CoDesign

Vol. 8, No. 1, March 2012, 4379

Fusion of horizons: Co-designing with Cambodian children who have

prosthetic legs, using generative design tools
Soa Hussaina* and Elizabeth B.-N. Sandersb,c
a
Department of Engineering Design and Materials, Norwegian University of Science and
Technology, (NTNU), Trondheim, Norway; bDepartment of Design, The Ohio State University,
Columbus, OH, USA; cMakeTools (http://maketools.com)

(Received 27 September 2010; nal version received 28 October 2011)

This paper presents a eld study exploring the challenges and implications of
applying a participatory design process through the use of generative design tools
with children using prosthetic legs in rural Cambodia in order to facilitate their
involvement in the design process. First, it reviews the main research paradigms in
which user research is conducted, including positivism, critical theory and
interpretivism, and compares the paradigms in terms of the motives they carry for
involving users in the design process. The case is then positioned in the
interpretivistic research paradigm using philosophical hermeneutics as a guide. As
the rst application of generative design tools with children in developing
countries who have special needs, the case revealed many challenges and pointed
to the need to go well beyond the contextual domains typically addressed in usercentred or product-centred design today. The paper concludes by presenting the
pyramid model, which designers can use to obtain an overview of the knowledge
they need for developing a relevant solution, and to reect upon how their
understanding develops in this process.
Keywords: generative design tools; philosophical hermeneutics; participatory
design; Cambodian children with disabilities

1.

Introduction

Product designers are trained to develop novel solutions that meet peoples needs;
however, some design projects require new approaches for designers to understand
what intended users really want and need. This was found to be the case when
improving prosthetic legs for children in rural areas of Cambodia. It was necessary
to understand the stigma associated with disability in Cambodia and the turbulent
history of the country to design and carry out useful design research activities.
Most people wonder why people are born with a missing leg. According to Buddhist
practice, it comes from our karma resulting from our deeds. When we were human in a
past life, we might have caught, tied or broken an animals leg, and so on. A hunter,
after shooting an animal, might choose not kill it, in order to keep the esh of the
animal fresh. So, instead, they would break the animals leg or the birds wing. As a
consequence, the person who had committed this sin would be born in this life with a
missing limb.

*Corresponding author. Email: soa@ntnu.no

ISSN 1571-0882 print/ISSN 1745-3755 online
2012 Taylor & Francis
http://dx.doi.org/10.1080/15710882.2011.637113
http://www.tandfonline.com

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S. Hussain and E.B.-N. Sanders

A Cambodian Buddhist monk explaining why some people are born with a disability
(personal communication, 19 June 2009).

In this article we describe a eld study where a participatory design process was used
with three child prosthesis users in Cambodia. We dene participatory design to be a
design practice that involves non-designers in various co-design activities throughout
the design process (Sanders et al. 2010). The non-designers typically include the endusers and other stakeholders in the design development process such as
manufacturers and distributors.
Participatory design has political roots. It began in the 1970s when the
Norwegian Iron and Metal Workers Union decided that it should involve the
workers in the research phase of a project so that they would have an opportunity to
inuence the design and use of the new computer applications in their workplaces
(Nygaard and Bergbo 1974, Bdker and Sundblad 2007). So in the beginning,
participatory design ideals, especially in Scandinavia, concerned democracy at work
and the supporting of skilled workers (Bjorgvinsson et al. 2010). Today, 40 years
later, practitioners of participatory design can be found all over the world applying
the approach in domains far beyond the workplace and organisational development.
For example, the North American approach to participatory design is generally less
political than the Scandinavian approach and it is more often directed towards the
design of useful and innovative products, systems and services for all domains of
peoples lives. The aim of and motivation behind current participatory design
projects can thus be political as well as non-political.
Generative design tools refers to a category of participatory design methods
characterised by the application of materials that have been designed to facilitate
non-designers in articulating their needs and dreams in the form of design proposals
that can serve as starting points for designers and/or design teams. To help to
organise the rapidly growing, global collection of tools and techniques for
participatory design, Sanders et al. (2010) have proposed a framework into which
all currently documented tools and techniques of participatory design can be placed.
The primary dimension of the framework is described by dierences in the form of
the tools and techniques for making, telling or enacting. Making refers to tools and
techniques for making tangible things. Making tools and techniques used in
participatory design include collages, maps, models and mock-ups that are made by
the non-designer participants. Telling refers to tools and techniques that support
verbally oriented activities such as talking and explaining. Telling tools and
techniques used in participatory design include diaries, logs and the use of cards for
organising ideas, for example. Enacting refers to tools and techniques to support and
facilitate acting and playing. Enacting activities used in participatory design include
role playing and improvisation, and the tools and techniques of enacting might
include props or puppets. The generative tools that were used in this eld study fall
primarily into the category of making activities, i.e. tools and techniques for
making tangible things.
Generative tools have been used for some time now in the early phases of the
design development process for the creation of products, services, systems and
facilities (e.g. Sanders 2000, 2001, 2006, Sanders and William 2001, Visser et al. 2005,
Sanders and Stappers 2008). This approach has been used with people of all ages and
backgrounds. It is ideal for working with children because the design language
supports both verbal and non-verbal forms of communication, with an emphasis on

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the use of visual material. But, to our knowledge, generative tools had never, until
this study, been used with children in developing countries who have special needs.
To understand why we chose to use generative design tools with the participants,
it is necessary to know the larger context of the project. The research presented in
this article is a part of an ongoing study conducted for the International Committee
of the Red Cross (ICRC). The ICRC supports a factory that produces prosthetic
components and two rehabilitation centres in Cambodia. The main priority in their
development of prosthetic appliances is the technical, biomechanical and economic
requirements. These are all necessary aspects that cannot be dealt with lightly.
However, to achieve further improvements to the prostheses, product developers
need deeper understanding of user needs and preferences. To accomplish this,
designers have to explore new ways of seeking and understanding user needs.
Generative design tools have been found to be very ecient and eective when
co-designing with children in the West (Sanders 2000), but using generative design
tools with children with disabilities in rural parts of Cambodia has not been a
straightforward process. Making the children comfortable with taking part in openended activities was challenging. Several visits were required before the relationship
with the children reached a level where it was possible to start doing these kinds of
creative exercises. However, once such relationships were established, we learned a
lot from the children through the use of generative design tools.
In our eld study we found that we had to take a deeper look at the underlying
assumptions about reality and knowledge of designers to understand the diverse
approaches taken towards users. To nd our path among various possible
approaches in this project we had to develop awareness of philosophical
underpinnings of several research paradigms. It is argued that designers motivation
for seeking user involvement is related to which research paradigm they lean
towards. The research paradigms of positivism, critical theory and interpretivism
and their relation to user participation will be described. It is advocated that
philosophical hermeneutics, which is based on an interpretivist epistemology, is
particularly useful when working with understanding the intangible aspects of a
product and its use. In addition, the ways in which participatory design through the
use of generative design tools can support hermeneutical informed design will be
explained through the eld study. Some guiding principles for grounding research on
user needs in philosophical hermeneutics are presented. Furthermore, a model that
can help designers to gain the knowledge needed for developing a relevant solution
and reect upon how their understanding has changed or developed in this process
will be presented.
1.1.

Design and research

Design itself is not research, but research may be needed in design projects to
investigate user needs, technical product requirements, cultural aspects, etc.
(Friedman 2003, Heylighen et al. 2009). As noted by Friedman (2003, p. 510):
Designers work on several levels. The designer is an analyst who discovers problems or
who works with a problem in the light of a brief. The designer is a synthesist who helps
to solve problems and a generalist who understands the range of talents that must be
engaged to realize solutions. The designer is a leader who organizes teams when one
range of talents is not enough. Moreover, the designer is a critic whose post-solution
analysis considers whether the right problem has been solved. Each of these tasks may

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S. Hussain and E.B.-N. Sanders

involve working with research questions. All of them involve interpreting or applying
some aspects or elements that research discloses.

