Learning by solving as a pedagogical approach to inclusive health innovation

ABSTRACT

Universities can foster inclusive innovation by establishing a learning and innovation ecology that assists students to pioneer new ways of addressing societal challenges. The paper examines learning by solving as a means of capacitating students with skills for inclusive innovation. Using a platform of engaged scholarship along with design thinking as a problem-solving methodology in a master’s level course, a case study is presented that addresses the experience of Deaf patients at a public healthcare facility in South Africa. The course bridged the gap between theory and practice, facilitated experiential learning, enabled students to handle complex challenges and enabled productive collaboration. The approach empowers students with a skill set for addressing contemporary social challenges, and resonates with the concept of the ‘developmental university’, which has the mandate of addressing the needs of the society in which it is located.

KEYWORDS:

• Learning by solving
• design thinking
• engaged scholarship
• community engagement
• interpreter services

1. Introduction

Developing countries have attempted to follow the innovation trajectory of developed countries with limited success. Many developing countries have registered an overall economic growth based on indicators such as gross domestic product, while masking economic and social stasis for large numbers at the margins (Chataway et al., 2014). The form of innovation giving rise to such growth carries the risk of fostering inequality and exclusion (Erika & Watu, 2010; Foster & Heeks, 2016). The imbalances that exist between the economic and social gains from innovation invoke questions of inclusivity and equitable development.

Inclusive innovation, by virtue of being focused on developing new goods and services for and by marginal groups such as the poor, women, the disabled and ethnic minorities, is aimed at bringing about equitable development (Foster & Heeks, 2013; Heeks et al., 2013) and promoting economic and social cohesion (Wilkinson & Pickett, 2011; Stiglitz, 2012; Piketty, 2014). Inclusive innovation systems directly serve the interests of low-income and excluded groups, particularly those outside the mainstream of economic growth, by improving their income, well-being and livelihoods (Altenburg et al., 2009). This entails horizontal expansion to bring on board social sectors that directly speak to the needs of the marginalised in developing countries, such as health, education and small-scale agriculture; and vertical expansion which brings on board innovators, entrepreneurs and consumers situated at the base of the economic pyramid (Paunov, 2013; Pervez et al., 2013; Foster & Heeks, 2015). Cozzens & Sutz (2012) argue that the implementation should focus on two aspects, namely inclusivity of process, which involves the participation of poor community members in design and development; and inclusivity of output, which entails the development, production and delivery of goods and services that are customised to the needs of the poor. These demands are multifaceted and call for the development of problem solving competencies.

The implementation of inclusive innovation can take various forms. For example, Scharmer & Kaufer (2013) argue for the creation of a new learning and innovation ecology at universities aimed at assisting students to pioneer new pathways for solving societal challenges. Learning is at the heart of any innovation process and involves a host of activities, including both formal and informal means of acquiring knowledge (Hekkert et al., 2007). Yet, the role of universities as drivers of innovation for development is increasingly being questioned (van den Broek et al., 2017; Benneworth, Pinheiro et al., 2017; Vallance et al., 2018). There is a proliferation of universities in many developing countries, yet social problems have continued to grow. Criticisms have been levelled against the classical training models in higher education which render universities as ivory towers of research that are detached from societal problems (David & Motala, 2017; Göransson, 2017; Benneworth, Barrioluengo et al., 2017). In response, there is an emerging notion of a relational university which is permeable to the local needs of learning, knowledge and innovation (Castro-Spila & Unceta, 2014; Torres Valdés et al., 2018). This notion calls for learning methods that are focused on problem solving as opposed to the traditional paradigm, which is discipline-oriented, lecture-centred, and based on basic and applied technical knowledge in which students’ scope of action is limited to receiving information.

