Design Cards for Culturally Sensitive Mental Health Technologies: Integrating Hofstede’s Cultural Dimension Theory into Human-Centered Design Processes Nimra Ahmed nimra@ifi.uzh.ch University of Zurich Zurich, Switzerland Ibrahim Al-Hazwani alhazwani@ifi.uzh.ch University of Zurich Zurich, Switzerland Anton Fedosov anton.fedosov@fhnw.ch University of Applied Sciences and Arts Northwestern Switzerland Windisch, Switzerland Tim Schluchter tim.schluchter@uzh.ch University of Zurich Zurich, Switzerland Elaine M. Huang huang@ifi.uzh.ch University of Zurich Zurich, Switzerland Figure 1: Example of one annotated MHxC card. The card has three main parts. On the left: we have the information about the Hofstede’s cultural dimension; in the center human insight and creative inspiration are provided to the user; on the right an illustrative example of how the consideration could be designed. Abstract Despite the significant influence of culture on technology use, there is still lack of culturally sensitive approaches in mental health technology design within HCI. This paper introduces the Men- tal Health x Culture (MHxC) card deck, a translational tool developed to support researchers and designers in this space. Draw- ing on Hofstede’s Cultural Dimension Theory, the deck comprises double-sided cards that depict contrasting cultural values for the five cultural dimensions. Each card combines findings drawn from existing research and illustrative examples and provides targeted design considerations and creative inspirations. We discuss the Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for third-party components of this work must be honored. For all other uses, contact the owner/author(s). NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden © 2024 Copyright held by the owner/author(s). ACM ISBN 979-8-4007-0965-4/24/10 https://doi.org/10.1145/3677045.3685446 process of creating the cards and feedback we gathered from UX designers and psychologists regarding the composition and poten- tial value of the cards in supporting design processes. By making cultural considerations explicit and actionable, this tool encour- ages critical engagement with culture in technology design to help bridge the research-practice gap. The MHxC card deck has the potential to enhance cultural sensitivity in mental health technol- ogy design and support the integration of cultural awareness into human-centered design processes. CCS Concepts • Human-centered computing→ Interaction design. Keywords Mental Health, E-Mental Health, Culture, Design Process, Cards https://orcid.org/0000-0002-1609-2937 https://orcid.org/0000-0003-1873-104X https://orcid.org/0000-0003-1604-2419 https://orcid.org/0009-0007-5293-8198 https://doi.org/10.1145/3677045.3685446 http://crossmark.crossref.org/dialog/?doi=10.1145%2F3677045.3685446&domain=pdf&date_stamp=2024-10-13 NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang ACM Reference Format: Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang. 2024. Design Cards for Culturally Sensitive Men- tal Health Technologies: Integrating Hofstede’s Cultural Dimension Theory into Human-Centered Design Processes. In Adjunct Proceedings of the 2024 Nordic Conference on Human-Computer Interaction (NordiCHI Adjunct 2024), October 13–16, 2024, Uppsala, Sweden. ACM, New York, NY, USA, 23 pages. https://doi.org/10.1145/3677045.3685446 1 Background Recent research in Human-Computer Interaction (HCI) highlights the critical influence of gender and culture on mental health mani- festations, prompting the call for culturally sensitive technology de- sign [2, 6, 11, 42, 51]. This aligns with the growing recognition of the need for culturally informed healthcare practices, especially evident in studies on mental distress across various cultures [3, 8, 17, 41, 47]. For instance, in many Asian countries, mental distress often mani- fests through somatic symptoms such as stomach pain and muscle tension, contrasting with the psychological expressions typical in Western cultures [30]. Moreover, research indicates that migrants, ethnic minorities, and religious individuals may exhibit passive behavior during medical consultations, asking fewer questions and taking less initiative compared to other general population [35, 45]. Ahmed et al. [2] extend this line of inquiry by using Hofstede’s Cultural Dimension Theory to examine how cultural influences impact mental health help-seeking behaviors. Drawing upon Rei- necke & Bernstein’s application of Hofstede’s theory in interface design [42], Ahmed et al. emphasize the importance of culturally sensitive approaches in mental health technology design. Their analyses resulted in informed design considerations for researchers and practitioners. However, translating these types of insights into practical ap- plication is often challenging as many practitioners find design guidelines and implications as presented in research publications to be abstract and inaccessible [10], limiting the impact of academic work [40]. The difficulty of implementing research findings in real- world design leads to the so-called ’research-practice gap’, a gap between theoretical knowledge and practical domain applications [10, 43, 48]. To bridge the research-practice gap in HCI [39, 43, 