Research paradigms are therefore relevant not only for researchers but also for
designers. Moreover, designers motivation for involving users in research is
inuenced by the paradigms they support (either consciously or on a subconscious
level).
In the eld study, our aim as design researchers has been both to investigate user
needs and to learn how the use of generative design tools can support designers in
doing this.
2. Research paradigms and their relevance to user participation
The way in which designers choose to conduct research on user needs is closely
linked to how they reason about the nature of reality (ontology) and what and how
human beings can learn about reality (epistemology). A researchers ontological and
epistemological stand has direct implications for the methods they choose to use for
seeking knowledge (Guba 1990). Similarly, the way in which designers reect upon
what really exists and what humans are able to know inuences how they choose to
do research on user needs and communicate with users in the design process. It
makes a dierence whether designers believe that knowledge exists independently of
the observer, as an absolute that can be uncovered through the use of scientic
methods, or whether designers subscribe to the view that knowledge consists of ideas
constructed in the mind. When conducting research on user needs and user
satisfaction, designers can benet from reecting upon which research paradigm
their approach ts into and thereby make conscious decisions about how to involve
users in the design process. This is especially important when working with
vulnerable users, such as impoverished children in developing countries.
A paradigm can be dened as a worldview or a basic set of beliefs that guide
action (Guba 1990). The number of paradigms and the names associated with each
paradigm dier from author to author. We have chosen to use the categorisation
used by, among others, Guba and Lincoln (1994) and Willis (2007):
. positivism/postpositivism
. critical theory
. interpretivism.1
It should be noted that this is a supercial way of grouping existing belief sets in
research as there are several forms and subgroups of each paradigm. In addition,
paradigms are not static but constantly evolving. This is especially the case for
critical theory and interpretivism. Even among proponents of these two paradigms,
there is no nal agreement about their denitions, meanings or implications (Guba
and Lincoln 1994). It is not possible in this limited space to give a full overview of all
the subbranches and dierent philosophical stands within each paradigm. Instead,
we aim to provide broad descriptions of their main characteristics and the underlying
communalities of the dierent forms of each paradigm in order to position our own
approach for carrying out research with users in design projects.
Positivism is based on the idea that there is an objective reality that can be
studied, captured and understood using the scientic method (Denzin and Lincoln

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2005, Willis 2007). Scientists working within this paradigm prefer a methodology
that is standardised and repeatable, and that tests a predened hypothesis
(Liamputtong and Ezzy 2005). In social research, positivism refers to a belief that
social science can be scientic, i.e. empirical and objective, in the same way as
physical science (Liamputtong and Ezzy 2005). Postpositivism is a moderate form of
positivism and has, to a high degree, replaced positivism in the social sciences. The
emphasis here is also on nding universal truths through the scientic method, but it
is believed that reality can never be fully apprehended, only approximated. Research
can therefore only contribute to indicate that a hypothesis is true or prove that it is
false, and never prove that it is true.
In contrast to positivism, critical theory2 rejects the separation of facts and values
and focuses on ideology as a guide to research, for example, feminism, neo-Marxism,
materialism or Freireism. Reality in this paradigm is seen as a virtual construct
shaped and crystallised over time by social, political, cultural, economic, ethnic and
gender values (Guba and Lincoln 1994). It is argued that the whole research
process from the selection of research topics to the creation of research instruments
and analysis of data can never be objective and value free. The researcher should
therefore reect critically on his or her own values, ideological imperatives and
methods (Gomez-Muller and Rockhill 2011). In critical theory, the aim is not only to
describe or interpret reality and raise knowledge but also to confront injustice,
empower individuals who are held down by power structures and create political
change (Kincheloe and McLaren 2005).
Interpretivism is based on the idea that humans cannot come to know how the
world really is, regardless of the research method being used. Not all interpretivist
researchers deny the existence of an external, physical reality, but they agree that
how we perceive and make sense of external reality is socially constructed (Willis
2007). Interpretivists believe that all research is shaped by the pre-existing theories
and worldviews of the researchers. Therefore, this approach advocates seeking local,
context-bound understanding rather than searching for generalisable truths and laws
(Guba 1990). There is no single, right way of viewing a specic situation. Instead, it
is believed that there are multiple, legitimate perspectives on a topic. This does not
imply, however, that researchers have to regard all answers as equal. Realities are
not more or less true, but they can nevertheless be more or less informed (Denzin and
Lincoln 2005). Traditional, positivistic research is not rejected but is considered only
as one of many sources of knowledge and not viewed as superior to other ways of
conducting research. There is no correct path to knowledge and pre-existing
formulae therefore cannot be applied uncritically. Both quantitative and qualitative
methods are accepted within the paradigm, although qualitative methods are often
preferred. In addition, reective methods, such as reective discussions on
professional practice and personal stories, are considered to be meaningful research
methods (Willis 2007).
In the positivism paradigm, the perception of a product is entirely dependent on
physical product properties (Figure 1). That reality can be perceived objectively
implies that there is only one correct interpretation of a product. Consequently, the
designer can control how the user experiences the product by tailoring product
properties. The designer is the expert who understands how the product should
function. When investigating the needs of children using prosthetic legs in
Cambodia, rooted in the positivism paradigm, typical motivation for carrying out
research on user needs would be to investigate how far children usually walk every

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S. Hussain and E.B.-N. Sanders

Figure 1. In positivistic informed design, the interpretation of a product is believed to be

determined by physical product properties. By investigating what properties users need and
value, designers know how products should look and function. (Adapted from Hussain and
Keitsch 2010, p. 146.)

day, under what sort of weather conditions the product is used, how the prosthesis
impacts the users gait, etc. By acquiring this kind of information, the designer will
know how an ideal prosthesis should function. Involving users is only necessary if
the information cannot be obtained from other sources, such as from rehabilitation
workers, literature or databases. Users will usually be included when the
functionality of products needs to be tested or in structured interviews or
questionnaires to measure user satisfaction.
Both in critical theory and in interpretivism, the way in which products are
perceived and interpreted is connected with the historical, social and cultural context
of the user and the use of the product. In critical theory, power structures and
political context are also given emphasis. For designers working within these
paradigms it is therefore necessary to include users in the design process to
understand these underlying, tacit structures. The methods used by designers
inuenced by interpretivism may not dier from methods used by critical theory
oriented designers. The dierence lies in what is seen as the purpose of and
motivation for user participation. For an interpretivist designer the primary aim of
including users in the design process is to get to know their culture and seek deeper
understanding of the context of product use, whereas for a critical theory designer
the inclusion of users is a political act and the main aim is to empower users and
change social power structures. Politically motivated participatory design projects t
into the paradigm of critical theory. Critical design projects are defended based on
an ideology. See, for example, DSouza (2004) on universal design, Bardzell (2010)
on feminist humancomputer interaction and Barb et al. (2004) on the design of
educational games for children. In interpretivistic motivated projects the designer/
researcher acts as a passionate participant, whereas in critical theory oriented
projects the role of the designer/researcher is of a transformative intellectual acting
as an advocate and activist (Guba and Lincoln 1994).
It should be noted that designers do not have to work within just one paradigm
and that the three research paradigms are not mutually exclusive. Design projects are
usually not limited to a single paradigm. The aim of participatory design projects to
bring forth marginalised user perspectives, for example, relates to both critical theory
and interpretivism. Moreover, when developing products it is necessary to evaluate
technical, ergonomic and economic requirements. Positivistic methods will therefore
be an integrated part of designing. Knowledge about research paradigms, however,
can help designers and researchers to become more aware of the values that guide the
methods they choose to use, especially when investigating user needs. Our aim is not
to promote one paradigm and dene it as the correct one for all design projects.
Scientically, it is not possible to prove that one paradigm is better than another,
and both researchers and designers choose paradigms based on personal preferences

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and conviction. The main paradigm that guides research in a design project should t
with the personal values of the designer in addition to the aim and scope of the
project. In this article we show how interpretivism helped us to work with prosthetic
legs without reducing these products to mere technical artefacts.
3.

Towards a philosophical hermeneutics-oriented design approach

The research methodology in the project for children with disabilities in Cambodia is
primarily based on an interpretivist perspective. The core of the research project is
that product design is as much concerned with human beings users, designers and
society in general as with the tangible solutions being developed. Through the use
of positivistic concepts such as technical requirements and ergonomic adaptation,
product developers have not been able to capture the complex relationships between
users, prostheses and community (Groce 1999, Murray 2004). An interpretivist
approach gives more space for taking into consideration the cultural and social
context of product design, production and use, and acknowledges that other
worldviews are legitimate. Therefore, communication with children, their families,
health professionals, as well as Buddhist monks and traditional medicine men (kru
khmer) has been an important part of the project (Hussain 2011).
It can be argued that the project has elements from critical theory as it is
concerned with empowerment of underprivileged children (Hussain 2010). However,
it does not focus on children living in developing countries as an oppressed group,
and research methods and data analysis are not based on an ideology. The
empowerment of child participants is seen as a positive and important extended
result of a design project but not the primary reason for organising and conducting
the project. The approach chosen in our eld study is based on philosophical
hermeneutics as an interpretivistic research approach (Figure 2). Philosophical
hermeneutics aims at developing understanding of a phenomenon, i.e. an object,
person, event or experience, in a holistic context (Willis 2007). In philosophical
hermeneutics, the perception of an object is never a mere reection of its visual
appearance but is aected by the qualities that humans ascribe to it based on their
preunderstanding; previous experiences, cultural background, associations, biases,

Figure 2. In philosophical hermeneutics-oriented design, the interpretation of a product is

believed to be inuenced by the physical product, the user, and the society and culture in
which the product is used and interpreted. It is by seeking understanding of the reciprocal
relationships between products, users, society and culture that designers can gain deeper
understandings of user needs. (Adapted from Hussain and Keitsch 2010, p. 153.)

