergency. This technology provides practical support for this current
app but necessitates a fallback plan. It is believed that A.I. could better handle these
challenges and provide a robust experience.

­AUTOMATIC 911 CALLS
The upcoming next-generation 911 service in Canada allows people to interact with 9-11 call centers using innovative services and capabilities such as text messaging and the
transmission of photos and videos (Government of Canada, Canadian Radio-television,
and Telecommunications Commission (CRTC, 2017). Companies like Apple and Google
have started utilizing this feature in their SOS systems to request emergency responders’
help (Dhara Singh, 2019) (Apple, 2020). Apps such as Lifeguard employ this feature
to alert emergency medical services of a drug overdose incident and provide all the
required information such as location, number, etc. (“New Lifeguard app launched to
help prevent overdoses,” 2020). This feature facilitates prompt action and saves time in
an emergency.

FALL DETECTION
Fall detection has been an invaluable addition to medical alert systems. The automatic
fall detection feature uses an accelerometer to detect hard falls by detecting the abrupt
changes of body movements and provides alerts for assistance to the chosen contacts.
Apple has included this in their Apple Watch, where it alerts the emergency services in an
emergency incident (Apple, 2020).

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Similarly, Lifeline from Philips is a medical alert system for seniors with fall detection and
allows quick access to help (“Medical Alert Systems for Seniors with Fall Detection | Fall
Detection Device,” 2020). This technology equips the alert systems with an added feature
and ensures to provide early assistance.

GPS LOCATION
In case of an emergency, the most important factor in providing care is the person’s
accurate location. The majority of cell phone apps use GPS to track the person. However,
it does not tell us about the building elevation, which can pose a challenge to first
responders helping in an emergency. A Sensory App developed by Columbia University
could identify the caller’s exact location by detecting elevation and translating it to a floor
number. If this feature integrates with the current smartphone, this would be a gamechanger for emergency services, who often have difficulty locating the incident (Baraniuk,
2017).

­MASS NOTIFICATION & TURNING BYSTANDER TO LIFESAVERS
Mass alert notification leverages technology to send critical messages to reach a larger
population during emergencies such as COVID-19 outbreak, natural disaster, biological
hazard etc. Emergency alert systems such as Alert Ready is a Canada wide program used
by government officials to issue emergency alerts. The alert helps the public respond as
directed in emergencies and stay safe (“BC Emergency Alerting System Test,” 2019).
Every minute is crucial in an emergency, and bystanders, such as family, friends,
and good Samaritans, play a vital role in increasing the likelihood of survival until
professional medical responders arrive. Many apps such as Pulse Point, Unity Philly
understand the community’s power and prepare bystanders ready to help save lives
(French, 2020) (“Inform and engage your community,” 2020). However, these require
an additional app that the citizen needs to download to get the information and provide
assistance that may be restrictive for some people. Providing alternate options to
downloading an app could motivate more citizens to help others in need.

DETECTING HYPOGLYCEMIA BASED ON ECG
A recent Pilot Study on deep learning for hypoglycemic events detection based on ECG
uses personalized medicine and artificial intelligence (A.I.) to detect nocturnal (nighttime)
hypoglycemia automatically (Porumb, Stranges, Pescapè, & Pecchia, 2020). The
results show that hypoglycemic events can be automatically detected using a few ECG
heartbeats recorded with wearable devices in free-living conditions using personalized
classifiers based on deep-learning artificial intelligence algorithms.

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Combining the CGM glucose readings with this data could help reliably detect early
hypoglycemia and proactively alert the user of any impending incident.

ACTIVITY RECOGNITION
An individual’s activity dramatically affects the blood sugars, and it would be helpful to
know about the person’s physical activity when he/she has diabetes to avoid low blood
sugar (“Blood Sugar and Exercise | ADA,” 2021). Accelerometer-based activity monitors
are capable of quantifying human motion. A study proves this by using a single tri-axial
accelerometer (the same for fall detection) to recognize different activities and classify
them into four categories, i.e. ambulation, cycling, and sedentary activities (Mannini,
Rosenberger, Haskell, & Intille, 2017).
This reliable recognition will assist the person in having a greater understanding of their
activity effect on blood sugar, in turn, better manage diabetes.

­

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3 CONTEXT AND FRAMING
3.1 Situating Research
3.2 Scope of Intervention

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3 CONTEXT AND FRAMING
3.1 Situating Research
Diabetes research and health care generally have been divided into two distinct phases
for receiving medical care: pediatric and adult. The transition period between pediatric
and adult care occurs in late adolescence. The next developmental stage of life is
emerging adulthood, and the population in this bracket are emerging adults1. This stage
of emerging adulthood has not been considered extensively in managing chronic illness
(Paone & Whitehouse, 2011). Yet, this is a critical time when a person not only assumes
responsibility for their diabetes self-care and interactions with the health care system but
when they become more independent, potentially moving out of their parents’ home to
attend college or to join the workforce (Peters & Laffel, 2011).
The current literature does identify a wide range of issues regarding transitioning.
A document generated by the BC Children’s hospital titled “Developing a transition
initiative for youth and young adults with chronic conditions and special needs in British
Columbia” addresses specific diabetic challenges (Paone & Whitehouse, 2011). Within
the context of this transition, the lacunas in diabetes care can lead to substandard
health care utilization, deteriorating glycemic control, increased occurrence of acute
complications, the emergence of chronic complications of diabetes that may go
undetected or untreated. These gaps include poor glycemic control, working with new
healthcare providers, assuming independent care for diabetes, etc. (Iyengar, Thomas,
& Soleimanpour, 2019; Monaghan, Helgeson, & Wiebe, 2015). Moreover, there are
risks associated with psycho-social, behavioural, and emotional challenges (Peters &
Laffel, 2011). Young adults’ challenges include maintaining control of diabetes, finding
a good team of health professionals, drugs, and alcohol, leaving school/starting work or
university, moving out of home, relationships, and many more (Buschur, Glick, & Kamboj,
2017).
With the increasing incidence of both type 1 and type 2 diabetes in childhood,
adolescence, and young adulthood, there is a surge in the total numbers of young adults
with diabetes in this transition period. Emerging adults with diabetes face even more
complicated decisions in their life than their healthy peers. T The daily requirements of
diabetes care include coordinating daily care, finding an appropriate care provider,
and accessing proper supplies and medical care. All of this must be woven into all the
normative choices regarding relationships, occupations, living arrangements, financial
management, etc. The developmental period after high school represents a definite
stretch with unique demands which are separate from adolescence (Peters & Laffel, 2011;
Ford, 2015; Palladino et al., 2013; Weissberg-Benchell, Wolpert, & Anderson, 2007).
1 Emerging adult is the age group in late teens through the twenties, focusing on ages 18 to 25 (APA Dictionary of
Psychology, 2014).

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Figure 4: Affinity map of challenges faced by young adults in transition: Secondary research (Mapping by author)

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Each year, in British Columbia, around 1,700 youth with chronic diseases reach 17
years of age and transition into the adult care system (Paone & Whitehouse, 2011). This
process often occurs in an unplanned manner, can be poorly coordinated, and threatens
care continuity.
Inadequate planning for transition demonstrates significant negative consequences that
include a deterioration in health status and increased morbidity and mortality.