48], design cards can be a powerful translational tool [10] for transform- ing abstract theory into actionable formats. The efficacy of design cards has been demonstrated in diverse domains[28], including the creation of services in the sharing economy[15, 16], reflection on information systems for interna- tional justice [32], the design of resources for aging populations [37], and societal resilience [40]. Additionally, recent advancements in AI have facilitated the creation of design cards from academic papers, addressing the challenge of distilling complex research findings into actionable design insights [46]. Their tangible for- mat supports several stages of the human-centered design process such as collaborative and playful ideation, co-design, and formative evaluation of concepts [16, 21, 28, 32, 33, 40]. Building on prior research [2, 42], ourMental Health x Cul- ture (MHxC) cards (see Appendix B) operationalize Hofstede’s cultural dimensions in mental health technology design, making insights from prior research more tangible and accessible to HCI practitioners (e.g., UX designers and researchers). We envision the following benefits of theMHxC card deck: (1) aiding designers in creating culturally sensitive digital health solutions; (2) inspiring in- novative approaches to mental health challenges; and (3) evaluating the cultural sensitivity of existing mental health tools and services. The aim of this work is to improve existing mental health tech- nology design and research and provide an educational resource, promoting a broader appreciation of cultural influences in design practice. Our approach builds upon (and can be used with) par- ticipatory design methods, which typically implicitly incorporate variations in culture by including participants’ culturally informed perspectives in resulting designs. While participatory design meth- ods ensure that aspects of culture are represented in the outcomes of the process, they may be somewhat incidental in comparison to more explicit design goals. Thus, our toolkit strives to make the inclusion of culture more intentional, conscious, and prominent by incorporating it systematically and explicitly into the steps of the design process. This work contributes in three main ways: first, we present the MHxC card deck, enabling design researchers and practitioners to adopt the toolkit in practice; second, we describe the process of creating the card deck, discussing the decisions, assumptions, and trade-offs in its design; and third, we offer initial reflections and reactions from experts in psychology and UX on the potential value of the cards for designing culturally appropriate mental health technologies. 2 Mental Health x Culture Cards TheMHxC card deck is designed for HCI researchers and UX de- signers to inspire ideas and deepen cultural understanding and awareness, particularly in teamwork activities. It builds on suc- cessful tools that encourage creativity and help individuals grasp design nuances [10, 16, 21, 32, 33, 40]. Hsieh et al. categorize the intents of design cards into seven categories: Creative Inspiration, Human Insights, Material & Domain, Methods & Tooling, Problem Definition, Team Building, and Values in Practice [28]. The MHxC deck emphasizes Creative Inspiration and Human Insights. Creative Inspiration aims to stimulate innovative ideas through prompts or visuals, while Human Insights embeds knowledge about human behavior to aid designers in understanding the impact of their designs. TheMHxC card deck consists of 22 color-coded, double-sided cards and an instructional leaflet (see A), which provides a brief ex- planation of the cards’ purpose and content. The cards are divided into five groups, each focusing on one of Hofstede’s cultural dimen- sions: Individualism vs. Collectivism (five cards), Power Distance (four cards), Masculinity vs. Femininity (three cards), Uncertainty Avoidance (four cards), and Long-Term Orientation (six cards). 2.1 The Dimensions Hofstede’s cultural dimensions theory provides a framework for understanding societal values and behaviors across national cul- tures [24–27]. It is widely used in fields such as HCI, industrial psychology, and healthcare [2, 9, 13, 19, 35, 42, 52], offering ac- tionable insights into cultural traits through tools like Hofstede’s online platform1. Below, we summarize the connections between 1https://www.hofstede-insights.com/country-comparison-tool https://doi.org/10.1145/3677045.3685446 https://www.hofstede-insights.com/country-comparison-tool Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden these cultural dimensions, health-related concepts, and design as synthesized by Ahmed et al. [2] based on their systematic review. Individualism vs. Collectivism contrasts societies that prior- itize individual achievements with those that emphasize commu- nity goals [24, 36]. Themes include Orientation (balance between independence and family influence in health decisions) [45, 53], Autonomy and Help-Seeking Behaviors (preferences in health man- agement) [2], Information Exchange (communication styles) [11, 31], and Views on Digital Support (variations in digital health engage- ment) [5, 29]. Power Distance explores how societies handle power inequali- ties [24, 36]. Themes include Power Inequality (respect for authority vs. balanced guidance) [50], Expectations (therapeutic approaches) [2], Self-Disclosure (privacy levels in health discussions) [22], and Collaboration (doctor-patient joint exploration in health care) [4]. Masculinity vs. Femininity contrasts cultures that value traits viewed as masculine, such as assertiveness, with those emphasiz- ing feminine traits like nurturing [24]. Themes include Attitudes (cultural openness to medical care) [2], Approach to Treatment (pref- erences from action-oriented strategies to emotional support) [24], and Engagement Strategies (increasing intervention engagement) [2]. Uncertainty Avoidance addresses how cultures manage uncer- tainty and ambiguity. Themes include Trust & Innovation (openness to new health technologies) [14, 34], Proactiveness (attitudes to- wards symptoms and treatment initiation) [49], Communication (health discussion styles) [2], and Empowerment (perception of control over health outcomes) [12]. Time Orientation assesses how societies prioritize long-term commitments versus short-term gratification. Themes include At- tribution (understanding health outcomes) [24, 38], Preventive Care (proactive health measures) [18], Habits (lifestyle choices) [20], Traditions (adherence to health practices) [2, 24], Social Network (role of interpersonal relationships) [34], and Causality (interest in understanding health conditions) [23, 44]. 2.2 Visual Design of the Cards Prior to selecting cards as our communication tool, we explored other formats like checklists and guidelines. However, research suggests that these formats can be challenging for practitioners to process effectively [43]. Cards, by contrast, are versatile and facilitate discussion and reflection on cultural dimensions, fostering teamwork, creativity, and physical interaction [10, 15, 28, 33]. Their tangible nature integrates well into design workflows, serving both practical and educational purposes [10, 16, 40]. The card deck’s visual representation and layout are designed for ease of use, drawing inspiration from existing design cards in research (e.g., IDEO cards [1], SEDC [16]). We used distinctive color themes for each cultural dimension to facilitate identifica- tion, organization, and recognition during browsing, sorting, and referencing tasks. Each card within a dimension shares the same color and is double-sided, showcasing contrasting cultural extremes. This double-sided design maximizes space efficiency and helps de- signers grasp the spectrum of cultural variation at a glance. Each card includes (see Fig. 1): (1) Dimension, (2) Theme, (3) Human Insight, (4) Creative Inspiration, (5) Illustrative Example, (6) Justification of Example and (7) Source and QR Code. TheHuman Insight section presents specific findings on health behaviors for each Dimension, while the Creative Inspiration section offers corresponding design considerations and ideas. These insights and considerations are based on the systematic literature review by Ahmed et al. [2], where they were originally presented together as Themes. By separating them into distinct sections, we aim to help practitioners differentiate between empirical findings and design ideas, encouraging critical thinking and the exploration of alternative strategies. These sections are placed next to each other to clearly illustrate their relationship as suggested in prior research [15, 16]. Drawing on prior HCI work on card-based translational re- sources [10, 15], we included an Illustrative Example on each card. These examples provide concrete cases of how the Creative Inspi- ration can be applied, based on HCI research. They demonstrate how design considerations have been implemented in previous studies, helping practitioners gain a specific understanding of the recommendation at hand. This makes abstract concepts tangible and offers opportunities to explore further relevant research, po- tentially bridging the research-practice gap. To find these examples, we used a systematic approach leverag- ing our team’s expertise in mental health research and design. We divided the cultural dimensions among the authors, each respon- sible for a subset. Using resources like the ACM Digital Library and Google Scholar, we conducted keyword searches related to themes and design considerations. We collaboratively evaluated the relevance and applicability of identified examples, considering their human insights. Through discussions and consensus-building sessions, we finalized the set of examples and added Justification of Example to provide context and relevance. Lastly, we included Source and QR Code, allowing for easy access to the source for the Illustrative Example, whether the cards are in digital or printed form. 3 Preliminary Feedback Session Exploring the Design of Card Deck To collect initial feedback and insights into the design and poten- tial applications of the card deck, we conducted 6 semi-structured interviews (2 female, 4 male), in which participants were asked to reflect on theMHxC card deck. The interviews lasted between 30 to 40 minutes each and were conducted with a diverse group com- prising 3 UX/UI designers (P1, P2, P3) with 4-10 years of industry experience, 2 