This paper is situated at the nexus of learning and inclusive innovation. We focus on how the dual mandate of the university both to educate and to serve the public can be leveraged to drive social innovation that is inclusive. Our motivation is derived from the emerging discourse on the role of the university in fostering social development, which emphasises that education should function not only to teach new knowledge, but do so in a way that opens learners to contemporary social concerns. The paper is anchored on the argument by Arocena et al. (2015) that the ability to produce new knowledge does not lead directly to a capacity to use it elsewhere for community development. Instead, there is a need to align learning with the demands of society as a way of fostering inclusive innovation. ‘Developmental universities’ have a role to play as institutions whose academic mission is to foster development, through the democratisation of knowledge and overcoming inequality (Arocena et al., 2015, 2018). Such universities position themselves as highly integrated with society, and having the mandate of addressing societal problems and improving human livelihoods, particularly of the marginalised, as opposed to functioning in isolation or connecting only with privileged elites.

This comes at a time when the complexity of human and technological systems has expanded rapidly, so that discipline-specific knowledge and skills on their own are insufficient. Du & Kolmos (2006) argue that mastery of a combination of disparate capabilities is required; these include interdisciplinary skills of cooperation, communication, project management and life-long learning in diverse social, cultural and globalised settings. The need for new competencies challenges existing and traditional lecture-based approaches to teaching and learning, which have prioritised the learning of knowledge over skills. Lehmann et al. (2008) advocate for problem-oriented and project-based learning as approaches for educational development geared towards providing solutions to societal challenges. This paper stresses the notion of ‘learning by solving’ which according to Arocena & Sutz (2010) responds to a strong social demand for knowledge and expands endogenous capabilities which are necessary for inclusive innovation. Using the case study of a postgraduate course on Health Innovation and Design at the University of Cape Town, we explore how learning by solving can be applied to address health challenges affecting local communities in an inclusive manner.

2. Learning approaches for inclusive innovation at universities

At the most rudimentary level, learning describes the rewiring of neurons within the nervous system to form new associations in response to interactions with the environment (Messinger et al., 2001). Learning is thus understood as a change in capacity or behaviour that occurs when potentially useful information has been extracted from experience (Gross, 2010). Learning is therefore a crucial prerequisite for any kind of economic and social transformation as it enhances the competence and productivity of students (Lundvall & Lema, 2014). However, within the cognitive sciences, several different modes of learning have been described (Greene, 2005). Not all forms of learning preferentially activate brain regions required for complex problem solving, and education systems vary in the extent to which their teaching approaches recruit these different modes of learning. In order to challenge conventional ways of problem solving, universities, as bastions of learning, should aim for inclusive innovation to exploit the strategic and privileged position that they occupy in society (Blass & Hayward, 2014).

The extent to which learning contributes to the building of graduates who are competent to solve societal problems depends on how it is structured. Various forms of learning include learning by didactic teaching (Pedersen et al., 2018), learning by searching (Ghosh et al., 2018) and learning by doing, using and interacting (Nielsen 2018).

Learning by didactic teaching is a common, lecture-style approach in which the key emphasis is on reception of knowledge. Students have little agency over the learning process and encode facts without necessarily understanding them (Ab Murat, 2018). Thus students are dependent on lecturers as sources of information (Miller et al., 2013). Learning by didactic teaching neither inculcates critical problem solving skills and autonomy (Kaur, 2011) nor stimulates innovation inquiry and scientific attitudes towards problem solving (Meguid & Collins, 2017).

In contrast, learning by searching requires students to take a more active and self-directed role in acquiring information particularly through web-based activities (Yin et al., 2013). Active searching has the capacity to rouse the brain’s central, dopaminergic reward system and bring online important cognitive systems that help to process consciously-accessible information (Tzschentke, 2000; Wright & Panksepp, 2012), but this will depend in large part on each individual student’s level of interest in the topic. Furthermore, while learning by searching is useful in promoting discovery and developing students’ ability to take the initiative to acquire knowledge, there is a risk of deriving incorrect or inappropriate information that is not subjected to critical scrutiny (Bilal, 2000).

