Designing for honest disclosure

The lung health check service helps people understand their risk of lung cancer based on their smoking history and other health factors. A phone-based service was already running when a digital version was commissioned, offering people a more flexible, private way to complete their risk assessment.

When I joined the team, two versions of a digital prototype had already been built and initial research conducted with around 30 participants. My role was to deepen the behavioural understanding of how people respond to the service, make sense of what had already been learned, and test the service end-to-end with real users in a lab setting for the first time.

Understand whether people would disclose their smoking history honestly in a digital environment and whether the service was designed in a way that made honest disclosure possible. Evaluate the prototype against real user behaviour and inform what needed to change before the pilot launched.

• Synthesised 42 user needs into five memorable themes mapped across the patient journey : presented to clinical teams who engaged more deeply with patient experience as a result
• Introduced Pew Research on modes of responding:  framing the team's thinking about why phone and digital environments produce different disclosure behaviours
• Led shisha research end-to-end:  from pop-up research at screening sites through snowballing to specialist agency engagement
• Surfaced that users were self-moderating because they couldn't see how many questions were coming an insight that informed subsequent interaction design decisions
• Planned and led the first end-to-end lab prototype test with real users
• Worked with a data scientist to define what the pilot needed to measure quantitatively and designed the qualitative complement; enabling a mixed methods approach to pilot evaluation

Designing for sensitive disclosure
Smoking history carries shame, guilt and judgment for many people. The service needed to feel safe enough for honest answers: not clinical, not interrogative, not judgmental.

Inclusive design across varied literacy and digital confidence
The service needed to work for people with low health literacy, low digital confidence and varied accessibility needs not just the assumed average user.

Balancing clinical safety with usability
Every design decision had to be clinically safe as well as usable. These two requirements sometimes pulled in different directions and required careful navigation across clinical, design and research teams.

Regulated environment
Building a digital health service within NHS regulatory frameworks meant research findings had to be actionable within real constraints; not just theoretically sound.

Joining a project mid-flight
Two prototype versions already existed and research had already been conducted. My role required building on what was there, not starting over — while still bringing fresh eyes to what hadn't yet been questioned.

People who smoke shisha described it very differently from cigarette smoking. Social. Seasonal. Not harmful in the same way. Some only smoked on holiday or in summer,  making questions about "how long have you smoked" almost impossible to answer accurately.

When we tested a redesigned eligibility question, listing specific tobacco types including shisha, rather than just asking "have you ever smoked?" something changed. Users who wouldn't have previously identified as smokers began to recognise themselves in the question.

But the research also revealed where the redesign still fell short. Asking whether someone had smoked shisha "for 1 year or longer" confused people with episodic use patterns. Someone who smoked heavily over a summer but not across a continuous year didn't know how to answer. We were still missing people with meaningful exposure because our questions assumed consistent behaviour that episodic shisha use simply doesn't follow.

The main point was clear: shisha is not just another tobacco type that can be slotted into an existing journey. It involves different mental models, different patterns of use and different expectations. If the service was designed only around cigarette smoking, it would continue to miss an entire group of people with genuine lung cancer risk.

Making sense of existing knowledge
The team had identified 42 user needs across the project. I synthesised these into five memorable themes mapped across the patient journey, exploring whether needs were hierarchical or mutually exclusive. I presented this framework to clinical teams, who engaged more deeply with the patient experience as a result. The framework gave them a new lens on how users moved through the service.

Behavioural research on mode and disclosure
I introduced the team to Pew Research on modes of responding,  an external evidence base that framed our thinking about why phone and digital environments produce different disclosure behaviours. I then designed the mixed methods approach, working with a data scientist to define what the pilot needed to measure quantitatively and designing the qualitative complement that would explain the numbers. She led the quantitative analysis; I led the qualitative and brought both strands together.

The shisha research 
I led this from initial discovery through to service change. Starting with pop-up research at screening sites, I recognised that shisha smokers had a fundamentally different mental model to cigarette smokers. I extended the research through snowballing and eventually engaged a specialist agency to reach shisha-smoking communities. The finding that the mental model of shisha smoking didn't match how our questions were framed, became the central insight that changed the service.

Surfacing the self-moderation insight
Research sessions I led revealed that users were self-moderating their answers because they couldn't tell how many questions were coming. This surfaced a structural issue in how the questionnaire was sequenced  and informed subsequent interaction design decisions made by the interaction design lead.

First end-to-end lab prototype testing
I planned and led the first full end-to-end prototype test with real users in a lab setting : the first time the complete service had been experienced by real users from start to finish. This gave the team a complete picture of where the service worked and where it broke down.

Enabling mixed methods pilot evaluation
I worked with the data scientist to define what the pilot needed to measure - for example comparing time spent on phone versus digital and designed the qualitative complement. I enabled a mixed methods approach to pilot evaluation that gave the team a richer picture than either method alone could have provided.

Question redesign
The eligibility question was redesigned to list specific tobacco types including shisha, with a catch-all phrase to capture episodic use. The research I led directly informed this redesign.

Mobilisation strategy
The service provider changed how they approached shisha-smoking communities. The research made clear that shisha smokers couldn't be reached or communicated with in the same way as cigarette smokers : the framing, the language and the outreach approach all needed to reflect the different mental model. This was a programme-level change, not just a design tweak.

Interaction design decisions
Research sessions surfaced that the service flow was causing self-moderation an insight that informed subsequent interaction design decisions made by the IxD team on how questions were sequenced and presented.

Pilot evaluation approach
The mixed methods framework I helped design enabled the team to evaluate the pilot with both quantitative rigour and qualitative depth,  giving them what they needed to make evidence-based decisions about what to change before scaling.

The most important thing this project taught me is that when people don't answer a question accurately, the instinct is often to assume dishonesty or lack of engagement. Our research showed repeatedly that the real issue was design: questions that didn't match how people understood their own behaviour, service flows that inadvertently trained people to hedge, eligibility criteria that excluded people with meaningful risk because they didn't fit the assumed profile.