graduate students in psychology specializing in e- mental health technologies (P4, P5), and 1 psychologist specializing in culture, gender, and mental health (P6). The aim was to gather feedback on the concept and components of the cards, as well as to understand how participants envisioned using them. Participants were recruited through the authors’ pro- fessional networks and were provided with the link to a digital copy of the card deck, an instructional leaflet, and as reference, the cul- tural dimensions tables from [2] 2-3 days prior. They were asked to review these materials prior to the interview. While tangible inter- action with the cards is an important aspect of their use, this phase NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang focused on concept and content feedback to improve the cards be- fore evaluating them in a collaborative workshop.Interviews were conducted in person or over Zoom (not recorded), with extensive notes taken during and immediately after each session. We em- ployed the well-known affinity diagramming technique to analyze the data from the interviews [7]. Perceptions of the Design Cards. Participants generally thought that the MHxC card deck would be valuable for incorporating cul- tural dimensions into design. They believed that it would simplify complex cultural concepts and demonstrates how culture influences design and user behavior, prompting them to think about aspects they had not considered before. P3 and P5 raised concerns about the dimension names, noting that they may sound too scientific or complex, and suggested re- wording terms like "masculinity" 2 to avoid misinterpretation. P2 and P3 felt the leaflet needed to offer more background information on Hofstede’s framework and suggested adding more detailed de- scriptions. P1 also suggested explaining the importance of consider- ing culture, highlighting its economic value to encourage adoption by individuals and companies. P4 found it particularly valuable that the examples were con- nected to actual papers, allowing her to discover more relevant studies from the field of HCI and bridge her background in psy- chology with HCI research. She suggested that including links to relevant psychology research for each card could also enhance understanding for UX/UI designers and HCI researchers by broad- ening their knowledge of psychological concepts relevant to mental health technology. P1, P2, and P6 also appreciated how the cards connect research and practice, valuing the links to materials for further reading, which they often do not have time to explore in their daily work. They also suggested including links to real-world examples in addition to scientific publications for greater coverage and accessibility. Most participants, despite having no prior experience with de- sign cards, were enthusiastic about the concept. P3, who had pre- vious experience with cards, noted that the inclusion of guiding questions or discussion prompts could be beneficial. He mentioned that such prompts would help facilitate discussions and make it easier for users without prior card experience to engage with them. P2 also suggested including icebreaker exercises to help users to get comfortable with the cards. Visuals & Layouts of the Cards. Overall, the feedback on the layout and visuals was positive, with only small suggestions for improvement. P1 and P3 providedminor visual comments regarding text size and the positioning of the example picture. P1 and P2 proposed using a gradient or inverting the colors on the opposite sides of the card for greater visual representation of the contrast between the cultural values. This visual differentiation could help users better understand the semantic contrast of the two sides of the cards. 2Note that this dimension has been recently renamed by Hof- stede Insights Oy, which we’ll account for in the next itera- tion of the cards: https://hofstede-insights.com/frequently-asked- questions#whydidyouchangethenameofthemasdimensionfrommasculinitytomotivation towardsachievementandsuccess P2, P3, and P5 discussed the hierarchy of the cards, noting that some cards felt higher impact than others. They suggested that the visual design could reflect this hierarchy, possibly through applying a gradient throughout the cards with the same suit, introducing numbering within each suit, highlighting the order or establishing branching on the reference leaflet. Opportunities & Envisioned Usages of Design Cards. Partic- ipants identified various opportunities for using the MHxC card deck to fit their needs. P1, P3, P4, and P5 primarily saw the cards as valuable in the early phases of design, such as brainstorming and forming project directions. P1 also highlighted their potential use in scoping research questions and conducting interviews, noting that the cards increased her awareness of how cultures have differing expectations, perceptions, and acceptance regarding mental health. P2 also felt that the cards could be useful for evaluation purposes, helping to assess why certain designs might perform better in one country than another what adjustments might be necessary. P1, P2, and P4 emphasized the cards’ value as an educational resource and tool for fostering cultural awareness in general. They believed the cards could help designers consider cultural factors more actively in their practice, not just within the mental health space, but also in advocating for the consideration of culture in the broader design process. Overall, participants appreciated the flexibility of the cards in addressing different stages of the design process and enhancing cultural sensitivity. 