To gain a deeper understanding of the user, the primary and secondary
research collection seeks to answer the following research questions:
­

1. How can design support young adults in
providing immediate life-saving assistance
in extreme hypoglycemia conditions?
2. How can design support young adults in
alleviating the stress associated with hypoglycemia?
3. How can we engage young adults with type
1 diabetes in the creative process and make
sure we hear their voices?
4. How can we empower young adults so that
they have control over their medical emergency?

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3.2 Scope of Intervention
Young adults with diabetes face additional challenges with diabetes-specific psychosocial
stressors linked to adherence to regular medical regimens, which require frequent blood
glucose monitoring, insulin administration, and dietary restrain. Not all young adults
want their peers to know about their medical condition. Young adults with diabetes
report fewer friendships, resulting from a drop in intimate friendships and a reduction
in the level of intimacy and trust in relationships. Additionally, alcohol and tobacco
exposure could result in short- and long-term complications for diabetes, including death
(Monaghan, Helgeson, & Wiebe, 2015).
Even though new diabetes technologies such as continuous glucose monitoring or
closed-loop systems (system that automatically adjusts and deliver insulin based on CGM
blood glucose reading) continue to revolutionize this field, they may not be accessible
because they are either expensive, not covered under medical insurance, or still in early
development stages.
While much research continues in the area, few tools are being designed directly for
young adults to navigate this change. A program titled “ON TRAC 2” has been designed
to support youth transition with chronic conditions from pediatric to adult care (Paone &
Whitehouse, 2011). However, most of the interventions are combined in the form of bulky
guidebooks and workbooks. Another critical issue with the development of most current
tools is the absence of user involvement in the creative process leading to unmet user
needs.
Additionally, fear of hypoglycemia is prevalent among the targeted demographic
(Driscoll, Raymond, Naranjo, & Patton, 2016). According to Diabetes Canada, a
person with type 1 or type 2 diabetes needs to have a rescue plan if their blood
sugar level becomes so low that they are unable to help themselves. It recommends
a plan in place, so those around the diabetic will be prepared for unexpected lows.
During a hypoglycemic event, actions range from drinking a beverage containing
sugar to paramedic/emergency assistance, with about 1 in 5 taken to hospital (Severe
Hypoglycemia in Canada, n.d.).
Severe hypoglycemic episodes require the assistance of another person to treat. The
diabetics may show some or all the symptoms of mild and moderate hypoglycemia,
and in rare cases, they may also lose consciousness or have seizures. If a person cannot
eat or drink, a glucagon emergency kit may be used to treat the severe hypoglycemia
episode, and emergency services must be contacted. Various causal factors have been
identified, yet very few interventions exist to avoid it or provide aid in an emergency.
Glucagon is a medicine used to treat severe hypoglycemia, but it only works if there is
someone around who knows where it is, when to use it, how to use it, and eventually do
it (Kedia, 2011; Freeborn, Dyches, Roper, & Mandleco, 2013).

29

Emily Perrins is a Paramedic and an Emergency Medical Call-Taker with British Columbia
Emergency Health Services. In an interview regarding hypoglycemic emergency calls,
she stated that “I am quite surprised the family members and friends who spend a lot of
time with these people that have diabetes don’t know enough about it, that does need
prioritizing” (E.Perrins, Personal Communication, November 27, 2020).
Another primary care paramedic, Nic Hume, states that “most people are not aware
of the protocols and what to do with their partner or that close person is becoming
unconscious or having a low.” He adds to this saying, “For someone who’s severely
hypoglycemic, things can go bad quickly” (N. Hume, Personal Communication,
November 30, 2020).

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4 PRIMARY RESEARCH
4.1 Methodology
4.1.1 Research Methods
4.2 Ethical consideration
4.3 Analysis and findings
4.3.1 Surveys
4.3.2 Semi-structured interviews
4.3.3 Cultural probe
4.3.4 Making connections- Key findings
4.4 Design direction
4.4.1 Persona & scenario
4.4.2 Co-creation
4.4.3 Expert interview

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4 PRIMARY RESEARCH
Secondary research has identified various challenges and gaps faced by young adults
living with type 1 diabetes. These challenges necessitated human-centered research to
gather a deeper understanding of the user (young adults) and various perspectives from
experts in surrounding fields.

4.1 Methodology
The research methodology focuses on human-centered design research practices, an
assortment of tools and methods that create a space where we acquire a profound
empathy with the stakeholders in a particular situation by putting them at the core of the
research process and ensuring they have a voice. This user engagement brings about
more inventive results, a superior “fit,” and higher acknowledgment rate of intended
solutions than traditional design methodologies (Health Design Lab, 2016).
IDEO, one of the world’s leaders in human-centered design, posts the following
definition on its website:

Embracing human-centered design means believing that
all problems, even the seemingly intractable ones like
poverty, gender equality, and clean water, are solvable.
It means that the people who face those everyday
problems are the ones who have the power to answer
them. Human-centered design renders a chance to
design with communities, deeply understand the people
we are looking to serve, dream up scores of ideas, and
create innovative new solutions rooted in people’s actual
needs.
(IDEO, 2015)
To further reveal the stakeholder’s knowledge various HCD2 methodologies were used.
These included collaboration with young adults living with type 1 diabetes through
surveys, interviews, cultural probes and co-creation workshops.
The global pandemic posed some severe challenges restricting mobility, gathering
people, and face-to-face meetings for interviews. To conduct research using the virtual
world, I used internet research methods to conduct digital ground research.
2 HCD refers to Human-centered design.

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4.1.1 RESEARCH METHODS
SURVEYS
It was first essential to find the young adult diabetic community and gather general
information. To break the initial barrier, I circulated an online survey on various Reddit
diabetic blogs, Juvenile Diabetes Research Foundation (JDRF) blogs etc. This survey was
completed by thirty-four respondents and built a basic understanding of some of the
real challenges faced by type 1 diabetic young adults and gave them an opportunity to
be further involved in the research study. Participants who do not use modern diabetic
devices such as continuous glucose monitor (cgm) and insulin were excluded from this
study. This survey is shown in Appendix 9.3.1.

BLOGS & PODCAST
The growing Coronavirus pandemic posed some severe challenges in connecting directly
with participants. The normal channels of group meetings and networking opportunities
became increasingly difficult. An alternative to personal meetings proved to be blogs
and podcasts run by the diabetic community (see appendix 9.3.2). M. Jones & I. Alony
talk about the potential of blogs in the paper “Blogs – the new source of data analysis.”
This media proved to be a rich resource for insights into diabetic young adults’ lived
experiences and the hurdles they encountered.