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and so on. Whenever we experience something we interpret it in the context of our

preunderstanding, and through this process we gain a new understanding of the
phenomenon. This new understanding becomes the preunderstanding used for
interpreting our next experience. This is a continuous, ongoing loop which is referred
to as the hermeneutic circle. Heidegger (1962) stressed that preunderstanding is not
something a person can step outside of or put aside since preunderstanding is a
condition for understanding; everything we experience has to be interpreted in the
framework of our background or history.
Gadamer extended the work of Heidegger and put it into practical application.
He understood hermeneutics as a process of co-creation between the researcher and
participant (Gadamer 1975). Knowledge is gained through a long process of
interpretation, which is neither subjective nor objective since it involves an
interaction between the individual (subject) and the phenomenon to be interpreted
(object). Even though two individuals can never have identical experiences
throughout their lifetime, and therefore cannot have the same preunderstanding, it
is evident that within a society people tend to have a somewhat coordinated
understanding of the world. Almost all modern literature on social anthropology
agrees that a culture can be viewed as a self-reective system with internal logic.
There is a certain cultural grammar within a society that helps us to communicate
with each other, even though we probably do not interpret experiences in exactly the
same way (Almkov 2005).
Gadamer (1975) promoted the idea that our biases and beliefs are the product of
our history. He used the term horizon for the totality of all that can be realised or
thought about by a person at a given time in history and in a particular culture. The
horizon thus includes everything that can be seen from a particular vantage point.
Our preunderstanding, or prejudices as Gadamer sometimes calls it, does not merely
arise from ourselves. It is rather a consequence of all that has gone before; the preexisting worldview that our parents, neighbours and nation had: Understanding is
not to be thought of so much as an action of ones subjectivity, but as the placing of
oneself within a process of tradition, in which past and present are constantly fused
(Gadamer 1975, p. 258).
Gadamer (1975) placed great emphasis on language. He believed that language
is a vehicle for understanding of the world; language is the universal medium in
which understanding occurs. It is through communication with others and
interpretations of texts that a persons preunderstanding can be challenged and
altered. This can lead us to transcend our horizon and develop new understanding. For this to happen, however, researchers must have an open mindset
(Gadamer 1975).
Early hermeneutics was focused on formulating rigid rules, methods and
techniques for textual interpretation. However, based on the philosophical thoughts
of Heidegger and Gadamer, hermeneutics is now viewed as a broad epistemology
and philosophy of understanding rather than a narrowly focused method. The
interpretation of the word text is no longer conned to written or verbal
communication but is expanded to include organisational practices and structures,
economic and social activities, culture and cultural artefacts, and so on (Prasad
2002). This much wider denition is partly based on Ricoeur (1971), who argued that
human action in general could be considered as texts. Accordingly, hermeneutic
phenomenology can be used in design research for investigating interpretations of
physical products, services and design activity.

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Philosophical hermeneutics is not a method guided by rules. Gadamer did not

believe that being aware of the rules for understanding is a precondition for
understanding (Gadamer 1975), nor did he suggest any method or methodology for
how to interpret texts (Fleming et al. 2003). However, there are some guiding
principles that can be extracted from his teachings and transferred to design
research. These principles can guide designers when investigating user needs or how
a product is interpreted by users.
(1) Understanding appears through the fusion of horizons of designers and
participants. Communication with participants is an invaluable tool for
gaining understanding of the situation of users, what sort of solution
would be useful and the critical aspects for making the implementation of
such a solution successful. Gadamer advocated that researchers should use
themselves as a research instrument and through conversations with the
users immerse themselves in the subject matter. As noted by van Manen
(1984) and Fleming et al. (2003), it is therefore important that seeking
dialogue with users is not outsourced to assistants, for example, but is
carried out by the researchers themselves. It should also be acknowledged
that the motivation for talking with users is not to see through their eyes
or put oneself in their situation. This is simply not possible, because of
the dierent backgrounds and preunderstandings of designers and
participants. The aim is rather to work together to reach a shared
understanding (Johnson 2000). Gadamer called this fusion of horizons
(Gadamer 1975).
(2) Designers should communicate with participants several times during a project.
Both designers and participants understanding of the issues being discussed
will change and develop over time. Through meeting several times, designers
and users allow for these changes to happen. Designers should give feedback
to participants about how their input has been analysed and interpreted to
foster further discussions that can lead to a shared understanding (Fleming
et al. 2003).
(3) Designers should reect upon their preunderstanding and how it evolves
throughout the project. In the writings of Gadamer, the words bias and
prejudice are not used with the same negative context as modern meanings of
these terms. Instead, they refer to preunderstanding, which is a precondition
for all understanding. Unlike in phenomenology as described by Husserl,
researchers should not identify their preunderstanding in order to set it aside
and ensure that it does not aect the research. Researchers and designers
preunderstanding will always inuence their analyses.
(4) Analyses of a text should be done by moving from its parts to the whole text
in ongoing spirals. In philosophical hermeneutics it is believed that everything
has to be seen in relation; the parts can only be understood from the whole,
and the whole from the parts. When designers gain new understanding of one
part of a project or a product, for example, they should analyse how this
aects their understanding of the project or product as a whole and then
return to the parts. These iterations can, in theory, go on innitely as
understanding is never fully developed. However, it is natural to stop when
the interpretations give sensible meanings and there are no inner conicts in
the analyses (Kvale 1996).

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The strength of philosophical hermeneutics is that it does not fetishise method.

Qualitative as well as quantitative methods can be used (Prasad 2002). This is
important in design where several types of knowledge are often needed. When
working with prosthetic legs, for example, designers need to understand the users
feelings about the aesthetics of the product. Methods such as qualitative interviews
and participatory design research exercises can be used for doing this. In addition,
designers have to consider biomechanical properties and the durability of the
prostheses. Quantitative methods such as gait studies and mechanical tests can be
important for investigating such product requirements.
4. Hermeneutically informed use of generative design tools
The core ideas behind the use of generative design tools t into the perspectives of
philosophical hermeneutics since the use of generative design tools promotes
dialogue between designers and users without seeing the designer as the expert.
Communicating with users is essential for developing an understanding of what
solutions should be designed. The aim of using generative design tools is to expand
not only the horizon of the designer, but also the users horizon. Through using
generative design tools, users develop a deeper understanding of their own needs,
views and perspectives. It is not the information given by the user to the designer that
leads to an understanding of user needs, but a new shared understanding developed
through the dialogue between the designer, user and the artefact created with
generative design tools.
When using generative design tools, a number of components are selected and
put together in toolkits. The toolkits generally consist of visual as well as verbal
elements. The components of a toolkit can be two-dimensional and/or threedimensional. Participants are asked to select from these components, or add
components of their own, to create artefacts that express their feelings, thoughts or
ideas. The artefacts can be in the form of collages, maps, models, stories, etc.
(Sanders 2000). After the participants have created the artefact, they are asked to
present what they have made by telling a story about it, describing what it will do or
by showing how it will work. The use of generative design tools promotes a new
language that creates a synergy between verbal and visual forms of communication
and allows the participants to imagine and express their abstract and rough ideas in
more concrete form. Generative design tools are not limited to visual media but can
also include sound, smell and haptic perception (e.g. Khanna 2006).
In participatory design projects, any artefact produced by participants can be
viewed as text in a metaphorical sense. The objects created can be read, understood
and interpreted in a similar manner to written texts. The story that the participant
tells about the artefact results in another kind of text. Through inspiring people to
create something that communicates their feelings, thoughts or ideas and then
listening to the stories told, designers can improve their knowledge about users
experiences. Both designers and users reach a new understanding of the phenomena
being discussed through this process. The aim is not to nd a correct description or
interpretation but to seek a deeper understanding of something by seeing it in a
larger cultural and social context. Through the creation of artefacts and sharing
ideas and feelings about these artefacts, designers and participants extend their
horizons. Thus, the very essence of generative design tools is grounded in
philosophical hermeneutics. The application of generative tools also serves to

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extend the approach of philosophical hermeneutics to include not only the

understanding of past experience but also the anticipation of future experiences.
Whereas Gadamer insisted that understanding is determined by the past,
Heidegger believed that the prestructures of understanding are linked not to the past
but to the future. Thus, to him, understanding is oriented towards the future;
anticipation of future existence and future goals (Grondin 2002). The practice of
using generative design tools incorporates the views of both Gadamer and Heidegger
by stressing the importance of understanding the experiences of the end-user and
other stakeholders based on their past and current experiences as well as their hopes
and dreams for the future. People understand new experiences with reference to their
past experiences as well as to the past experiences of their families, communities
and culture. Moreover, they interpret what is going on around them in anticipation
of their hopes and fears for the future. The language of generative tools therefore
supports and facilitates peoples expressions of past, present and future experiences
(Sanders 2001).
It should be noted that the mere use of generative design tools does not make a
project automatically belong to philosophical hermeneutics. Rather, the way
designers use the tools and reect upon the information gained through using
them is what places a project in this category. The principles listed in Section 3
should be followed. When working with generative tools, some additional principles,
i.e. beliefs, apply as well:
. All people are creative. But they are not often invited to take part in creative
activities so they may need some preparation and support.
. All people have dreams. But they may not have had the opportunity to share
their dreams with others and will need facilitation to do so.
. People will ll in what is unseen and unsaid based on their own experience and
imagination. By asking them to make artefacts from ambiguous components,
we can see what is important and meaningful to them.
. People project their needs onto ambiguous stimuli because they are driven to
make meaning. The artefacts that participants create using the generative
design tools can therefore be used for initiating conversations about their needs
and dreams.
These principles are based on over 30 years of practical experience in applying the
generative design tools in the predesign phase to inform and inspire the design of
hundreds of products, systems and services across a wide range of industries
including consumer, industrial, medical/healthcare, education, retail and military
(e.g. Sanders 2000, 2001, 2006, Sanders and William 2001, Sanders and Stappers
2008).
5.