4 Summary, Limitations & Future Work We developed the MHxC card deck to integrate cultural dimen- sions into mental health technology design. Our initial interviews yielded promising feedback, highlighting the potential of the cards to help bridge the research-practice gap and connect the interdis- ciplinary fields of HCI and psychology. While Hofstede’s Cultural Dimension theory offers a valuable framework for understanding cultural differences, it has notable limitations, particularly pertinent to the context of mental health technology. The theory tends to oversimplify and generalize cultures, potentially leading to stereo- typing and ignoring individual complexities. Additionally, while recent research continues to use Hofstede’s dimensions, the find- ings may still carry biases from the original Western-centric point of view. Moreover, the theory’s national-level analysis may over- look regional, ethnic, and organizational subcultures, and may not be as relevant in our globalized world with pervasive cross-cultural interactions. As future work, we plan to improve the card design based on participants’ feedback, particularly by incorporating prompts or guiding questions to facilitate discussions [40] in generative design sessions. We are also considering how to support practitioners in applying cultural dimensions in specific design activities (e.g., reflection, evaluation) and on an individual level. To further validate and refine our card deck, we will employ an approach used in prior card-based research in HCI [10, 15] by conducting collaborative workshops. These workshops will help us explore the cards’ usability and effectiveness in practical settings with different stakeholder groups. Furthermore, we will make the cards available in an open-source format, allowing the UX design https://hofstede-insights.com/frequently-asked-questions#whydidyouchangethenameofthemasdimensionfrommasculinitytomotivationtowardsachievementandsuccess https://hofstede-insights.com/frequently-asked-questions#whydidyouchangethenameofthemasdimensionfrommasculinitytomotivationtowardsachievementandsuccess https://hofstede-insights.com/frequently-asked-questions#whydidyouchangethenameofthemasdimensionfrommasculinitytomotivationtowardsachievementandsuccess Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden and HCI research community to add new findings, include bespoke examples, and improve the card deck. This approach will keep the cards useful, up-to-date, and foster a community-driven effort. 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University of Minnesota. https://doi.org/10.1145/1806491.1806494 https://doi.org/10.1145/1806491.1806494 https://doi.org/10.1145/3613904.3642686 https://doi.org/10.1145/3359169 https://doi.org/10.1145/3359169 https://doi.org/10.25300/MISQ/2013/37.2.06 https://doi.org/10.1145/2470654.2466257 https://doi.org/10.1145/3613904.3642266 https://doi.org/10.1145/3491102.3517710 https://doi.org/10.1145/3491102.3517710 https://doi.org/10.1145/3386247 https://doi.org/10.1145/3170427.3174368 https://doi.org/10.1145/3170427.3174368 Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden A Leaflet Figure 2: Fold-able instructional leaflet which explains the card deck and a brief introduction and overview of the dimensions NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang B Card Deck Here below the full card deck is presented. Each subsection represents one of Hofstede’s cultural dimension. B.1 High Power Distance Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden B.2 Low Power Distance NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden B.3 Individualism NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang B.4 Collectivism Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden B.5 Long Term Orientation NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden B.6 Short Term Orientation NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden B.7 Masculinity NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang B.8 Femininity Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden B.9 High Uncertainty Avoidance NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Nimra Ahmed, Ibrahim Al-Hazwani, Anton Fedosov, Tim Schluchter, and Elaine M. Huang B.10 Low Uncertainty Avoidance Design Cards for Culturally Sensitive Mental Health Technologies NordiCHI Adjunct 2024, October 13–16, 2024, Uppsala, Sweden Abstract 1 Background 2 Mental Health x Culture Cards 2.1 The Dimensions 2.2 Visual Design of the Cards 3 Preliminary Feedback Session Exploring the Design of Card Deck 4 Summary, Limitations & Future Work References A Leaflet B Card Deck B.1 High Power Distance B.2 Low Power Distance B.3 Individualism B.4 Collectivism B.5 Long Term Orientation B.6 Short Term Orientation B.7 Masculinity B.8 Femininity B.9 High Uncertainty Avoidance B.10 Low Uncertainty Avoidance