Sexual and gender minority youth (SGMY; eg, lesbian, gay, bisexual, and transgender youth) are at greater risk than their cisgender heterosexual peers for experiencing adolescent relationship abuse (ARA; ie, physical, sexual, or psychological abuse in a romantic relationship) [1-4]. According to a recent nationally representative sample of high school youth in the United States, 13% of sexual minority youth and only 7% of heterosexual youth reported physical ARA in the past year [5]. Even greater disparities are present for sexual ARA, with a prevalence of 16% among sexual minority youth and only 7% among heterosexual youth [5]. Gender minority youth are also at greater risk for ARA than their cisgender peers [6]. SGMY ARA inequities are problematic because ARA is associated with many poor health outcomes later in life, such as mental health disorders and HIV [7,8]. Thus, prevention efforts for SGMY may mitigate health inequities more broadly.

Despite researchers and national agencies calling for interventions to reduce ARA among SGMY [9-11], there exist few evidence-based interventions addressing this public health inequity [9,12]. While there are several efficacious interventions for reducing ARA for the entire adolescent population [13], a 2019 systematic review revealed that there were no evidence-based ARA interventions specifically for SGMY at that time [12]. More recently, one study examined the efficacy of a universal intervention for reducing ARA among sexual minority youth; for sexual minority youth, this intervention reduced stalking victimization but not sexual violence, sexual harassment, and physical dating violence victimization [14]. More research is needed to address the lack of evidence-based interventions to prevent and reduce ARA in SGMY.

One innovative method for stimulating new stakeholder-driven intervention ideas to catalyze ARA research among SGMY is to leverage the field of human-centered design [15]. Human-centered design is a discipline focused on improving existing or developing new products, services, or experiences by involving the perspectives of the target population at every possible stage [16-27]. Human-centered design methods often incorporate multiple ways of soliciting user and other stakeholder input, including through observation and dialog, cooperative design activities, and the shared creation of meaning by collaboratively synthesizing, critiquing, and ranking self-reported data and observations. In a practical sense, this often means that individuals involved in human-centered design processes create their own artifacts, including assembling, disassembling, and reassembling qualitative data points written on Post-it notes or a digital analog.

When bringing stakeholders together to design interventions, human-centered design generally harnesses the strengths and limits the weaknesses of more traditional approaches (eg, focus groups). For example, focus groups traditionally use group-based discussions and interviews generally work with participants one-on-one. Human-centered design methods, however, often combine tasks to be completed in groups with tasks to be completed as individuals, thereby harnessing the strengths of focus groups and interviews [28,29]. Focus groups are also prone to groupthink (conformity of individuals working in groups, despite their individual differences, which can lead to inaccurate results or poor decision making [30]) that may inadvertently reinforce social hierarchies that silence certain people (eg, marginalized or shy people) [31-34]. In contrast, many human-centered design techniques require each participant to brainstorm independently and record all their ideas in written format (before sharing output with other group participants), making data collection more comprehensive and equitable [28,35]. In addition, focus groups are prone to social desirability bias because the moderator has an active role in guiding and influencing the discussion [32-34,36]. In human-centered design, facilitators have a less subjective role as they usually only lead participants through task instructions without any probing [28]. Finally, conventional methods (eg, focus groups or expert panels) for bringing stakeholders to translate research findings into intervention concepts are often challenging and time-intensive [37-41]. To overcome these barriers, human-centered design uses structured activities that are time-limited, engaging, and accessible to laypersons, including youth [16-27]. Overall, human-centered design activities can be applied as a novel form of stakeholder-engaged research to rapidly generate and iterate intervention concepts to reduce emergent public health problems.

To date, health research that uses human-centered design methods has been predominantly conducted with stakeholders in-person [42], but most in-person research activities have been impeded by the COVID-19 pandemic. Although, the pandemic has presented many barriers for safely conducting in-person research, it has simultaneously catalyzed the use of web-based technologies for interacting and collaborating. Young people have especially become accustomed to using web-based technologies (eg, Zoom, a videoconferencing platform) because many schools have transitioned to remote learning. Therefore, youth are uniquely poised to use web-based human-centered design methods. Previous research has shown that youth can feasibly engage in web-based research as well as in-person human-centered design activities [43-47]. However, to our knowledge no study has explicitly tested whether human-centered design methods are feasible, acceptable, and appropriate for engaging with youth in a fully web-based environment. A study that rigorously pilot tests such methods, by setting a priori benchmarks, can help inform the public health field about the utility of conducting these methods on the web and further demonstrate and codify the use of web-based human-centered design as a method for stakeholder-engaged research.

This paper describes a protocol for conducting web-based human-centered design sessions with SGMY to create novel intervention ideas for addressing ARA. The specific aims of this study are as follows:

1. Test the feasibility, acceptability, and appropriateness of conducting web-based human-centered design sessions with SGMY (primary study aim).