Learning by doing is form of learning that involves trying things out, formulating hypotheses and testing them to acquire knowledge through first-hand experience, instead of watching others perform or listening to a lecture (Reese, 2011). Although learning by doing results directly from real life experiences that may be enjoyable for learners, knowledge and skills acquired gradually through practice without deliberate reflection tend to be stored in the brain as ‘procedural’ or implicit forms of memory which are typically unavailable through explicit, introspective means (Cohen & Squire, 1980; Eichenbaum, 1993). This may limit the application of the knowledge to the context where it has been generated.

Learning by using is a user-driven approach based on the fact that the process of acquiring knowledge is not only a function of the experience involved, but also of how it is utilised (Mukoyama, 2006). This method is advantageous in that it engages the end user to gain useful insights, but it can be highly episodic and discontinuous, which adversely interferes with incremental learning (Tyre & Orlikowski, 1996).

Learning by watching and interacting is characterised by the transfer of knowledge between actors (Lundvall, 1992) and is a mode of social learning traditionally described as ‘observational learning’ (Bandura, 1971). Observational learning is a powerful but largely implicit form of learning which rests on the imitation of others’ behaviour following observations of positive or desirable outcomes. It has been described as an important process for the transfer of embodied, cultural knowledge (Gieser, 2008). However, research has indicated that observational learning is only effective when learners are motivated to learn from a model (Bandura, 1965).

The forms of learning described here differ from each other depending on how knowledge is acquired, stored and processed. Although some methods may offer an advantage over traditional lecture-based teaching styles, the call for transforming education at universities into new forms of learning capable of tackling complex global challenges (Luna Scott, 2015) requires that learners be imparted with life skills such as critical thinking as well as the ability to innovate and solve diverse problems through creativity (Batchelor, 2011; Tan et al., 2017). This demands a rethinking and revitalisation of pedagogy by incorporating competencies that are needed to solve contemporary challenges. There is a need for paradigm shift towards learning by solving as an evolutionist approach that is key to inclusive innovation (Arocena & Sutz, 2001; Arocena & Sutz, 2010). Learning by solving comprises action-based steps taken by students to reach anticipated goals when faced with a problem situation. It is regarded as one of the highest forms of learning as it capacitates students with ways of coping with the problem of knowledge for development (Klausmeier & Goodwin, 1993).

In learning by solving, the content and skills that are to be learned are organised in relation to specific problems rather than being structured hierarchically as a list of topics. In this way, learning is contextualised around the problem. This kind of contextualisation brings meaning to the learning process (Schank et al., 1994) and is known to be advantageous for later recall because events are encoded explicitly in memory stores alongside a rich array of cues (Roediger et al., 2007). As learners traverse the knowledge gap and grapple with the dissonance arising from what is known and unknown in the context of a new problem, they are obliged to continuously monitor and evaluate their understanding of both the issue at hand and the range of strategies that are to be implemented (Marra et al., 2014). The challenge brought on by this experience tends to be intrinsically motivating. In fact, research shows that problem solving and divergent thinking is sustained in the brain by neurochemical pathways of reward (Reuter et al., 2006; Durstewitz & Seamans, 2008), which activate prefrontal structures closely involved in higher-order forms of thought (Tzschentke, 2000; Flaherty, 2005). Thus, learning by solving effectively engages students, affords them with maximum agency during the learning process, and requires a great degree of critical, reflective thinking – a mode of processing referred to as ‘metacognition’, which is characterised by high levels of self-awareness and analytical thinking (Veenman et al., 2006). These qualities make learning by solving ideally suited for dealing with the complexity of real-world challenges.

Learning by solving supports an individual’s self-sufficiency, creativity, empathy, rational thinking and entrepreneurship (Dobele, 2016). This form of learning thus plays an instrumental role in social and economic development as it strives to enhance social awareness, creativity and sensitivity to societal problems (Elias & Clabby, 1992). It capacitates students to see opportunities for solving problems in different areas and it prompts them to devise ways of overcoming them through innovative solutions (Smith, 1995).