SEMI-STRUCTURED INTERVIEWS
Survey participants who signed up for further engagement were asked to participate in
a semi-structured interview. Six participants aged 19 years to 25 years were consulted.
To better understand their lived experiences, the semi-structured approach allowed the
interviews to become enlightening conversations, and some of their unique challenges
surfaced.
Additionally, semi-structured interviews were conducted with five experts in diabetic care
to acquire multiple perspectives on the topic. Conversations with paramedics, emergency
call takers and dispatchers associated with British Columbia Emergency Health
Services (BCEHS) helped understand the challenges in diabetic-related emergencies.
These dialogues helped build an understanding of the healthcare system as it connected
with the diabetic community as well as the unique challenges faced by professionals in
administering care. The interview questions are shown in appendix 9.3.2.

33

CULTURAL PROBES
COVID-19 made it challenging to conduct an ethnographic study and observe
participants directly in their environment, necessitating the use of digital cultural probes,
which five young adults completed. Three activities were created specifically for living with
type 1 diabetes, which allowed them to record events and their feelings or interactions.
The purpose of utilizing this research tool was to gather a deeper understanding of
participants’ emotional space and daily lives. The probe (see appendix 9.3.3) was made
available to five participants through an online collaborative platform called MIRO. One
participant excluded herself from further research activities due to her busy schedule.

CO-CREATION
Co-creation is a design research method that empowers individuals for whom we are
designing to participate in the creative design process. It taps into the co-creators’ latent
and tacit knowledge and provides insights into their needs, hopes, and desires (“Design
Kit,” 2021). The primary purpose of utilizing this methodology was to acquire a greater
understanding from young adults living with type 1 diabetes on how they would like to
be helped during a hypoglycemic episode. Four young adults participated in Co-creation
discussion centered around scenarios related to hypoglycemia and how we could
improve outcomes.
These research activities provided rich data collection from different sources. They added
to the understanding of TID in young adults, which helped direct the project.

34

4.2 Ethical Consideration
Young adults with type 1 diabetes who are transitioning/transitioned to adult care were
invited via third party mechanisms (i.e., public postings) to participate in this project. Due
to persisting social distancing measures necessitated by COVID-19, all human-human
interactions were suspended. All research activities took place online: survey forms were
web-based; interviews were by phone or video; cultural probes were distributed, and cocreation activities took place on a collaborative online platform called Miro. Young adults
aged 19 years to 25 years were involved in this research. Only one participant older than
25 years was included in the research because of her rich experience of living with type
1 diabetes and also owns a diabetic podcast. The expert interviewees had a variety of
professional experience, practicing in different health settings.
Before conducting the research, it was necessary to obtain a participant’s informed
consent. This project’s documentation received full Research Ethics Approval from Emily
Carr University Research Ethics Board (May 6, 2020, ECU-REB #100379) (see appendix
1). From an ethical standpoint, this documentation explained the research’s intentions
and an understanding that the activities were a minimal risk.
It was considered that there might be minimal risks associated with participation.
Participants could encounter sensitive subjects and would likely have privacy concerns. It
was also identified that there could be emotional or psychological risks to the participant
due to the sensitive subject matter.
To mitigate the psychological risks participants were reminded of their right to withdraw
from research or limit their participation if they become uncomfortable. Participants were
thoroughly debriefed after research sessions were completed and appropriate resources
were provided beforehand in case someone experienced distress. To mitigate social risk,
all the data collected was confidential.
Anonymity was maintained throughout all the participatory research sessions to reduce
social risk.

35

4.3 Analysis and Findings
The subsequent section reveals the analysis and insights from the primary research
collection and how this information was brought forward in the brainstorming process.

SURVEYS
The research began with an online survey completed by thirty-four Canadian young
adults living with type 1 diabetes. While caution needs to be exhibited with a small
sample size, the results are based on the responses provided by thirty-four participants.
It was found that 97% of young adults experience hypoglycemic events when alone, and
one third of this population had experienced a severe hypoglycemic episode where they
have lost consciousness in public and needed third-party assistance. Approximately 85%
could realize that they had low blood sugar. When asked about the challenges faced
during the transition to the adult service, specific responses were identified.

Figure 5: Challenges faced during the transition to the adult service

SEMI-STRUCTURED INTERVIEWS
It was evident that hypoglycemia is prevalent among this age group; so, to proceed
forward, semi-structured interviews were conducted with participants who signed up for
further engagement. The interview questions were oriented towards hypoglycemia yet
open enough to tap into other challenges. Interviews with six participants took place,
and the dialogues have been divided into four categories: metaphorical expression,
improving an existing product, new design opportunities and other concerns of the user.

36

During the conversations, specific challenges surfaced. They include the need to connect
with fellow type 1 diabetics of similar age to interact and share their success and
failures with them. Some participants face challenges when calculating carbohydrates in
particular food and often stick to guessing games for doing this task because sometimes
they under or over bolus (a single dose) for the food consumed. The majority demanded
more affordable technologies and the need for better insurance coverage for continuous
glucose monitors and insulin pumps. Some of the participants use a closed looping
system3 and need it to be more sound and smoother. They feel that there should be more
resources available at the university to assist the transition. One issue that stood out
was the unexpectedness of low blood sugar. They require someone to help them during
hypoglycemia. They fear that in case of a diabetic emergency, most people around
individuals with diabetes are unaware of what to do.
When asked to discuss the fear of hypoglycemia, some interviewees responded by
saying:
“Then someone else who knows me, who knows where the glucagon is,
who knows how to mix it, It’s a complicated process. You have to know how
to mix the medicine and feel comfortable enough to inject it in a muscle,
which is a big deal”.
(Interview Participant,2020)

“I would want them to know what is happening, not make a huge deal out
of it (a big enough deal to get me the help I need, but not so big that I’m
ridiculously embarrassed after). Call 91, preferably administer glucagon or
oral gel - solve problem to get one of those things or something like it”.
(Interview Participant,2020)

3 Close looping system is a combination of CGM (continuous glucose monitor) and an insulin pump to regulate the
persons’ insulin with minimum interaction required. It is also referred to as artificial pancreas (Lovett, 2019).

37

CULTURAL PROBES
The cultural probe was vital for understanding the users’ emotions, feelings, and
reflection. The insights above were important and helped to inform the cultural probe
methods. When analyzing the results of the probes, existing challenges were confirmed,
and new ones identified. Some of the insulin pumps available in the market are not
well designed. Participants pointed out specific problems with their current diabetic
technology, such as a reusable cgm sensor applicator, better clips for the insulin pump,
better adhesive which is strong enough and does not leave a scar behind. However,
another common challenge highlighted was the condition of hypoglycemia. It illuminated
that there is a need for a solution that addresses hypoglycemia. Users are interested in
a solution that makes someone aware of what is happening to the person with diabetes,
acts promptly, alerts 911, knows how to help and helps quickly.

38

Figure 6: Cultural probe analysis

39

MAKING CONNECTIONS - KEY FINDINGS
After collecting and careful analysis of the primary research, an affinity diagramming
technique was used to cluster the qualitative information into key research insights.