Using generative design tools with children in Cambodia

Generative design tools have been found to be very ecient and eective when codesigning with children in the West (Sanders 2000); however, using generative design
tools with children with disabilities in rural parts of Cambodia has not been a
straightforward process. Making the children comfortable in taking part in openended activities was challenging. It required several visits before the relationship with
the children reached a level where it was possible to start conducting these kinds of

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S. Hussain and E.B.-N. Sanders

creative exercises. However, once such relationships were established, we learned a

lot from the children through the use of generative design tools.
There are several explanations to why it was dicult to perform such tasks with
the children. In Khmer culture, children are often thought of as not being cabable of
deep, reective thinking before they reach puberty (Smith-Hefner 1999). Children
are therefore not usually asked about their opinions, thoughts or feelings. In
addition, children are not encouraged to discuss or develop critical and creative skills
at school. The quality of education in rural schools is especially low (Chansopheak
2009, Bunlay et al. 2010). Therefore, children need time and some practice in getting
used to open-ended, creative tasks.
To understand the diculty of involving Khmer children in the design process it
is also necessary to know the history of Cambodia. From 1975 to 1979 Khmer
Rouge governed the country. Money, markets and private property were abolished.
Schools, hospitals, shops, oces and monasteries were closed (Chandler 2000). The
three million people living in cities were evacuated to rural areas where they were
forced to take part in agricultural labour. People were organised into communes and
were further divided into work teams according to age and gender. They were forced
to work with rice cultivation from morning to night without any reward and had to
survive on low food rations (Ledgerwood 2002). The communist regime saw private
property as a source of individualism and capitalism. Therefore, money, markets and
private property of all sorts were abolished. Khmer Rouge wanted to establish a
class-free society. To achieve this, the regime controlled all aspects of peoples lives
such as religion, language, clothing and hairstyle. Most of Cambodias population
was Buddhist. The regime believed that Buddhism was reactionary, exploitative and
feudalistic. Buddhism was therefore replaced by political indoctrination. Through
political meetings, people were told to raise their spirits to defend and build the
nation and that all loyalty must be directed to Angkar, the revolutionary
organisation (Ledgerwood 2002). Ethnic minorities and cultural diversity did not
t into the plan of establishing a uniform society. Vietnamese were expelled from the
country, and those who chose to remain in Cambodia were killed. Powerful Chinese
businessmen were executed while those who were found to be capable of changing
were forced to assimilate into the new society. Muslim Chams also had to abandon
their religion, language and customs. Many of them were killed (Ledgerwood 2002).
Intellectuals, people who knew foreign languages and those who wore glasses were
also persecuted. It is estimated that during the reign of Pol Pot (19751979) 1.5
million people, i.e. 20% of the population, were killed or died. Vietnam invaded the
country in 1979, and in 1989 the United Nations Security Council established a
peacekeeping operation which had the mandate to monitor progress towards
conducting elections, temporarily run several government ministries and protect the
populations human rights. Several years of political turmoil followed with political
actors not being able to cooperate and respect the results of elections. It was not until
Pol Pot died in 1998 and Khmer Rouge fell apart that it became possible to create a
stable government through democratic elections (Chandler 2000). It is within this
context that working with children with disabilities belonging to poor families has to
be understood.
Most parents of young children in present-day Cambodia are survivors of the
Khmer Rouge regime. Many of them were separated from their parents at the time.
A lot of people are still struggling with symptoms of post-traumatic stress disorder
because of the atrocities experienced during this time (Perry et al. 2007, Sonis et al.

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55

2009). As reported by Munyas (2008), many Khmer children display signs of

transferred trauma. This may be a contributory factor to why children in the eld
study found it dicult especially at the beginning of the project to talk about and
share with outsiders their feelings and inner thoughts.
5.1.

Participants

Generative design tools were used with the three participants: a 16-year-old boy
(Vannak), a 10-year-old girl (Siya) and a 12-year-old boy (Sockeat).3 The children
were found through the database of a non-governmental organisation providing free
prostheses to children living in rural areas close to Phnom Penh. Initially, the
designer had aimed to work with more children, but because of the time and eort
needed for establishing trust relationships and letting children become used to
talking about experiences and feelings, only three children were selected. These
children were chosen as participants since they lived in areas that are easy to access
from Phnom Penh and because, out of the six, they were the ones who seemed most
comfortable with taking part in research activities (Hussain 2011). All children were
unilateral, below-knee amputees and, by coincidence, they were all born with their
disability.
5.2. The research process
At this stage in the project, three eld trips to visit the children have been conducted.
In the rst eld trip, six children were interviewed together with their parents. This
was done to make both the children and parents feel at ease at an early project stage
when they did not know the designer. In the next eld trip, three of the children were
selected as research participants. They were revisited four times each to establish a
relationship of trust that made it possible for them to open up to the designer and
become used to taking part in research activities. This time, interviews with children
and with parents were conducted separately. Multiple-method, ethnographic
research was conducted, as shown in Table 1. The results from the rst two eld
trips are presented in Hussain (2010, 2011). In this article, the focus is on the results
from the last eldwork; however, these results have to be viewed in the context of the
previous research.
During the third visit to Cambodia, the focus was on understanding childrens
aesthetic preferences concerning prosthetic legs and more about their daily lives
using generative design tools. These two topics were identied as most important to
explore further based on analyses of the previous research. In earlier visits, children
had written, made drawings and talked about what a prosthetic leg should be like
(Hussain 2010). Some child and adult prosthesis users said during interviews that
they preferred to cover up their prosthetic leg (Hussain 2011). We wanted to
understand more about how prosthetic legs could be designed to make users more
comfortable with their self-image and to see whether preferences for clothing were
related to the appearance of the prostheses. Observations and conversations about
everyday activities had been conducted during the two rst eld trips. However, a
more structured method was now needed to obtain an overview of what children
normally do during a typical day.
We therefore designed two activities with generative design tools. These research
activities were carried out together with the three research participants from the

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Table 1.

Research process for the entire eld study.

Research
AugustSeptember 2008

JuneJuly 2009

FebruaryMarch
and August 2010

Method

Aim

Interviews with six children

together with their parents
Group interview with six
rehabilitation workers
Observation of patients at
rehabilitation centres and
production of prosthetic
components
Interviews with three children
combined with childfriendly techniques such as
drawings, role play and
photographs
Separate interviews with the
three childrens parents
Interviews with ve
Buddhist monks, six
traditional medicine men
and ve adults who had
been using prosthetic legs
since childhood
Group interview with seven
children with no disabilities
Use of generative design tools
with the three children from
the previous eld trip

Obtain an initial overview and

understanding of the main
usability issues

Understand cultural health

beliefs and social
implications of prosthesis
use

Seek deeper understanding of

how children are aected by
using prosthetic legs and
how changing the
appearance of the prostheses
can benet children

second eld trip. The rst author, who is an industrial designer, carried out the
eldwork in Cambodia. Both parents and children were asked for written consent.
The children were visited twice at their homes. All interviews were conducted
through a translator speaking Khmer and tape recordings from the interviews were
later translated into English and transcribed. The activities and the results found
using generative design tools will be explained in the following two sections. The
tools were seen as a means for initiating conversations and stimulating ideation with
the children.
5.3.

Paper dolls

In the rst exercise, paper dolls were used to encourage children to talk about
aesthetic preferences and self-image. The children were asked to dress the dolls with
clothes and prosthetic legs. Two sets of paper dolls and clothes were developed: one
for girls and one for boys (Figure 3). We wanted the children to feel enthusiastic
about the task. Therefore, three dolls of each gender with dierent drawing styles
were made. The children could select the drawing they liked the most. One of the
dolls had a more natural drawing style than the other two. For some children it
might be easier to talk about the problems of using a prosthetic leg if the dolls

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Figure 3.

57

Girls and boys toolkits for the paper doll exercise.

resembled themselves, whereas for other children the more cartoon-like dolls could
provide some distance from the sensitive issues being discussed. The children were
told that they could choose to give the dolls their own name or select other names. In
previous interviews, the rst author had experienced that it was easier to persuade
children to talk about sensitive issues if questions were made as general as possible.
For example, instead of asking Do you think it is dicult to live with a disability in
Cambodia? one should rather ask Is it dicult for people with disabilities to live in
Cambodia? The rst time the children were given the paper doll exercise, all of them
selected the dolls with the most natural-looking appearance. They also chose to give
the dolls a name other than their own. The task was repeated during the next visit to
Cambodia to give children a chance to reect upon their previous responses and
discuss possible changes in their opinions. This also gave the designer the
opportunity to conrm that the analyses were in line with the views of the children.