Developing countries’ persisting poverty has been attributed, in part, to their inability to transcend activities that are devoid of learning potential (Reinert, 2007). In developed countries, learning by solving is deeply entrenched in the curriculum as part of the knowledge-based and innovation-driven economy meant to empower students to address challenges (Ahghar, 2012). However, learning by solving has been weak in developing countries because it is costly and time consuming (Cimoli et al., 2009; Arocena & Sutz, 2010).

Various learning approaches facilitate learning by solving; these include problem based learning (Wood, 2003; Hmelo-Silver, 2004) and design thinking (Stickdorn et al., 2011). Although these approaches are not explicitly described in the literature as learning by solving, they fit into that category by virtue of being oriented towards the mobilisation and application of knowledge to develop problem solving capabilities. There is nothing radically new in learning by solving, except that it captures the accumulative nature of the process of building problem solving capabilities by adopting a student-centred perspective (Arocena & Sutz, 2001).

Design thinking is a human-centred approach to solving problems that engages implicit, intuitive, styles of learning as well as explicit processes of critical reflection and analysis. In its prioritisation of empathy and a tolerance for ambiguity in complex problems, design thinking is useful in generating innovative solutions (Brown & Wyatt, 2010). The method puts emphasis on engaging the end-users of solutions to gain an understanding of their particular needs (Brown & Wyatt, 2010; Lockwood, 2010). Ethnographic techniques are used to understand the underlying needs of the users, which form the basis for developing customised innovative solutions (Plattner et al., 2014). The use of design thinking in academic settings is meant to develop creative confidence among students. This is achieved by engaging students in hands-on design challenges that stimulate higher-order thinking skills and foster active problem solving (Cross, 2011; Kimbell, 2011; Glen et al., 2014). The special merit of design thinking as a form of learning by solving lies in its dual approach to dealing with complex problems: studies from the cognitive sciences suggest that solely relying on explicit forms of knowledge may interfere with critical learning that takes place as a result of implicit, experience-based learning (Fletcher et al., 2004).

Learning by solving can be implemented at universities through different platforms. One of these is engaged scholarship (Sandmann, 2008; Paynter, 2014), which allows discovery by bridging gaps between academic settings and civil society (Beaulieu et al., 2018). Engaged scholarship inculcates in students the understanding that not all knowledge and expertise resides in the academy, but that both expertise and great learning opportunities in teaching and scholarship also reside in non-academic settings (Fitzgerald et al., 2016). Engaged scholarship posits a framework for learning that moves away from emphasising products to focusing on the impact they have on society (Fitzgerald et al., 2016). This way of operating forces students to think beyond the immediacy for their goals by projecting future efficacy and sustainability in their problem solving. Since engagement implies a partnership and a two-way exchange of information, ideas and expertise, as well as shared decision-making (Jordan, 2009), it allows for academic teaching programmes to provide realistic training to students as an example of future work-related duties and assignments and to collaborate with community partners in service delivery (Paynter, 2014). Learning by solving provides a learning modality through which engaged scholarship can achieve its goals.

3. Case study: learning by solving for inclusive health innovation

The University of Cape Town offers a graduate-level course on Health Innovation and Design, which forms part of the curricula for the master’s degrees in Health Innovation and Biomedical Engineering. The course introduces participants to human-centred design of solutions to promote health and wellbeing and address needs identified through engagement with relevant stakeholders. It uses design thinking as an embodiment of learning by solving. The design thinking approach is implemented in six phases, which are applied iteratively – Understand, Observe, Define, Ideate, Prototype, Test – as shown in Figure 1.

Figure 1. Six phases of the design thinking implementation.