Figure 7: Affinity mapping, Primary research: Qualitative information clusters formed from primary research insights
(Illustration by author)

These insights were paired into themes, which translated into a list of key findings that
included a need for:
1. Low-cost diabetic technology.
2. Improved insulin pump.
3. Improved continuous glucose monitor (CGM) sensor and applicator.
4. Improved closed loop system (a system that automatically adjusts
and deliver insulin based on CGM blood glucose reading).
5. Helping T1D’s during extreme hypoglycemia.
6. Carbohydrate counting device.
7. Platform for diabetics to find each other and exchange supplies.

40

4.4 Design Direction
This exploratory research yielded much useful information. To further proceed with one
design direction, I decided to work on the incidence of hypoglycemia and helping T1D
young adults during extreme hypoglycemia. In an article published in the Healio Journal
regarding fear of hypoglycemia in young adults, Phil Neuffer states that caring for young
adults should include minimizing their worries about diabetes, including reducing fear
of hypoglycemia. It also talks about how this fear damages the quality of life for young
adults, and the goal should be to achieve a high quality of life while minimizing worries
about diabetes (“Hypoglycemia fear damages quality of life for young adults with type 1
diabetes,” 2018).
An online brainstorming session was held with fellow MDes cohort members to frame the
design problem. The session took place in the form of HOW-MIGHT-WE QUESTIONS,
and each of them posted ideas around “How might we help type 1 diabetics during an
extreme hypoglycemia emergency”? The question prompts people to offer specific ideas
and, at the same time, is broad enough to explore wild ideas.

PERSONAS AND SCENARIOS
The two personas represent the user profiles, which have been inspired by the research
insights. The construction of these personas allowed for a deeper understanding of a
young adult’s thoughts. Throughout this process, it was recognized that young adults
share similar ideas and emotions.

41

Figure 8: Personas

42

After persona development, I did scenario mapping, representing the different scenarios where hypoglycemic condition
arises and its treatment. This helped in building a better understanding of the user’s current experience and identified
opportunities for improvement. Based on the scenario maps generated (see appendix 9.4), detailed scenarios have been
developed, representing the user’s action, feeling, and thinking in each case. This helped in revealing pain points and
design opportunities at each step of the scenario allowing a comprehensive needs assessment.

Figure 9: Scenario Development with pain points and design opportunity

Following persona and scenario development, a Co-creation session took place with four participants through MIRO (online
collaborative whiteboard).

43

CO- CREATION
Co-creation sessions were valuable in communicating and gathering individual
perspectives directly from users and it was about developing the solution collaboratively.
Four participants came together in a digital space (MIRO), where two scenarios were
presented. Each scenario showed multiple situations through sketches. Scenarios were
discussed with the group, and participants voted on the preferred ideas along with
suggesting more ideas and giving more detailed responses on sticky notes.
In this session, the users made several choices concerned with being helped during
hypoglycemia. Participants discussed how others could handle hypoglycemia’s different
situations moving from a minor to a severe incident. They provided ideas that could be
implemented and listed some concerns. They all noted that they need more than one
option/choice for a particular task.

Figure 10: Co-creation activity 1- Partial Consciousness

The 1st scenario presented described a situation when the blood sugar starts dropping,
and the person is at a slightly altered level of consciousness. When asked about
communicating their needs with people around them when they are not in a position to
self-help, most participants prefer to request help if they can directly. Additionally, they
liked the idea of an automated text on the cell phone through a broadcast notification
with people nearby. The basic instinct is to draw attention to them.
All of them prefer to be treated with fast-acting glucose tablets if they can swallow.
However, they are open to treatment with glucagon.
One participant wrote, “I do not trust strangers to administer glucagon. My family and
friends know how to use it because I’ve taught them, but many strangers do not know
since it’s not a common medical device used, unlike an EpiPen that is used by many
people and is taught in First Aid”. They said that glucagon is super expensive, and since it
is not used frequently, hence it expires. Other participants stated, “I only have glucagon in
my house, so unless I’m low in my house, it’s not super helpful.”

44

Figure 11: Co-creation activity 2- Unconsciousness

The second scenario is severe hypoglycemia where a person has become unconscious
because of extremely low blood sugar. When discussing this, the group indicated a
preference for a wearable device that detects falls and alerts for help. They were equally
interested in voice-activated alert notifications to an emergency contact or medical
services.

45

This situation requires prompt action, and the idea is to turn bystanders into potential
lifesavers. While discussing how to ask for help in this condition, they mostly preferred
a text alert to the cell phone and, at the same time, a wearable that will ask for help
through an audio message. The alarm noise should be jarring in order to capture
attention from bystanders.
In discussing how bystanders might search for an emergency kit, they liked the idea of
a permanent floating notification on the diabetic’s cell phone with the kit’s location.
Additionally, they loved having a small alert device attached to the glucagon kit that
makes sound and blinks, making it easy for a person to find.
In this severe situation, for the diabetic to recover from hypoglycemia, someone else
needs to administer glucagon, which requires some training. There are many options
for glucagon available in the market, and each one has a different delivery mechanism.
Participants suggested sending detailed written instructions through the same notification,
which is also calling for help. They also selected the option of an audio message from a
wearable.
Most current continuous glucose monitors (CGM) allow the person with diabetes to share
data with their close contacts and some participants prefer to contact their emergency
contacts if an emergency incident takes place. They prefer an automated call or text
message, letting them know of the incident. They also choose to call the loved ones
personally afterwards.
When a hypoglycemic emergency takes place, it is essential to contact the medical
emergency services. Participants correspond to the idea of a voice-activated phrase that
will alert 911 and connect with medical emergency service.
Working with young adults in this session reaffirmed what was uncovered during the
primary and secondary research phases. To further understand this condition, expert
interviews were conducted with personnel from British Columbia Emergency Health
Services (BCEHS).

46

EXPERT INTERVIEW
Interviews with paramedics, emergency call-takers and dispatchers yielded specific field
insights. Ryan Ackerman (Interim Senior Leader, Practice Education BC Emergency Health
Services) said hypoglycemia is a reasonably typical emergency to which paramedics
are called. The majority of hypoglycemic emergency calls come from family members/
close contacts of the diabetic. Sometimes callers are not aware of treatment protocols, or
they are calling 911 for safety. He added that most of the calls occur in indoor settings
and predominantly in the late afternoon, evening, and midnight. He explained that
when the blood glucose levels fall below a magic threshold, which is individual to every
person, they can quickly move from confusion to coma. Once paramedics determine
that hypoglycemia is the cause, it is like a ticking clock. “Now, we are looking at how we
can get sugar back to their brain as quickly as possible.” He added that “It’s one of the
most common misconceptions is that people mistake hypoglycemia for intoxication” (R.
Ackerman, Personal Communication, November 25, 2020).
Emily Perrins is a call-taker and paramedic with British Columbia emergency health
services (BCEHS). She explains that family members and friends who spend much time
with diabetics do not know enough about it and need help prioritizing. BCEHS uses a
system to colour code the calls based on their severity so that resources could be directed
appropriately (E.Perrins, Personal Communication, November 27, 2020).
Nic Hume is a Primary Care paramedic with BCEHS. He states that “most people are not
aware of the protocols and what to do with their partner or that close person is becoming
unconscious or having a low” (N.Hume, Personal Communication, November 30, 2020).
For medical emergency services, knowing the exact location is the most important factor.
If the paramedic team also knows that it is a diabetic emergency, it helps prepare them
for the call. If the person is intoxicated, that knowledge also helps in their decisionmaking.
When discussing the design outcome, paramedics liked the idea of an early notification
assisted with an automated voice call, to help them respond quickly. The discussion
around emergency medication (glucagon) led to the paramedics indicating a preference
for nasal glucagon over standard injection delivery, which is less frightening and easier to
administer by a layperson.