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S. Hussain and E.B.-N. Sanders

The selection of clothes and cosmetic covers for the upper part of prosthetic legs
was based on earlier observations and interviews with children and prosthetists.
During the previous eld trip, the children had been asked to describe an ideal
prosthetic leg and a prosthetic leg that they would not like to have. All children had
put emphasis on the appearance of the prosthetic foot, which was often visible since
they usually wore open sandals or walked barefoot (Hussain 2010). Through these
interviews, we also learned that there seemed to be a relationship between the
appearances of prostheses and clothing that children preferred to wear, but it was
dicult to encourage children to talk more about these issues. The paper doll
exercise was therefore designed to explore this topic further. The clothes in the
toolkit tted with observations of what type of clothes children in rural areas usually
wear. Prosthetists had reported that children would like to have prosthetic legs with
dierent colours and that they wished these could be provided to the patients
(Hussain 2011). We therefore included cosmetic covers that had various colours and
patterns in the kit. One white cover was also provided, so that children could
decorate it as they wished. In addition, the kit had prosthetic feet with characteristics
similar to feet that are used in developing countries, for example, a black sole or no
toes, and feet that look more natural than what is currently available. It could be
argued that by giving the children a xed toolset, we narrowed their ability to
envision other types of prosthetic legs or assistive devices that they would like to
have. However, the aim of the exercise at this stage of the project was not to generate
design ideas for new types of prosthetic legs or assistive devices. Earlier interviews
and exercises had catered for more open-ended responses (Hussain 2010, 2011),
whereas at this stage we wanted to seek deeper understanding of childrens aesthetic
concerns and needs related to the type of product they were currently using.
Siya
In the rst visit, Siya named her doll Ly Ching. She looked carefully at the short
yellow dress but ended up choosing the long yellow dress instead (Figure 4). She
explained that she liked the colour and wanted a dress that covered her prosthetic leg
because she felt shy when people looked at her prosthesis. She selected a cosmetic
cover matching the dolls skin colour and a foot with dened toes and nails in the
same colour. Siya explained that she had not chosen the other feet because one had a
black sole, as did her own prosthetic foot, another one did not have toes, and one

Figure 4.

Siyas rst selection of clothes and prosthesis for the paper doll.

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59

foot lacked nails. With regard to the pale colour of the cosmetic cover of her own
prosthetic leg, Siya commented: I feel shy because the two legs have dierent
colours.
At the next visit, in August 2010, Siya chose another doll and gave it her own
name (Figure 5). It is dicult to know why she wanted to use her own name this
time. A possible explanation could be that she now felt more comfortable speaking
about herself and her feelings. She explained that she still did not dare to wear short
skirts or trousers to school: I do not have the heart [emotional courage]. However,
when she was at home or in the village she did not care if anyone saw her prosthetic
leg because they all knew that she had a disability (Figure 6). When going to the
market, on the other hand, she would always cover her prosthesis. She selected the
same cosmetic cover and foot as in the previous visit and repeated that it was
important to her that the prosthesis matched her own skin tone and had naturallooking toes. The cosmetic cover she had now was made of a soft foam that wore out
rapidly. Siya explained that she felt the appearance of the cover made it look like she
had a skin disease (Figure 7).
Vannak
Vannak named his doll Nara and dressed it up with an orange T-shirt, green shorts,
an orange cosmetic cover and a natural-looking foot. He explained that he had
selected the foot because it had a dark colour that matched the colour of his skin and
had dened toes and nails. I would choose the one that is the same as a real foot and
strong. He also explained that he preferred to wear long trousers at school, but
when playing with friends it was more comfortable to wear shorts: I also feel shy
when at school. I dont often wear short trousers. But its okay with my friends
because they know my condition. So I like to wear short trousers [when I am with

Figure 5.

The second time, Siya chose these clothes for wearing to school or to the market.

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S. Hussain and E.B.-N. Sanders

Figure 6. When at home or in her own village, Siya did not mind that other people could see
her prosthetic leg.

friends] because its not stuy (Figure 8). At school the boys uniform had long
trousers.
Vannak was asked to dress Nara with clothes that would be appropriate for
going to the market in the village. Vannak selected brown, long trousers and
replaced the orange cosmetic cover with one with natural skin colour (Figure 9). He
explained this replacement:
Vannak: Because that one looks similar to the real leg so other people will not know this
when they look at me.
Interviewer: So why is it important for you that people in the market dont see your
prosthetic leg?
Vannak: I feel ashamed.

When at home or working around the house, Vannak said that he would prefer to
wear shorts and have a cosmetic cover with natural skin colour. But at school he
would like to have an orange cosmetic cover: When going to school, we wear [long]
trousers and we only need to cover this a little bit [. . .] Because it appears [to have]
only a little colour and it looks nice (Figure 10).
In the follow-up interview, Vannak told the designer that he had changed his
view on when to wear short trousers. Now he felt that it was okay to walk with short
trousers in the village because everyone in his village knew him and that he used a

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Figure 7.

61

Siyas prosthetic leg.

Figure 8. In the rst interview, Vannak said that he prefers to wear shorts at home, but
otherwise he feels more comfortable with long trousers.

prosthetic leg, whereas when going to the market he did not feel comfortable
revealing his prosthesis. This time, Vannak selected a cosmetic cover with a natural
skin colour. He explained that if he could have several cosmetic covers, he would
prefer to have one with a bright colour also, but since the non-governmental

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Figure 9.
market.

S. Hussain and E.B.-N. Sanders

In the follow-up interview, Vannak selected these clothes for wearing to the

organisation only gave him one prosthetic leg at a time he would prefer to have one
that he could use in all situations.
Sockeat
Sockeat chose the name Lucky for his doll and dressed it up with a blue shirt, brown
long trousers, a purple cosmetic cover and a prosthetic foot with a black sole and no
toes and nails. He explained that the clothes resembled some clothes he had himself.
He liked the colour purple and chose the foot because he believed it was lighter in
weight than the other ones. His current prosthetic foot also had a black sole but
grass and mud got stuck between the toes. He therefore felt it would be better to have
a foot without toes. In earlier interviews, Sockeat had emphasised that he wanted a
prosthetic foot with natural-looking toes, but he explained that he had changed his
view.
Sockeat said that he only wore short trousers at home; When wearing long
trousers, [it is] easy to walk and nobody can see our leg (Figure 11). He explained
that people talked about previous lives when they saw his prosthetic leg; that he must
have been a soldier and laid out land mines in a previous life to deserve this fate in
this life. Sockeat belongs to an ethnic minority (Chams) who are not Buddhists and

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Figure 10. Vannak explained that if he could have two prostheses, he would like to have one
with an orange cosmetic cover and one that looks more natural.

Figure 11. Sockeat said that he wore long trousers when he was not at home to cover up his
prosthetic leg.

do not believe in karma and regeneration, but 95% of the population in Cambodia
are Buddhists. Even though Sockeat would have liked to cover his prosthetic leg
when he was not at home, he said he preferred to have a purple cosmetic cover:
Because I like it.
During the next visit, in August 2010, Sockeat conrmed that he still did not like
to be outside the house without his prosthesis covered because people said he had
probably done bad things in his previous lives. This time, Sockeat chose the same
doll and clothes as previously but he selected a cosmetic cover decorated with owers
and a prosthetic foot with a black sole and natural-looking toes with dened nails
(Figure 12). When asked about why he had selected another foot this time, Sockeat
said that although he had thought last time that it would be easier to walk with a
prosthetic foot without toes, he now felt that it was important that his prosthesis had
toes and nails.

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S. Hussain and E.B.-N. Sanders

Figure 12.

5.4.

At the next visit, Sockeat chose a cosmetic cover with owers on it.

Day description

The children were given a set of drawings and words and asked to use these, or create
their own, to describe their everyday activities (Figure 13). Two types of timelines, a
straight line and a circular one, were provided, because we were uncertain about how
time is perceived in Khmer culture. All the children chose the linear timeline. They
were asked to put positive events or activities above the timeline and those that were
associated with negative feelings below the line.
Siya
Siya explained her daily activities through drawings and text (Figure 14). She went to
school in the morning, came home, took o her prosthesis and changed clothes
before taking a nap. Then she did the dishes, fetched water from the well, washed
clothes, boiled rice and cooked dinner. In the afternoon she went to English classes.
She did not do all of the household chores every day, but if her mother was out
working, then she had to do them.
Under the timeline, Siya had drawn a tailors shop. She had placed the drawing
here since the timeline was too short. This drawing did not show something she did
now, but something she hoped for in the future; to have her own tailors shop and
learn to sew clothes. She had also drawn herself and her mother collecting rewood.
She explained that this was the only thing she did not like doing because it was heavy
work. She had never carried the wood herself, but she could tell that this was hard
for her mother to do. Still she emphasised: Even though number 10 [drawing
marked with 10 on Figure 14] is really dicult, it provides benets for cooking; if we
do not have wood, we cannot cook rice.

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Figure 13. The day description toolkit (the English words were translated into Khmer in the
toolkits that the children received).

Figure 14.

Siyas day description.