2. Elucidate the beliefs of SGMY about healthy and unhealthy characteristics of intimate relationships.

3. Elicit feedback from SGMY about the School Health Center Healthy Adolescent Relationships Program (SHARP), which is a universal evidence-based intervention for reducing ARA [48,49], and about adapted SHARP materials that are tailored to SGMY [50,51].

4. Brainstorm intervention ideas for reducing ARA inequities for SGMY and force-rank the intervention ideas based on their potential ease of implementation and potential impact.

5. Generate, iterate, vote on, and refine the intervention concepts to reduce ARA inequities for SGMY.

We followed both the Standards for Reporting Qualitative Research [52] and the Strengthening the Reporting of Observational Studies in Epidemiology statement [53] to craft our study, present our methods, and report our results. We used these two guidelines because there are no formal reporting requirements for human-centered design studies.

We are conducting a web-based, longitudinal human-centered design study to engage with 45 to 60 SGMY participants in small groups to generate intervention concepts for reducing SGMY inequities in ARA. We conducted longitudinal sessions in multiple cohorts of 8 to 15 participants each. Participants completed a web-based screener, four web-based, group-based human-centered design sessions, and a web-based follow-up survey (Figure 1). This study is primarily funded by the National Center for Advancing Translational Sciences at the National Institutes of Health (UL1TR001857).

We aim to enroll 45 to 60 sexual and gender minority high school students recruited via social media advertisements. Eligible youth are aged 14 years to 18 years, live in the United States, identify as sexual and/or gender minorities, and have internet, video camera, audio, and microphone access to attend the virtual sessions.

Participants are conveniently sampled and recruited throughout the United States using web-based advertisements posted on two social media platforms, Facebook and Instagram, using an approach similar to that in our previous research [54]. This approach allows SGMY from multiple geographic locations (eg, rural and urban areas and East and West) to enroll in the study without overextending our resources. Facebook is an appropriate recruitment platform because it is highly used by adolescents, approximately 71% of teens use Facebook [55]. Similarly, Instagram is used by approximately 72% of teens in the United States, with the majority using the site daily [56]. We created multiple photo and video advertisements for these sites, including those depicting youth with diverse gender expressions, race, and ethnicities.

Upon clicking the advertisements, potential participants are redirected to a brief web-based self-reported screener survey administered via Research Electronic Data Capture (REDCap), a free and secure Health Insurance Portability and Accountability Act–compliant system for managing web-based surveys and databases. Following a brief description of the study, the screener included questions about potential participants’ age, race, ethnicity, sexual identity, sex assigned at birth, gender (including transgender status), high school name, city and state of their high school, computer access, camera access, audio access, microphone access, and contact information. All participants received the ARA and SGMY resource lists after the screener.

After potential participants completed the screener survey, a research assistant will assess their eligibility. The research assistant will send a sociodemographically diverse group of eligible youth a web-based consent form, which must be completed to participate.

Potential participants are sent a link to a web-based consent form administered via DocuSign, a website that allows participants to safely and securely use a virtual signature. Youth in this study will consent for themselves because we obtained a waiver of parental consent. Our study is no more than minimal risk and requiring SGMY to obtain parental permission could out them as SGMY to their parents or guardians, which may put them at an increased risk of experiencing abuse. The consent form described all essential components of the study, including (but not limited to) the study purpose, the study background, study risks and benefits, privacy and confidentiality, participant payments, and voluntary nature of the study.

Once the consent form is virtually signed, the research assistant receives a PDF version of the signed form and emails or texts participants a link to the Zoom videoconference meeting, where the web-based human-centered design sessions are conducted. The message includes instructions on how to best prepare for the session and how to access MURAL, the web-based collaborative workspace used during our web-based sessions. The participants are sent reminders 2-3 times before each session.

In addition to the web-based consent form, participants provide verbal consent at the beginning of each web-based human-centered design session. A research assistant reads aloud a verbal consent script, asks if there are any questions, and then participants provide their consent by using Zoom’s thumbs up or via Zoom’s chat feature. In addition, before completing the follow-up survey, a brief consent script is provided to participants and participants voluntarily consented to taking the survey using a click-to-consent procedure.

We use MURAL and Zoom to conduct the web-based human-centered design activities. With each cohort of SGMY, we will conduct 4 sessions, each lasting 1.5 hours in length. All the sessions will be conducted in English. We will audio-record each session and take pictures of each session’s activity results. We only record the participants’ voices and the resultant data (not images of participants). The participants will receive a US $25 incentive for each session. Participants do not have to attend all sessions and can begin at any time, although we encourage attendance at all sessions because output from some sessions are then used as inputs in subsequent sessions.

Each session begins with an introduction to Zoom, an icebreaker, and (in the first 2 sessions) a short lesson on the topic at hand (ie, ARA in SGMY). Next, the participants are randomly assigned to different Zoom breakout rooms, with each room composed of 2 to 5 participants with 1 or 2 facilitators each. In these small groups, the facilitators introduce participants to MURAL and guide the participants through a series of human-centered design activities. Each session’s human-centered design activities are outlined and briefly described in Table 1 and described in detail in the sections below. At the end of each meeting, all participants are brought back together and report on the ideas generated during the human-centered design activities.