INTERVIEWEES
RYAN ACKERMAN
Interim Senior Leader,
Practice Education

EMILY PERRINS
Call-taker and
Paramedic

NIC HUME
Primary Care
Paramedic

DAVID BROWN
Call-taker, Dispatcher,
Paramedic

SCOTT KOZOL
Paramedic

47

5 DESIGN OUTCOME
5.1 Design criteria
5.2 Ideation
5.3 The concept
5.4 Mock-ups
5.5 Digital model and rendering
5.6 Prototype
5.7 User feedback

48

5 DESIGN OUTCOME
After developing a deep understanding of the user’s needs and wants through the
research activities, several concepts were developed to assist the young adults during
hypoglycemic episodes. The proposed solution builds on the existing diabetic devices
being used by young adults, CGM.

5.1 Design Criteria
Following the collection of primary research from the experts and users through
discussions, cultural probes and a co-creation workshop, the data was analyzed through
an affinity mapping process. This led to the development of key findings (see section
4.3), which informed the development of design criteria for the wearable device and
digital application. These acted as a translational tool, informing the generation of ideas
and prototypes that needed to be tested further. The design goal here is to achieve the
user’s unmet demands to create a solution that proactively addresses hypoglycemia and
provides the necessary assistance required by turning bystanders and emergency contacts
into lifesavers. They are as follows:
The Wearable
Technical requirements
• Speaker for an alarm system to attract attention.
• Emitting light for people to find it easily.
• SOS button to alert the medical emergency services system.
• Fall detection sensor.
• Voice-activation, which makes it easy for the user to call for assistance.
• Haptic feedback to the user.
• Guide the person (bystander and emergency contacts) step-by-step.
• Also request assistance through an audio message.
Aesthetics
• Fashionable, modern, and easy to carry.
• Seamlessly merge with all types of clothing or complement their style.
• Compact and easy to wear.
• Offer flexible options in terms of wearability.
The alert notification
• To people (bystander and emergency contacts) should be optional.
• Be sent via text to bystanders.
• Could also be a permanent floating notification (placement of glucagon,
how to help) on the diabetic’s cell phone.

49

The alert device (for finding glucagon)
• Should have a blinking light and beeping sound.
The alarm sounds
• Could be personalized.
• Should be a jarring noise that is different from everyday life.
The solution should instantly guide bystanders and emergency contacts to administer
glucagon (this should be done through audio message or/and detailed information
through text notification).

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5.2 Ideation
WEARABLE DEVICE

Figure 12: Concept Diagram wearable(Illustration by author)

51

ALERT DEVICE

Figure 13: Concept Diagram alert device (Illustration by author)

52

5.3 The Concept
The basic concept includes three components: a smart wearable device, a digital phonebased application, and an alert device.

Figure 14: Concept Diagram (Illustration by author)

The wearable device (1) acts as a personal alarm device to alert people and guide
them through the life-saving process in emergencies. It works in conjunction with an
existing CGM and is based on the CGM readings. The wearable connects to the user’s
cell phone through Bluetooth. It will come as a band that fits the wrist—this decision
was dictated by the need for accurate blood glucose readings, which will be achieved
by combining heart rate monitors. It also has a tri-axial accelerometer, which consumes
low power, has a small dimension and is lightweight, making it easy to wear. The
accelerometer serves two purposes: one used for reliable activity detection, and the
other is utilized to detect hard falls. It also has a vibration motor, which provides haptic
feedback stimulus based on different actions. The audio sensor embedded is a standard
microphone that is used for voice activation.
The wearable has an SOS button to report a possible emergency condition, which
activates by long-pressing two times. It has an alarm system accompanied by an
embedded LED and speaker, which provides the wearer with additional intuitive audiovisual feedback, i.e., it blinks and produces sound when low blood sugar is detected.

53

The alert device (2) attached to the emergency glucagon kit has a signal LED and
a speaker representing the alerting system. As soon as the button is pressed on the
wearable or through the app to locate the emergency medication, it starts blinking and
beeping, making it easy for the attendant to search and administer the medication based
on the app or text instruction notification. The solution is based on nasal glucagon which
is commercially available in the market and is easy to use as opposed to injectable
glucagon.
The smart wearable integrates with any CGM device through a digital application
(3) using Bluetooth technology. It alerts emergency contacts through a carrier app and
bystanders through mass text notification which doesn’t require an embedded app.
This is done through wireless emergency alerts (WEA), which disseminate emergency
alerts to mobile devices in a designated geographic area (Wilson, 2018). The app
initiates an automatic voice call to medical emergency service if required and also offers
customization options such as choosing alarm sounds, contact lists, voice activation
phrases etc.
As soon as the blood sugar starts dropping, the wearable follows a four-tier system
where the user only is alerted at level one through a discreet vibration and app alert. At
the second tier, the user’s nearby emergency contacts are alerted through a carrier app.
At the third level, bystanders are alerted and given detailed instructions for assisting the
person with diabetes via simple text messages. At the fourth level, medical emergency
services are notified of the emergency and location.

SYSTEM MAP
The system map represents how the wearable device system works in various scenarios. It
also shows all the components of the environment which are structured and helps better
communicate the results.

54

Figure 15: System Map (Illustration by author)

55

UNDERSTANDING CONCEPT THROUGH SCENARIOS
The next section explains the concept through different scenarios. Amy is a hypothetical
character who is a university student and often finds herself in hypoglycemic conditions.
Scenarios below will walk-through different situations and how the design will assist her
in each case.
Case 1
Amy is in her home and about to experience mild hypoglycemia. Her wearable detects
early low blood glucose and vibrates. At the same time, her application also sends her an
early warning alert through the app notification.
She notices the alert notifications and consumes a glucose tablet, after which the
vibration alerts are automatically turned off (as her glucose level rises). She could also
press the button on wearable thrice to stop the warnings.
If she has missed the alert notification as she was busy, after 10 minutes, the wearable
will start an alarm sound and flashing light to attract her attention. She might notice and
consume sugars and repeat the steps above, or she could long-press the SOS button on
the wearable to request assistance. She could also ask for help through a voice-activated
phrase.
Case 2
Amy experiences occasional hypoglycemia and has requested her new friends to become
her emergency contacts. The emergency contacts here are the people who are close to
Amy and are nearby such as partners, friends, roommates, colleagues etc. While setting
up the app, Amy chooses a list of these contacts. She sends them an invite to download a
carrier app called “Connect app,” which will be used by emergency contacts to help Amy
in a diabetic emergency.
Amy’s partner (an emergency contact) receives an alert notification on his dedicated app
that Amy is experiencing a low and might need assistance. He has two options: to call
or navigate to her. Since he is close to her, he walks to Amy, and the app shows him the
step-by-step instructions for help. Amy is in an altered level of consciousness at this point,
and he checks if she can swallow or not.
(1) If she can swallow, he feeds her with glucose tablets, and her blood glucose reaches
back to normal range after some time.
(2) If she cannot swallow, and he presses a button on his app to make an automated 911
call which connects to a medical dispatcher afterwards. He discusses with the medical
dispatcher if he can administer glucagon (emergency medication) or not.