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S. Hussain and E.B.-N. Sanders

Siya put all her activities in sequence, but she did not distinguish between good
and bad things. To admit that there might be things that she did not enjoy doing
seemed dicult for her. She had a very pragmatic view on what she had to do: If I
dont wash the dishes, I will have no dishes for eating; If I dont do this [getting
water from the well], I will have no water for cooking rice. She was therefore asked
to put numbers on the drawings indicating what she liked to do the most (no. 1) and
what she liked to do the least (no. 10). In this way, it became possible to have a
conversation about what she perceived as being most important to her. Going to
school and studying were the things Siya enjoyed the most. In addition, it was
important to her to take o her prosthetic leg to clean the stump and air the
prosthesis (no. 3) to get rid of bad smells that people might otherwise notice.
Vannak
Vannak informed us that during a typical day, he rst took the cows out for grazing,
then he collected cow dung, fed the pigs and cleaned the pigpen before cleaning the
yard and the house. Then he rode his bike to school. After school, he fed the
chickens and worked in the rice elds. When all his work had been completed, he
played with his friends and dog (Figure 15). Vannak had not placed the drawings of
his activities in sequence on the timeline and was therefore asked to put numbers (in
black on Figure 15) next to the pictures to show the order of his daily activities.
Vannak explained that he did not like lightning it scared him and he therefore
put this drawing under the timeline. He placed the drawing of working in the rice
elds close to the timeline to show that this was not something he liked to do very

Figure 15.

Vannaks day description.

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much. However, he did not place it under the line because it was not something he
did not like doing but something that he liked [. . .] but only a little. It was dicult
to make Vannak talk freely about activities that did not give him positive
associations. For Vannak it was a matter of course that he had to do his share of
household chores; it did not seem to make sense to him to reect upon whether he
liked to do this or not. Therefore, he was asked to use numbers (in orange on Figure
15) to rank activities according to what he liked the most. He selected playing with
friends as number 1 and wrote happy underneath the drawing. Under the drawing
of the pig and the cow Vannak wrote: Want money from it. For Vannak the
prospect of earning money for his family was a valid reason for liking to take care of
the animals.
Sockeat
The rst time we carried out this activity with Sockeat, it was very dicult to
understand the order in which things happen. He was asked to put numbers next to
each activity, but in the follow-up conversation it remained unclear whether the
numbers indicated the order of the activities or how much he liked doing them.
Sockeat had also selected several drawings that he liked, but which had no relation
to his daily activities. Therefore, the designer made a new attempt at conducting this
exercise during the next visit. This time, Sockeat was asked to cut out words and
drawings (or make his own) and put them on the timeline without gluing them. In
addition, he was not told to distinguish between good and bad things. Sockeat
seemed to understand the concept, but further out in the timeline things started to
become quite cluttered (the line should have been much longer to give enough space
for all the drawings). We therefore had to ask him again to use numbers to show us
the sequence of his activities (Figure 16).
Sockeat explained that the rst thing he did in the morning was to put on his
prosthetic leg and feed the chickens, then he looked at his watch and got dressed to
go to school. At school, according to Sockeat, he always got the best results. When
he came home from school, he took a bath, changed his clothes and had a meal.
After this, he went to worship in the mosque. Then he had lunch and did his
homework (no. 5 in Figure 16). Some days Sockeat played football after completing
his homework (no. 6), and he gave water to the cows when he came home from
playing. Sockeat usually took a nap in the middle of the day and read a book,
newspaper or magazine when he woke up (no. 8). Then he had his dinner (no. 9) and
drank some hot water. He watched television for a while, but kept an eye on his
watch (no. 11) so that he would know when to return to studying. Sometimes he also
played with his younger niece and nephew while watching television or after
completing his homework. After this, he went to bed. The dog watched over the
house during the night and prevented thieves from breaking into their home.
Sockeat included some pictures in his day description that were not about his
daily activities but communicated various aspects of his life and things he hoped for.
He had added a drawing of a tuk tuk (motorised rickshaw) because he liked it. He
also included a drawing of a motorbike and explained that he wanted to have a bike
to make it easier for him to get to school but that he could not aord to buy one. He
had selected a picture of his own house placed on poles and a picture of a home
without poles. He explained that the house without poles was made of concrete and
not of wood as is his own home. The drawing of working in the rice eld was

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S. Hussain and E.B.-N. Sanders

Figure 16. Sockeats day description. (Sockeats real name has been removed from the
middle of the picture.)

included because Sockeat took part in this work in the mornings during the farming
season on Sundays and other holidays when he did not have to go to school. The
drawing of the bird showed his bird Lork Lork.
Sockeat was asked to choose a coloured pencil with his favourite colour, and one
with a colour that he did not like very much. Sockeat selected blue and yellow. He
put a blue dot next to the things he liked, and a yellow dot next to the things he was
less fond of. Sockeat explained that he liked his prosthesis because it enabled him to
walk. He liked feeding the chickens because he knew that his family would get more
money when selling them if they were fat. He also liked the cow because it helped his
family with ploughing in the elds and transporting rewood. He liked his watch
because it helped him to be organised. He liked his teacher because she always
explained if there was anything he did not understand. He also liked the drawing of
the house that resembled his own one. But he hated the other house because it was
made of bricks and was therefore expensive: I hate it because I dont have the
[economic] capacity to build it. About working in the rice elds, Sockeat said: I like
the rice eld. It is where [we] can harvest corps and we can all eat. The dog was given
a yellow dot because it could not be eaten; also, Sockeat did not like that he could
only see the crescent for Eid (Muslim holiday) once a year.
5.5. The childrens experience of being project participants
At the nal visit during the third eld study, all three children were asked about how
they had experienced being part of the research project. Siya found it dicult to talk
about taking part in the project in general. Instead, she focused on the activities she

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had done with the designer on that particular day. She had liked cutting out
prosthetic legs and feet for the paper dolls but she had not enjoyed colouring the
drawings in the day descriptions. She explained that she felt that the drawings
sometimes did not look good after she had coloured them. She also said that some
questions during the interviews had been dicult to answer, although she could not
remember those questions now.
Vannak said that he liked talking about his feelings because it made him think
about the future and plan for changes. In previous interviews, he had drawn a
chicken farm and explained that he hoped to have a farm in the future (Hussain
2010). Realising that this is what he wanted to do when he grew up, he had decided
to buy some chicken to breed them. Unfortunately, the chickens became ill and died.
Nevertheless, Vannak had felt encouraged to try to do something that could improve
his future. He also said that during the interviews some questions had made him feel
shy and others had been dicult to answer. The dicult questions made him
nervous, whereas the fun exercises, such as the role play carried out in the second
eld trip (Hussain 2010), made him feel happy. He still claimed that taking part in
the research had raised his condence in his own abilities: Because if I talked with
you, it made me brave . . . dare to talk to other people [. . .] For example, before I
didnt dare to speak to other people, but now I dare to speak with them.
Sockeat said that it had raised his status in the local community that we had
come to talk with him: People admire me: Hey boy, you have people come to
interview you! [. . .] You are like this [disabled] but have other people to interview
[you]. He also felt that his participation in the research has made him stop
worrying about the future: Before you came to interview me, I felt sad and worried
but now you are here; I feel happy not worried any more. Sockeat said his
participation had made him more articulate and forced him to reect upon issues:
Before I have never been interviewed but now I am being interviewed so the way I
speak is making progress. [. . .] Because you ask me new questions and I also try to
think and solve [answer] your questions. [. . .] My thinking is making progress.
Sockeat insisted at rst that none of the questions during interviews had been
dicult. However, he explained later that if the designer had given him examples or
some alternatives for answering questions it would have been easier for him to reply.
For example, instead of asking How do you feel about taking part in the interview?
it would have been better to ask How do you feel about taking part in the interview?
Do you feel happy, worried, or do you feel bored?
When children are given questions or research activities that are perceived as
being too dicult, it can have a negative eect on their self-esteem. Designers should
try to challenge child participants, but children may feel disappointed or discouraged
if they are not able to answer or complete tasks. It is therefore necessary to nd a
balanced approach adapted to each childs abilities and development. Generative
design tools allow for high levels of exibility, but designers have to make sure that
they set aside enough time for getting to know the children, to understand how the
tools should be adapted and how questions should be asked.
In qualitative research interviews, open-ended questions are encouraged (Kvale
1996). However, this project found that the children felt that it was dicult to
answer such questions and appeared to become nervous if there were many questions
they could not answer. It was therefore decided always to start interviews with some
simple, closed-ended questions. In addition, when children seemed to be struggling
during interviews, some simple yes/no questions were asked before returning to the

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S. Hussain and E.B.-N. Sanders

more challenging topics. This was experienced as a good way of making children
relax and provide richer information when going back to the dicult topics. Our
experiences correspond with Irwin and Johnsons (2005) recommendations based on
interviews with young children in Canada. Sockeats suggestion about providing
alternatives for answers as a means of clarifying the questions is also supported by
Irwin and Johnson (2005).
5.6.