Before the course begins, a community-based project partner is engaged to provide a real-life challenge that the partner wishes to address. After the challenge has been presented to the students, the design thinking process starts with the ‘Understand’ phase where students share their own personalised interpretation of the problem. This is done to bring to the surface the assumptions, prejudices and biases of the students with regard to the project challenge, and enables them to share the emotions invoked by, and their perspectives on, the challenge. The Understand phase is followed by an ‘Observe’ phase where there is direct engagement with the end-user by means of interviews and/or immersive practices, towards developing a deeper understanding of the context of the problem. It involves fieldwork to engage the different stakeholders towards uncovering the underlying causes of the challenge and is strongly guided by empathy. The information gathered through interviews is examined and students identify insights and infer needs which inform a reframed statement called a ‘Point-of-View’ – the key feature of the 3rd phase, ‘Define’. The reframed statement becomes the entry point for finding solutions that are grounded in true and lived experiences of the community. Potential solutions are generated during the ‘Ideate’ phase. In this phase, many ideas are proposed and when a particular threshold of innovative ideas is reached, the students synthesise them and select those they wish to take forward as solutions to the challenge. They use the selected ideas to make low fidelity prototypes in the ‘Prototype’ phase. These are presented to users in the ‘Test’ phase for early feedback. The feedback from the users forms the basis for iteration, which involves using what has been learnt from testing to amend the solution. Design thinking harnesses participatory methods of user engagement, particularly in the Observe and Test phases, as it is during these phases that the end-user is able to give critical feedback on the challenge and the proposed solution. Beckman & Barry (2007) argue that engagement with users serves as the foundational aspect of the innovation process as this is where the fundamental needs of the user are assessed and established.

To illustrate how design thinking has been applied to create solutions that address health challenges, we refer to the challenge of redesigning the way in which Deaf patients access healthcare services at an Ophthalmology Clinic in a public hospital, in a world where the use of sign language is limited. The Deaf community in South Africa is still marginalised and studies have shown that they experience exclusion when attending health facilities (Lomofsky & Lazarus, 2001; Morgan, 2008; Kritzinger, 2011). The students were presented with this challenge at the beginning of the semester-long Health Innovation and Design course. A sign language interpreter service provides support to Deaf patients at the Ophthalmology Clinic for one day a month. Students interviewed Deaf patients and health care workers at the Clinic, observed the clinical procedures and developed a user experience profile for the patients. Deaf participants were recruited for the study from current and past outpatients of the clinic. Clinicians and healthcare workers participated in the project by sharing their experiences of working with Deaf patients and sign language interpreters. From the interviews, students learnt that interpreters provide an important service for Deaf people by enabling them to communicate in their own language. It emerged that Deaf patients preferred independent interpreters to family or friends as they needed some privacy in dealing with sensitive matters. However, due to a shortage of accredited interpreters, scheduling interpreter appointments was difficult. Besides the limited number of interpreters, transport and logistics also adversely affect their availability. The value of conducting such in-depth observations before attempting solution-finding, is that students could eliminate many of their ideas and solutions. For example, speech-to-text technology was what many students were thinking of as a solution to address communication problems for the Deaf. However, they discovered that the reading and writing level of the Deaf patients in this setting was relatively low as sign language does not have a written equivalent. This makes written communication not only time consuming, but also challenging.

The engagement with Deaf patients revealed that interpreters create a more productive and inclusive experience. However, lack of adequate access to interpreters affects the level of care that the patients receive. After the Understand and Observe phases, the reframed challenge statement, or Point-of-view was: ‘A deaf patient needs a convenient way to communicate in a world where there is a heavy reliance on interpreters for relaying information in healthcare’. Through ideation, solutions were generated and the students settled for a video calling interpretation service for Deaf people to provide increased access to registered interpreters through mobile telecommunications technologies. Through a mobile application, Deaf users would be able to access available interpreters from various geographical locations. This would address the shortage of available interpreters on-site, and reduce or eliminate transport costs as well as travel time, especially given the limited public transport system in South Africa. There would also be greater access to a wider pool of interpreters from across the country and problems of accents and dialects in sign language would be addressed.