56

The dispatcher recommends him to administer the medication, but first, he needs to find
the kit, for which he presses a button on his app to locate it. An alert device attached
to the glucagon kit sounds an alarm and flashing lights, making it easy for him to find
inside Amy’s backpack. He then reads detailed instructions from the app on how to
administer it and save Amy’s life.
Case 3
Amy is at a grocery store and experiences a severe hypoglycemic episode. Her app sends
a mass alert text notification to bystanders asking for help in a 50m radius (customizable
radius).
The bystander receives an emergency text message which explains the incident and states
that this person needs your help. The text message has a link that opens a web page
and gives instructions on how to help, starting from showing navigation to Amy and then
checking if she can swallow or not. In case she cannot, they are advised to call 911,
narrate the incident and discuss administering the glucagon. All of this is guided through
the web page that is linked to the text message. They can then locate the glucagon kit
either by pressing the button twice on Amy’s wearable or read about the glucagon’s
location. They are then guided through the administering instruction to complete the lifesaving assistance. The wearable that she is wearing also asks for help through an audio
message. All above procedure is happening but with the audio message and requires a
bystander to interact with the wearable.
Case 4
Amy is out for a long run and experiences severe hypoglycemia in a park where she is
alone. Her blood glucose is severely low, and she has passed out. The wearable detects
the fall and alerts the emergency medical services (through an automated call) of the
incident and shares her blood glucose reading and live location. The paramedics reach
her in no time and save her life.

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CONCEPT SKETCH

Figure 16: Wearable device concept sketch

Figure 17: Alert device concept sketches

58

APPLICATION USER FLOW & WIREFRAMES
The accompanying app prototype has been designed based on the wearable features
and allows for customization of the wearable functionality. Moreover, this application
communicates between CGM and the wearable and enables the user to perform specific
actions simultaneously. The app makes it easy to alert and notify emergency contacts
(through a carrier app), bystanders (through text messages) and emergency services
(through an automatic voice call). The app is visualized below as a user flow.

Figure 18: Information architecture showing the user flow for the App (illustration by the author)

59

Figure 19: App wireframe

Figure 20: Information architecture showing the user flow for the Carrier app (illustration by the author)

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Figure 21: Connect App wireframe

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5.4 Mockups

Figure 22: Smart wearable mockups

Figure 23: Alert device mockups

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5.5 Digital model and rendering
WEARABLE DEVICE CAD MODEL AND RENDER

(a)

(b)

Figure 24: (a) Wearable device turned off; (b) Wearable device when activated

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ALERT DEVICE CAD MODEL AND RENDER

(a)

(b)

Figure 25: (a) Alert device turned off; (b) Alert device when activated

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5.6 Prototype
WEARABLE DEVICE PROTOTYPE

Figure 26: Wearable device prototype

ALERT DEVICE PROTOTYPE

Figure 27: Alert device prototype

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Figure 28: Wearable and alert device prototype

Figure 29: Wearable device prototype on hand

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Figure 30: Alert device prototype placements

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APP PROTOTYPE SCREEN

Figure 31: App prototype

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CONNECT APP PROTOTYPE SCREEN

Figure 32: Connect app prototype

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5.7 User Feedback
Following the concept development phase, I presented the ideation sketches to the three
participants in an individual online session. The sessions started with explaining to them
about the system map (see appendix 9.5) of the concept and how it will work in different
scenarios. There were some questions listed for which the participants provided answers
and suggested more promising solutions.
The next part of it was selecting the shape and form of the wearable (see appendix 9.5).
Participants were provided three dots to vote on the concepts: one is the primary choice,
and the third being the last. The sketches consist of ideas that have been divided into
unique or generic shapes. The participants preferred a unique shape that may not be
mistaken for a regular watch/fitness tracker. However, the form should be sleek and slim
and should not represent the medical reason for wearing it.
When asked about the strap/band design, they all prefer silicone as it is easy to wear
and clean simultaneously, but they also liked swappable bands for a change. On asking
about the colour preferences, they prefer neutral colours but would love to have some
colourful covers for some occasions. They also prefer a pin and tuck band closure instead
of no buckles for adjustability and secure grip.

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6 REFLECTION AND FUTURE
DIRECTION
6.1 Insights & learning
6.2 Barriers and limitations
6.3 Contributions and implications for design practice
6.4 Future implications

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6 REFLECTION AND FUTURE
DIRECTION
6.1 Insights and learning
The research started with the question, “How could we support young adults living with
type1 diabetes transition to independent living?”
The proposed design is based on the needs of young adults who may need more support
than an older and presumably more independent adult. During this transitional age,
young adults tend to become more independent, possibly leaving their parents’ home to
start university or join a workplace with new people around who are unfamiliar with their
medical condition. In diabetic emergencies, new friends may be unaware of the protocol
for helping, leading to life-threatening situations. The developed solution caters to those
needs and makes sure that young adults are facilitated with immediate assistance and
avoid those severe episodes. It provides a stepping stone to complete independence.
However, the resulting solution may also prove to be beneficial to older adults as well. All
diabetics share ongoing concerns with hypoglycemia and this tool may prove helpful to a
range of ages.
I believe that human-centered design is more important than ever and becomes an
effective means of targeting limited resources towards building empathy. With rapid and
continuously changing behaviors and expectations, understanding the human perspective
is fundamental, influencing us to think differently and implement innovative solutions
for shifting realities. The user’s mindset is essential for successful design, and here it is
rapidly evolving. With the changes necessitated by COVID-19, I quickly learned how
promptly designers have to adapt to emerging situations and devise new methodologies
when we are not able to meet users in their own environment. COVID-19 also allowed
me to rethink how often overlooked resources such as online blogs and podcasts could
prove useful in gathering qualitative information.
The most striking aspect was the co-design part of the research, where young adults
meaningfully partnered to create more inclusive solutions. Co-design made it possible
for the user and the designer to share power; co-designers and individuals built a
cooperative relationship and moved together as active partners who were also involved
in surveys, interviews, cultural probes and user feedback sessions. However, if I had more
time, co-creation would involve more users, and the research would benefit from sharing
multiple perspectives and generating numerous ideas.