The researchers reections on working with the children

The use of generative design tools gave us valuable insights into the lives of the
children. During previous visits, the rst author had tried to encourage the children
to talk about aesthetic preferences and self-image. The children had all emphasised
that they wanted prosthetic feet that looked like real feet (Hussain 2010). However, it
had been dicult to dig deeper into these somewhat abstract and sensitive issues.
The children seemed afraid of criticising the prosthetic legs they received free of
charge from a non-governmental organisation. The use of dolls gave the children a
distance that made it easier to admit that they wanted something other than what
they were currently receiving. The toolkits also made it easier for them to envision
cosmetic covers and prosthetic feet that were dierent from those of their current
prostheses. Whereas none of the children had previously said that they wanted a
cosmetic cover with a bright colour or a decorative pattern, Sockeat now wanted a
purple cover or one decorated with owers, and Vannak selected an orange cover in
addition to one that looked more natural.
During the rst eld trips, children were asked about their daily activities.
Through interviews and observations, the designer had a general picture of what the
children normally did during a typical day. However, the day description toolkit
made it easier for both the designer and children to communicate about their
activities in a more structured way, although only Siya was able to structure her
activities in the right order. In previous research, children had made drawings of
things they hoped for in the future (Hussain 2010). Both Siya and Sockeat
incorporated things they wished for in their day descriptions. This indicates that they
had reected upon their current situation and future plans since the last visit, and
wanted to tell the designer more about things they needed or wanted to do.
An important part of succeeding in using generative design tools with children
has been to make them believe that they have something to oer; that their thoughts
and ideas matter. The notion that children with disabilities and poor villagers have
limited intellectual abilities seems to be quite common in Cambodia. Before
conducting interviews in June 2009, we asked community leaders for permission to
carry out research in their areas. One of the community leaders was astonished that
we wanted to talk with villagers. He explained that they were poor people without
much education and probably would not be able to give us any useful information.
During an interview, one of the kru khmer kept turning towards his family members
and saying, surprised: They have come to interview me! Income and wealth play an
important role in the Cambodian social hierarchy. Poor people and people with
disabilities have low social ranks in this system. This is related to Buddhist beliefs in
karma, as further explained in the next section. Generally, older people are more
respected and have a higher social position than younger people. The children
participating in the eld study were therefore facing discrimination because of their
economic status, their disability and their age. The designer was acting in conict

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71

with cultural norms by showing interest in their lives, thoughts and opinions.
Although this seemed to be highly appreciated by both parents and children, it was
only natural that it took some time before the children got used to being project
participants. Both Vannak and Sockeat said that they now felt more condent in
talking about their perspectives, and Vannak also reported that he was becoming
better at talking with new people who he met.4
During the research process our preunderstanding related to several aspects
changed. For instance, the literature had painted a grim picture of the social position
of Cambodian children with disabilities within their families: children were
discriminated against by family members and possibly also kept away from the
community because of the stigma associated with having a disabled child. Although
there may certainly be children who are in this situation, the children the designer
met were all cared for and supported by their families. The parents showed extra
concern for the education of the children and their future because of their disability.
The rst author has previously worked with prosthesis users in India and Nepal
(Hussain and Keitsch 2010). In these countries, it was discovered that the leather belt
used for attaching the prosthetic leg to the residual limb caused social exclusion,
since in Hinduism all animal products are seen as impure. Hence, prosthesis users are
not allowed to enter temples and sometimes also expelled from private homes. Based
on this earlier research, we had expected to nd cultural aspects that could have a
direct impact on what are considered appropriate materials for prostheses in
Cambodia. However, in Cambodia religion seems to be less inuential than in India.
Buddhist monks in Cambodia, for example, do eat meat even though this is
discouraged in Buddhism. The violent history of the country and the cultural chaos
and poverty that followed made it necessary for monks to take a pragmatic approach
in interpreting religious doctrine (Kent 2009). The links between materials and
religion are therefore not as strong as might be expected.
We had initially thought that the children would like to have prostheses in other
colours than skin tones or with colourful, decorative patterns and that this could
help them become less self-conscious about their disability and feel better about
having a prosthetic leg. Sockeat and Vannak selected prosthetic covers with bright
colours and/or patterns. Vannak, however, later pointed out that if he could only
have one prosthesis, it would be better if it looked like a natural leg so he could use it
in all situations. All the children focused more on the appearance of the foot than on
the cosmetic cover. They did, nonetheless, emphasise that if the cosmetic covers had
a natural skin tone, it should match with their own skin colour so that both of their
legs look similar.
We have reached a new understanding regarding the issues of working with
children. At the beginning, we thought that the biggest challenge in conducting
participatory research with children would be to make adults appreciate childrens
input and allow their voices to be heard. However, it soon became clear that seeking
childrens opinions was not simply a case of visiting them, providing them with
materials to work with and asking about their ideas. Rather, the challenge was to
nd ways to make it possible for the children to feel comfortable in expressing their
views.
It was challenging to nd good ways of giving feedback to the participants about
how their responses had been interpreted. In the day description exercise, the
designer asked for and claried responses during the interviews. This method was
chosen since we already had a good understanding of the childrens usual activities,

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S. Hussain and E.B.-N. Sanders

and no major contradictions to earlier responses were found. The method was
eective, but it did not give the children a chance to comment on the results from
deeper analyses of their collages and explanations. In the case of the paper dolls task,
the designer returned after transcribing and analysing the interviews. The main
problem was that four months had elapsed since the last visit and the children no
longer remembered their responses. It is recommended that feedback sessions are
conducted as soon as possible to avoid this problem. Another challenge was that
whenever children were asked about the same issues several times, they seemed
uncertain about why the question was repeated, even though the designer tried to
reassure them that it was only to make sure that their answers were correctly
understood. There will always be a risk of children changing their responses just
because they believe that designers are repeating questions since their previous
responses were wrong or not good enough. In addition, children who are
constantly learning and developing often change their opinions, and when
confronted with this they may feel that there is something wrong with altering ones
view. We therefore believe that it might have been a better solution, in this case, if we
had found new exercises that could have supported and claried the knowledge
gained through previous research tasks, rather than to repeat tasks, questions or
answers given by children.
6. Understanding childrens responses in the context of social and cultural aspects
Through the use of generative design tools, we learned that the children were
concerned about the appearance of their prosthetic legs. Whether or not they wanted
their prostheses to be covered depended on the situation. For Vannak and Siya, the
home and the village were places where they did not feel concerned about other
people seeing their prosthesis, whereas Sockeat preferred to cover his prosthetic leg
in all areas except for at his home. The exercise with paper dolls showed that children
were very concerned that the toes and nails of the prosthesis should look as natural
as possible. The upper part of the prosthetic leg can be easily hidden by clothes, but
the foot will usually be visible since people in rural areas often walk without shoes or
in open sandals.
The day description exercise showed that the children performed many activities
for their families throughout the day. Many of the chores were labour intensive,
requiring prosthetic legs that are durable. The children spent more time outdoors
than children in Western countries, working in rice elds and taking care of animals.
This often involves walking in mud, especially in the rainy season, which lasts from
May to October. In earlier research (Hussain 2010), children pointed out that getting
their prosthesis stuck in mud and water entering the socket interfered with their
ability to take part in income-generating activities such as catching sh and
cultivating rice. Designers and engineers need to be aware of the lifestyle of rural
children in developing countries and strive to support it when making decisions
about prosthetic appliances.
In accordance with the general principles of philosophical hermeneutics
presented in Section 3, the information gained through analysis of one part of a
project should subsequently be viewed in the context of a bigger picture. The
childrens strong emphasis on aesthetics is not linked to vanity but can be
understood by investigating cultural health beliefs. In earlier stages of the project,
parents of children using prosthetic legs, traditional medicine men (kru khmer) and

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73

Buddhist monks were interviewed about cultural beliefs regarding disability

(Hussain 2011). In Buddhism, a persons condition in this life is seen as a
consequence of the individuals deeds in previous lives. Through doing good deeds a
person builds up merit (karma). Good health, material goods and many children are
all indicators of good deeds in previous lives. A disability, on the other hand, is seen
as a result of sins and bad deeds done in former lives. Sockeat explained that he
usually covered up his prosthetic leg when not at home, because people would make
remarks about the possible sins he might have committed, such as being a soldier or
putting out land mines. In this cultural framework, when people see someone who
uses a prosthetic leg, they see not only a person with a disability but a sinner who has
deserved his or her fate. It is within this worldview that we have to understand why
children ask for prosthetic legs that have natural-looking feet and cosmetic covers
that match their own skin colour. The visual appearance of the prostheses may have
direct implications for how children are treated and their possibilities for being
integrated in their local communities. Even though we did not nd any connection
between material preferences and religion, there is a strong link between aesthetic
needs and religious beliefs.
The day description exercise showed that children do a lot of work inside and
around the home. From a critical theorist viewpoint it may be perceived as negative
that children are forced to work long hours. However, designers should respect
customs in other countries and create solutions that support their culture. The fact
that children were reluctant to talk negatively about the tasks they had to do should
not be uncritically linked with oppression, but has to be understood in the context of
Buddhist beliefs and Khmer society. In Buddhism, individuals are encouraged to
accept their fate and show gratitude for the things they have. Having a cow or a pig
that can provide an income was seen as a blessing by the children. To complain
about tasks that have to be done for the well-being of ones family goes against
Khmer values. The smiley faces did not seem to be symbols that the children could
relate to, and the children did not want to admit that there was anything that they
did not like doing. The designer therefore had to rephrase her question to: What are
the things you really like to do and what are the things you that you like to do but
not as much? In traditional Cambodian culture children are expected to show
complete obedience towards their parents (Miles and Thomas 2007). Children are
not encouraged to nd their individual identity in the same manner as children in the
West: Knowing oneself means knowing how to behave properly according to ones
status within the family and community; with self-knowledge, one would be aware of
social obligations and would accept responsibility for ones actions (Smith-Hefner
1999, p. 94). This ts with attitudes reected in the responses of Siya, Vannak and
Sockeat in the day description exercise; it is their social responsibility to help their
family. Poverty is widespread in Cambodia and 35% of the population is below the
poverty line (United Nations Development Programme 2009). The families that we
visited lived in basic houses without water or electricity. Each family member had to
contribute to the household. It is important for the self-esteem of children using
prosthetic legs and their social position in their local communities that they are able
to take on responsibilities in a similar manner to other children in their communities.
There are many situations where it can be challenging to respect culture and local
norms, for example, when interviewing people who clearly express negative views
about people with disabilities.5 However, researchers and designers cannot expect
interviewees and participants to give them insight into their cultural beliefs if they