Deaf participants expressed that an interpreter service was required for every aspect of their lives and not only when visiting a hospital or a clinic. The solution was meant to minimise the degree of exclusion of Deaf patients and may be applied to the broader Deaf community requiring interpreter services for various tasks. Given the iterative nature of the design thinking approach, refinement of the prototype could take place in a subsequent semester of the course with a new group of students, who would similarly benefit from learning by solving. Development of an implementable solution and examination of its impact would take place outside the course.

4. Discussion

In the case study presented, engaged scholarship provided a platform for understanding and addressing the needs of a user community, in this case Deaf patients. Design thinking provided a methodology for crafting a solution. The form of learning adopted may be characterised as learning by solving.

From the onset, the students developed a mindset of problem solving as their task was not solely to understand the theoretical aspects of the challenge for an academic purpose, but to effect the desired change through generating knowledge that could be applied for direct impact on the community. In this regard, the course offered a transformative orientation to problem solving in which the students took an active part in the production of knowledge beyond the gate-keeping of professional knowledge makers in universities. The orientation of the course towards community-based action stimulated students to develop an awareness of the social impact of the knowledge that they generated. Thus, students were able to combine the knowledge and experience in communities and in the university to solve the challenge in a mutually beneficial way that added both value to Deaf communities and legitimacy within the academic arena. The approach used in the course instilled confidence in students that they could make a difference in their communities as they were connected to the Deaf patients through a collaborative and productive relationship.

The engagement of the students with the project partner bridged the gap between theory and practice. It addressed the perceived lack of relevance of academic theory and research which emanates from disparities in the epistemological and ontological commitments of academic and practitioner communities. Unlike the traditional academic approach where emphasis is on the construction of decontextualised scientific knowledge which is based on technical rationality, the students in the Health and Innovation Design course were focused on practical knowledge with the aim of addressing societal challenges. The course brought practical and tacit knowledge into juxtaposition with scientific knowledge; these tend to be viewed as mutually exclusive. The use of design thinking in the course created a collaborative learning community which positioned the Deaf patients as fully-voiced partners in the development of actionable knowledge. It was through this engagement that the students acquired practical knowledge, not simply as a derivative of scientific knowledge, but as a distinct form of knowledge which serves as the foundation for problem solving.

This learning approach has the potential to overcome the cost and time constraints that may have hindered the implementation of learning by solving in developing countries. The students applied design thinking as part of their learning programme, without the need for extra-curricular time commitments. Low fidelity prototypes incurred minimal costs. Therefore, developing countries can benefit from adopting design thinking, not only due to its effectiveness in facilitating learning by solving, but also due its time- and cost-effectiveness. The superiority of design thinking over other methods of problem solving is echoed by Roberts et al. (2016) who argue that the willingness to ‘learn as you go’ is a safe recipe for innovating within the health sector as it is a reliable and cost-effective way to garner new perspectives and insights about problems and their possible solutions.

In combination, engaged scholarship, design thinking, and learning by solving provided a way of devising a solution to address a particular health need of a marginalised community by including their voice in the design of the solution. The approach empowers students to execute projects that are responsive to contemporary social issues. It resonates with the concept of the ‘developmental university’, which has the imperative of addressing the needs of the society in which it is embedded. Such an approach invigorates universities to be agents of change by directing their energy towards achieving inclusive innovation.

5. Conclusion

The application of design thinking through the platform of engaged scholarship in the Health Innovation and Design course demonstrates an implementation of learning by solving in an academic setting. The students and community partners deliberated critically about the challenge they were working on and arrived at solutions collaboratively. Such an approach develops students who are able to engage in socially relevant knowledge production outside the university environment and advances the notion of inclusive innovation.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Trust Saidi http://orcid.org/0000-0002-9337-4268

Tinashe Mutsvangwa http://orcid.org/0000-0003-1210-2832

Tania S. Douglas http://orcid.org/0000-0003-2024-4179

Additional information

Funding

The research was supported by the SARChI programme of the South African Department of Science and Technology and National Research Foundation (NRF) under [grant number 98788] and the Community Engagement programme of the NRF under [grant number 105548].