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6.2 Barriers and limitations
It becomes essential to identify this research’s constraints, including conducting humancentered research during the global pandemic. The radical shift from physical to digital
human engagement made it extremely difficult to do much of the design research
originally proposed. “If there is one thing that one can say about ethnography, it is that
social intimacy, and not social distancing, is crucial” (“Fine, Johnson, & Abramson,
2020). Social distancing conditions made it cumbersome to observe and interact with the
participants in their real-life environment. The question which arises here is how we can
better understand and meet these young adults’ needs and aspirations in the new reality?
The proposed concept is based on the diabetic patient wearing a continuous glucose
monitor (cgm), and it relies on everyone having a smartphone and internet access.
Participants who do not have access to them were excluded from the participation and
would not benefit from this research outcome. The first step to better manage glucose
levels and have fewer low blood sugar emergencies is access to cgm (National Institute
of Diabetes and Digestive and Kidney Diseases, 2021). Persons of lower socioeconomic
status would not value from this study. Also, the system works on the internet; hence it
may have difficulty working in poor coverage areas. The solution has been built on the
needs of specific participants who have access to the technology.
Due to limited mobility and exposure risk, I learned the working of the British Columbia
Emergency Health Services (BCEHS) through semi-structured interviews with call-takers,
medical dispatchers, and paramedics. It otherwise would have been a visit to their
physical spaces and perceiving things in greater depth.
This new normal delayed the research, forcing me to quickly pivot to alternative methods.
Additionally, the global pandemic directly affected the participants’ original condition by
burdening them with one more challenge.
The shift necessitated the use of digital media and the internet for primary and secondary
research while suspending all physical in-person research activities. This restricted
the gathering of many participants for the research, and to some extent limited the
knowledge creation to be based on fewer narratives and viewpoints.
However, to further refine the design outcome, it would greatly benefit from an in-depth
ethnographic study and more users involved in each research method to gather multiple
perspectives. The use of “shadowing” for qualitative research involving young adults
with type 1 diabetes would also help me get more familiar with their lifestyle and better
understand their challenges. Additionally, physically meeting the participants would
have established a trustful relationship and allow more knowledge sharing. Having the
participants do the user testing of the wearable and application in a physical space would
fetch better results than doing it virtually and relying on anecdotal evidence.

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6.3 Contributions and implications for design
practice
Current research has identified a wide range of transition issues; however, few actual
interventions exist to cope with those challenges. After conducting primary research, I
formulated a list of critical findings from the research activities, and many opportunities
beyond the scope of this project emerged such as designing improved insulin pump and
CGM, sound looping system, carbohydrate counting device etc. This list demonstrates
opportunities for other researchers in the design and medical domain to work towards.
Another striking feature was online blogs and podcasts in this research, which provided
rich information. Their use is comparatively new in research yet offers a unique and
inspiring frontier. During COVID-19, it became difficult to hear from the participants
because of social distancing, Instead I looked at various blogs and social media groups
run by the diabetic community. By examining bloggers and commenter’s interactivity in
different entries, comments, and threads, I found evidence of the many challenges. The
addition of this methodology allowed for a reliable and accessible examination of human
behavior.

6.4 Future implications
IMMEDIATE STEPS
The proposed design is aimed at young adults living with type 1 diabetes. A wearable
working prototype could be developed to validate its functionality to move forward with
this concept. Testing it with the user to check its feasibility and reliability in emergency
conditions would be helpful. Also, analyzing the prototype in different scenarios will help
to illuminate any problems and provide opportunities for improvements.
The proposed solution is a 24/7 medical wearable; hence it should be subtle enough so
that wearers forget that it’s on their wrist. A comprehensive trial for the device’s comfort
and wearability would be valuable, which could be done by making the user wear a
lookalike prototype and recording their feedback.
Working closely with emergency contacts and bystanders to understand their perspectives
on receiving alert notifications and acting promptly would be important. It is crucial to
observe bystander response in the persisting COVID-19 situation. Additionally, measuring
the success rate of a broadcast text notification to bystanders would also be beneficial.
This will help us develop a cohesive product that is more realistic.

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A part of this system involves automatic emergency calls to 911; testing the feature with
the BCEHS would help acknowledge its practicality and ensure it is not burdening the
existing 911 systems. This will also help us ensure that calls are colour-coded correctly
and not ignored, as the case with automated voice calls.

LONG TERM DIRECTION
Tracking blood glucose fluctuations is crucial for patients living with diabetes. Researchers
are trying to create less invasive procedures for hypoglycemia detection. Future
development might include more sophisticated use of artificial intelligence (i.e., deep
learning) and other biometrics to predict hypoglycemic episodes before they happen. It
also opens the opportunity to include other physiological indicators that might influence
the glucose imbalance, such as activity levels, temperature, skin conductivity or nutrition
information that might enhance the A.I. system’s performance.
As the health wearable industry grows exponentially with new smart wearables launching
in the market, stakeholders’ and designers are trying to perfect various devices in this
ecosystem.
Alarming systems such as this project could be incorporated within more extensive
emerging interconnected networks. Such a system could link lifestyle wearables (fitness
trackers), location sensors (tracking activities), and insulin pumps to allow blood sugar
levels to become more automated as to approach non-diabetic biological systems.

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8 GLOSSARY
Young adults: A person ranging in age from their early twenties to their thirties.
Statistics Canada defines the age range from 20-24 years.
Transition: It refers to health care transition (HCT), a purposeful and unplanned
movement of young adults with chronic medical conditions child-centered to adultoriented health care systems.
Blood Sugar: Blood Sugar or blood glucose is a sugar that is transported through the
bloodstream to supply energy to all the cells in the body. This sugar is made from the
food an individual consumes.
CGM: It stands for Continuous glucose monitor and is a device that tracks blood sugar
throughout the day and night. It takes glucose measurements at regular intervals and
translates readings into data on a screen.
T1D: It is an acronym that stands for Type 1 Diabetes.
Hypoglycemia & Hyperglycemia: When a type 1 diabetic’s blood sugar is too high
or too low, he or she feels very unwell. Hyperglycemia or high blood sugar symptoms
include frequent thirst and urination, blurred vision, fatigue and nausea. Hypoglycemia
or low blood sugar symptoms include sweating, fatigue, nausea, shakiness and severe
moodiness.
Glucagon: It is a hormone that raises an individual’s blood sugar (glucose). It is also an
emergency medication which is used to treat severe hypoglycemia. It is available in two
forms: an injectable solution and a nasal powder.
Human-centered design: It stands for Human-centered design (HCD) that is an
approach to problem- solving where the user is the heart of the process. It starts with
people we are designing for ends with innovative tailor-made solutions.
Co-creation: It refers to a collaborative effort of designer, stakeholders, and users in
the design process. It ensured that we received significant inputs while working with
communities for whom we are designing.

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6 APPENDIX
9.1 REB application
9.2 Nasal glucagon
9.3 Research activities
9.3.1 Surveys
9.3.2 Semi-structured interviews
9.3.3 Blogs and podcast
9.3.4 Cultural probe
9.4 Scenarios of use
9.5 User Feedback

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9 APPENDIX
9.1 REB Application

Figure 33: REB Application

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9.2 Nasal glucagon

https://www.baqsimi.com/what-is-baqsimi

Figure 34: Nasal Glucagon

https://www.baqsimi.com/how-to-use-baqsimi

Figure 35: Nasal glucagon delivery (Source BAQSIMI)

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9.3 Research Activities
9.3.1 SURVEY
Survey posted on various blogs run by diabetic community. This was done to invite
participants for the research and gather information from those sources.