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S. Hussain and E.B.-N. Sanders

display a judgemental attitude. It is important to listen to people and try to

understand (but not necessarily agree with) their position in the context of their
culture, society and history. The key to changing discriminating attitudes is to
understand the deeper, interconnected structures of such attitudes. In India, for
example, it was discovered that dierences in the colours of the upper part and foot
of a prosthetic leg contributed to discrimination since people sometimes misinterpret
this as a skin condition called vitiligo, which leads to depigmented patches on the
skin. Vitiligo is falsely believed in some rural areas to be contagious and therefore
prosthesis users experience people avoiding them if they are seen at a distance where
it is not clear that they are wearing a prosthetic leg. Changing attitudes should
therefore relate both to designing prostheses where all parts have the same colour,
which also matches the users skin tone, and to educating people about vitiligo
(Hussain and Keitsch 2010).
7.

The pyramid model

The process of understanding how prosthetic legs for children in Cambodia should
be improved has been a long journey. We had to start by learning about Cambodian
religion, culture and society through the literature. Knowing the dramatic history of
the country was important for understanding the current society and culture. The
next step was to understand how the rehabilitation sector in Cambodia is organised.
The designer had to learn about the non-governmental organisations providing
rehabilitation services and assistive devices to people with disabilities and their cooperation with the government. Through Khmers working in the rehabilitation
sector, the designer learned about social codes for communication with people.
Cambodia is a society with a clear hierarchical structure. Elders must be respected
and there are certain rules for how women should behave. People are greeted as
family members, e.g. older sister, grandma or uncle. Although such rules are
becoming increasingly less important in urban areas, they are still important in rural
areas. They are also still valued in cities. Learning such codes turned out to be the
key to getting to know the Khmer people. From people working in the rehabilitation
sector, the designer received advice on how to approach users and their families
living in provincial areas. Initially, the designer tried to interview children at schools
and clinics but found that the children seemed very uncomfortable in this setting and
did not provide any insight into their situation (Hussain 2010). The designer was
then advised by local prosthetists to visit the children in their homes and conduct
interviews there. The rst visits were made together with a prosthetist hired as a
translator and a community worker who already knew the children. By arriving with
familiar people, the designer gained peoples trust and was given access into the
users homes. Interviews with prosthetists and physiotherapists gave us a basic
understanding of the predominant problems with the prosthetic legs (high weight
and low durability) but it was through communicating with users and their families
that a deeper understanding of the implications of prosthesis use for children was
developed.
In philosophical hermeneutics, history serves as an important part of the context
(Prasad 2002). Acquiring knowledge about history is also seen as key to this
research; the history of the country and its people, the history of the development (or
lack of development) of the rehabilitation sector and peoples personal histories were
investigated. Many of the conversations with the rehabilitation workers and ICRC

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75

employees were about the period of the Khmer Rouge and how it has aected all the
institutions of society. Knowing the history of the country was therefore essential in
getting to know its people.
The pyramid model in Figure 17 shows the layers that led us to the understanding
of the users needs. The designers personal journey through these layers resulted in
the acknowledgement of latent, tacit user needs that would not have been recognised
in a positivistic oriented design process and might have easily been dismissed as mere
unimportant, aesthetic concerns.
The pyramid model is grounded in the epistemology of philosophical
hermeneutics. It promotes an approach to design that is neither product centred
nor user centred but focused on seeking understanding in context. In each project,
designers have to dene their own layers. The journey through the layers is not
linear, since new understanding of one layer will always alter understanding of other
parts of the pyramid. Designers can work across layers and explore several layers of
the pyramid at the same time. By being conscious of the intangible product aspects,
the model encourages them to see design decisions in a wider context. By keeping an
open mind and communicating with participants, designers can broaden their
perspectives. Generative design tools can facilitate communication with participants
and facilitate their ability to express ideas about the future. The knowledge gained
through this process is not a reection of the views of only the designer or the
participants but a fusion of horizons.
Communication with the children made it clear that the appearance of the
prosthetic foot was a concern and had implications for how they were treated by
others (Hussain 2011). It was therefore decided to redesign the prosthetic feet

Figure 17.

The pyramid model.

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S. Hussain and E.B.-N. Sanders

Figure 18. The new foot (on the left) has a shape and toes that look more natural than the
old one (on the right).

produced by the ICRC in Phnom Penh for children. A local sculptor was asked to
develop models of feet in clay, with an emphasis on making the toes look natural.
Prosthetists at the ICRC modied the clay models to make sure they fullled
technical requirements of prosthetic feet before they were used to create aluminium
moulds for producing rubber feet. The designer also made changes to the internal
components of the rubber foot to improve the products biomechanical properties.
The emphasis on the aesthetic user needs was grounded in the contextual
understanding of what it means to have a disability in Cambodia. In a positivistic
informed design project, the focus would typically have been on nding ways of
enabling children to walk longer distances by improving the biomechanical
performance of the foot. This was also given a high priority in this project, but
the designer placed equal emphasis on aesthetic issues since, during the journey, as
revealed in the layers described by the pyramid model, she had learned how
important the appearance of the foot is to the users.
Eight children who were new to the project tested the old and new prosthetic feet
(Figure 18) at the ICRC-supported rehabilitation centre in Battambang. They were
then asked to choose which of the two prosthetic feet they would like to have. All of
the children chose the new foot and said that it was important to them that their
prosthetic feet looked good in addition to being comfortable to walk with.6 Further
work should look into inexpensive ways of providing feet and cosmetic covers in
dierent shades, as people in Cambodia have dierent skin tones.
8.

Conclusions

The eld study demonstrated the use of generative design tools to facilitate the
involvement of the children from rural areas of Cambodia in the design process
for prosthetic legs. This process turned out to be quite a challenge. The children
did not answer open-ended questions, they did not share their feelings about their
daily tasks and they initially had diculty expressing their dreams for the future.
The pyramid model describes the broader and deeper layers of contextual
understanding that were needed for the authors to make sense of these and other
ndings.
In conclusion, we oer a reection on some of the guiding principles of
philosophical hermeneutics and co-designing with generative design tools.

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77

. All people are creative. In Khmer culture, children are not encouraged to
discuss or develop critical or creative skills at home or at school. It took a
number of visits and preparatory sessions to establish a relationship with them
before their creativity could be revealed.
. All people have dreams. These children are not usually asked about their
opinions, thoughts or feelings, and certainly not about their dreams. The
designer asked them to describe their dreams in earlier interviews during
the rst and second eld trips to Cambodia. Eight months after the last
visit, their dreams emerged, unprompted, in the day description exercise.
One of the children had taken action in beginning to full his dreams as
well.
. Designers should reect upon their preunderstanding and how it evolves
throughout the project. It is important for the members of a design research
team to share their preunderstandings with regard to the choice of research
paradigm so that there is agreement from the start about why users are being
involved in the process and what types of tools and methods can best be used
to facilitate that goal. It is also important for the members of the design
research team to observe and iteratively reect on their learning process so that
they are able to dene and explore the multiple layers of understanding needed
to make relevant and useful design decisions.
. Understanding appears through the fusion of horizons of participants and the
designer. Researching from a philosophical hermeneutics approach establishes
a relationship between the designer and the participant. In the eld study, both
parties learned and grew in this relationship. The children grew in their selfcondence and ability to express their thoughts, opinions and feelings. The
authors grew during their journey in their ability to see and to understand the
larger contextual domains that are necessary for designing with children from
developing countries who have special needs.
Acknowledgements
We would like to thank the Norwegian University of Science and Technology for
funding the eld visit and the International Committee of the Red Cross for
supporting the development and testing of new prosthetic feet.
Notes
1.
2.
3.
4.

5.
6.

This paradigm is also referred to as constructivism and hermeneutics (Denzin and Lincoln
2005).
Guba and Lincoln (1994) claim that there are at least three forms of critical theory:
poststructural, postmodern and a blend of these two.
These are not the real names of the children.
Later in the project, researchers returned to the children and asked them for suggestions
on how to improve some prototypes of products that could make it easier for prosthesis
users to walk in mud. All three children gave valuable suggestions about what could make
the prototypes better. This was far beyond what we had expected from them based on
earlier struggles with getting responses. It shows that the children had gained more
condence in themselves and were becoming more comfortable with articulating their
views.
This happened several times during the project (see Hussain 2011).
The test results of comparing childrens gait when walking with the old and new prosthetic
foot will be presented in later publications.

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S. Hussain and E.B.-N. Sanders

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