For quantitative data analysis, we will use StataSE version 15 (StataCorp). For qualitative data analysis, we will transcribe, deidentify, and quality check all audio-recorded data from sessions 1 to 4 [68-71]. We will also export all session data from MURAL into text-based documents. We will then perform qualitative coding in Dedoose software [72], cross-referencing the audio transcriptions with PDF exports of the MURAL workspaces.

We calculate statistical power based on our primary outcomes (study aim 1), per the best practices for feasibility studies [64,79-84]. Given a conservative sample size of 45 participants and 5% type I error rate, we have the ability to estimate a 95% CI margin of error ≤0.43 for our primary outcomes, which we derived from the largest upper 95% CI limit of the SD measures in previous studies that used the same outcome measures [16-27].

For our other study aims (study aims 2-5) about the outcomes of our human-centered design methods, the purpose is idea generation, not saturation [16-27]. Given our previous work implementing similar activities, a sample of 45 to 60 participants is sufficient to generate unique and useful ideas.

Our team represents a wide range of sexual identities (ie, gay, lesbian, queer, bisexual, and heterosexual) and gender identities (ie, nonbinary, cisgender women, and cisgender men). We also comprise a multidisciplinary multitiered team, representing the fields of public health, counseling, human-centered design, library science, medicine, medical anthropology, political science, psychology, rehabilitation science, social work, and many roles in academia, including undergraduate, masters, research assistants, assistant professors, and full professors. Our diverse representation of sexual and gender identities complements our range of multidisciplinary expertise and professional backgrounds in informing data collection and analysis through lived experience.

We acknowledge that there are several ways in which our backgrounds may have influenced our research. Primarily, our facilitators for the human-centered design sessions were sexual minorities and gender minorities. This could help put our SGMY participants at ease, especially in rare instances when the interviewer disclosed their sexual or gender minority identities to participants. Furthermore, the diversity and range of disciplines represented by our research team provide us with the ability to interpret our findings.

All study procedures were approved by the Human Research Protection Office of the University of Pittsburgh. To protect participants from having to reveal their sexual or gender minority identities to their caregivers, thereby potentially putting them in harm’s way, we received a waiver of parental consent [85]. This allowed the participants to provide consent for themselves. To further protect participants, we asked SGMY (before and during each session) to find a quiet and private space where they could participate in activities with minimal distraction and interruption. We also allowed participants to use Zoom’s chat function if they are unable or feel uncomfortable speaking out loud. This study was also protected by a Certificate of Confidentiality from the National Institutes of Health. It is important to note that we never inquired about participants’ personal experiences with ARA. Nevertheless, we provided all people who completed the screener with the ARA and SGMY resource lists. In addition, the study participants received resource lists after each session.

This study protocol has several methodological innovations that can inform future public health research that aims to incorporate methods from the field of human-centered design. First, our method is an example of how human-centered design research can be performed on the web. This is important because it is a resource-friendly and accessible method for engaging diverse stakeholders from a wide geographic region. Moreover, the COVID-19 pandemic hindered our ability to engage safely with participants, and these web-based methods enable our research to continue despite current limitations on in-person research activities. Our study also demonstrates how to combine human-centered design, which is often quite flexible, into research processes, which tend to be much more structured. By rigorously testing the feasibility of such an approach, our study has the potential to demonstrate and codify the use of human-centered design as a novel stakeholder-engaged research method.

Our study has the potential to lead to many substantive innovations in the field of ARA interventions among SGMY. If successful, our study could yield several novel intervention concepts. Importantly, these interventions are directly derived from SGMY themselves, as opposed to researchers. By centering youth voices and opinions in this manner, the generated interventions may be highly acceptable and impactful, but that cannot be determined until the interventions are tested further. Nevertheless, given the great lack of interventions, our study can help catalyze the field of SGMY ARA intervention research.

Although there are many strengths to this study, it is not without limitations. Although participants in our sample are sociodemographically diverse, they are not necessarily representative. For example, SGMY without internet access are excluded from our study, and sessions were only conducted in English. In addition to youth, the inclusion of other stakeholders (eg, parents and school personnel) would likely have important insights for intervention concepts, but they are not included in this study. Despite our study yielding potentially new intervention concepts, this study will not produce complete interventions. Additional work from researchers, designers, and stakeholders will be necessary to develop and test the derived interventions. Finally, this is a pilot study testing the feasibility of our methods. We are not testing the effectiveness of our methods versus more traditional methods (eg, focus groups) for producing intervention concepts, which can be executed in future trials if our methodology proves to be feasible.

Interventions to reduce ARA among SGMY are lacking. To address this gap, our study investigates the feasibility of a new method for generating new intervention concepts. This work has the potential to contribute to substantive health impacts as well as immediate methodological impact by integrating human-centered design methods into public health research.