Figure 36: User survey form(1/5)

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Figure 37: User survey form(2/5)

Figure 38: User survey form(3/5)

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Figure 39: User survey form(4/5)

Figure 40: User survey form(5/5)

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9.3.2 SEMI-STRUCTURED INTERVIEWS
Participants who signed up for further engagement in the research study were invited
for semi-structured interviews facilitated through zoom video calls. A few predetermined
set of questions were asked from the participants,while the rest of the questions are not
planned in advance. The questions were as follows:
1. How long have you had diabetes?
2. How often do you have to test your glucose levels?
3. Do you use an insulin pump or injections/pens? How often do you need to inject it?
4. Can you recognize the symptoms of low blood sugar? What symptoms do you experience?
5. Can you recognize the symptoms of high blood sugar? What symptoms do you experience?
6. Have you ever experienced hypoglycemia? Was it severe?
7. How do you treat hypoglycemia?
8. What is the hardest part of diabetic management?
9. Does your diabetes cause you any other problems?
10.What would you like a non-diabetic to know about having diabetes?
11.Have you transitioned from parent-managed care to self-managed care?
12.How complicated was that process?
13.Can you elaborate? What things were most difficult? What helped?
14.Who do you get the support from now?
15.How do you manage your diabetes at your workplace? Was there any instance that
makes you feel uncomfortable?
16.Do you hide your diabetes at work or socially?
17.Is there anything you would like to change about your diabetes care? If so, can you
explain what you would like to change?
18.Are there any support tools or services that you wished existed to help you manage
your diabetes?
The question were structured to cover the transition, and it challenges, however, there
were opportunities to spontaneously explore a topic relevant to a particular participant
and proceed further with unstructured questions. The conversation was oriented towards
hypoglycemia, and its challenges as that issue was prevalent in the survey results.
The experts from British Columbia Emergency Health Services (BCEHS) were also asked a
set of questions which are as follows:

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1. Have you encountered cases where people with diabetes have become unconscious
because of extreme hypoglycemia?
2. When do people call paramedics if a person is experiencing hypoglycemia?
How do you treat them? Do you give them Glucagon? What type of Glucagon do you
use?
3. Does a patient carry fast-acting oral gel with them? Why/why not?
Do you inform the person’s emergency contact regarding the incident? How are they
contacted?
4. Can an automated voice message call 911 and inform them of a medical emergency? Does 9=11 accept such calls?
5. Can you explain about the automated 911 devices?
6. Can a novice person not administer Glucagon?
7. Who is trained to use a Glucagon injection in case of severe hypoglycemia?
8. Can an unknown person administer it? Can a first responder administer Glucagon?
9. How do you think a person/ bystander /family member can respond quickly when
someone is experiencing hypoglycemia?
10.How can a person with hypoglycemia communicate some of their needs with the people around them?
11.How do you think the presence of a bystander can be taken advantage of when a
person is experiencing hypoglycemia?

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9.3.3 BLOGS AND PODCAST
This shows some of the Reddit and Type one nation blogs run by the diabetic community.

Figure 41: Screenshot of survey posted on Online blogs

Here are some of the podcasts that facilitated plenty of conversation between different
diabetics.

Figure 42: Screenshot of podcast from spotify (1/2)

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Figure 43: Screenshot of podcast from spotify (2/2)

9.3.4 CULTURAL PROBE
A cultural probe is a research methodology that is utilized to understand the experience
of others. Coronavirus made it challenging to conduct the ethnographic study and
observe the user physically in their environment. Hence, I decided to go for digital
cultural probes. It consists of three activities specific to living with type 1 diabetes, which
allows them to record events, feelings, or interactions. The purpose of utilizing this
research tool was to gather a deeper understanding of their feelings and daily life. The
probe was made available to participants through an online collaborative platform called
MIRO.
The probe functioned as visual diary, allowing the young adults to:
• Observe and reflect on their experiences of living with type 1 diabetes and challenges
faced.
• Provide an insight into the life of a type 1 diabetic.

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Activity 1

Describe some of the pros and cons of the diabetic technology you are
currently using. Use these stars to rate your devices. Just drag and drop
the stars on the star outline below .

Blood glucose monitoring

If you are experiencing extreme hypoglycemia and not in a position
to self treat, how would you want to be helped by a third party ?

Type here...

Type here...

Insulin adminstration
Type here...

Who would you want to know that you are
in an emergency situation ?

Is there anything you would like to change about your diabetes
care? If so, can you explain what you would like to change?

What advice you would give to your younger self regarding diabetic
management?
Type here...

Type here...

Activity 2

1.
2.
3.
4.
5.
6.
7.
8.

Love

Hate

Use this space to tell us about it. Just select, remove the text and start typing!

Use this space to tell us about it. Just select ,remove the text and start typing!

Activity 3
Click on the link below for this activity. The platform is called "Padlet" which will allow you to annomyously share photos with me. Rememeber this link is for
you only, and only you and me can see it. Please do not share it with someone else. Use the link provided to upload photos and add caption to it. Have a look at
the instructions below. This is how the "PADLET" looks like.

Use this to edit
title and caption.

After clicking on this, a dialogue box will appear as shown
down, click on options to upload the picture, Give litle and
write something about the picture taken.

IMAGE

Click here
Use this to upload photo
from phone/computer

Figure 44: Cultural Probe Activities

Use this to snap

Link: https://padlet.com/kgupta9/Michelle

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9.4 Scenarios of Use

Figure 45: System map of scenario from first person(diabetic) perspective

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Figure 46: System map of scenario from first second (person observing diabetic) perspective

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Below are the detailed scenarios listed with pain points and design opportunities.

Figure 47: Scenarios of use

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9.5 User Feedback
GET FEEDBACK
I've learnt and built something. Now its time to share with people whom I'm designing for and see what you think.
We will be going through the cue cards at the bottom to get into specifics of developing the product.

1

2

3

Voting Dots

1

2

3

Use the dots to rank the ideas that you like

Card 1
Which form/design excites you and
why?
4

5

Unique/ di erent shape

Generic shape

Card 2
Would you like to wear something
that has a unique shape/form or
something that has a more generic
form (eg, fitbit ) ?

vs

Band/strap design

Card 3
what material would you prefer?
silicone, leather, textile, beaded etc.

Metal

Silicone
rubber

Braided

Textile

Leather

Color

Card 4
What are you thoughts on the
color? Do you prefer standard
colors(black/grey) or funky colors?

vs

Strap closure

Card 5
Which type of strap/band closure do
you prefer or would like to have ?

vs

Strap with pin and
tuck closure

Figure 48: User feedback activity

Strap with no
buckles or clasps

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9.6 App Screens - Main Application

Figure 49: Main application screens(1/2)

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Figure 50: Main application screens(2/2)

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Savr Connect Application

Figure 51: Savr connect application screens(1/2)

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Figure 52: Savr connect application screens(2/2)