This photo essay is the second installment in a series summarizing the work conducted by Breakthrough ACTION Guyana. View the first installment here.
Part 1
KEY INSIGHTS RECAP
View the short video below for a recap of our 11 key insights from the first phase of our project, the Define phase. To learn more about our insights and research, view the full report.
GUIDED BY THE SOCIAL AND BEHAVIOR CHANGE (SBC) FLOW CHART
Breakthrough ACTION’s SBC design process integrates research, behavioral science and economics, human-centered design (HCD), strategic communication, and community capacity strengthening into a cohesive, flexible approach. In Guyana, Breakthrough ACTION uses HCD, strategic communication, and community capacity strengthening.
In Guyana, malaria is an issue in Regions 1, 7, 8, and 9, particularly among gold mining populations.
In response, the Ministry of Health (MOH), the Pan American Health Organization, and the Global Fund to Fight AIDS, Tuberculosis and Malaria have introduced malaria rapid diagnostic tests (RDTs) to provide services in hard-to-reach areas. To support this initiative, Breakthrough ACTION is collaborating with the MOH to improve malaria outcomes.
Part 2: Design & Test
The second phase of the SBC Flow Chart is a cyclical and iterative process that focuses on generating and refining ideas to suit a specific target audience and context.
The Design & Test phase is a highly iterative process that translates problems into solutions through idea generation and prioritization, prototyping, user testing with key audiences in context, learning, and improving. More than 790 ideas were initially generated from a cross-section of stakeholders. These ideas were ultimately categorized into eight broad concepts under which various low-fidelity prototypes were developed and tested with 145 people in Regions 7 and 8.
THE IMAGINE WORKSHOP
Stage I of the Design & Test phase included an Imagine Workshop which took place in Georgetown over four consecutive days in March 2019. Through a structured yet flexible approach, the objective of the workshop was to collectively generate, develop, and prioritize ideas around how to improve an effective malaria testing and treatment program in Guyana to increase the use of MoH services.
Once a final idea was decided on for each theme, workshop participants were tasked with building tangible, low fidelity versions of the ideas, known as prototypes. Prototypes allow the design team to test the idea with real audiences quickly and cheaply. Low fidelity prototypes were constructed from craft materials such as play-doh, colored paper, markers, and string. Some used digital mockups and photoshopped images.
Thirty-five participants attended the workshop from 10 distinct partner organizations. Many of the participants were involved in the Define phase and prior research activities in Regions 7 and 8, which helped to ensure continuity and the application of learnings from the Define phase. Upon the completion of the workshop, the goal was to have a set of initial ideas represented as simple, low-fidelity prototypes that could be taken out to the regions to be rapidly tested and refined with representatives from local communities, mining camps, and health facilities.
More than 790 ideas were generated and collapsed into Eight broad categories.
THE ORIGINAL PROTOTYPES INCLUDE:
1. An SBC campaign, which started off with four distinct creative concepts:
- Go for Gold was meant to show the economic impact of not using “gold standard” MOH-approved tests and treatment.
- Man vs. Mosquito pitted humans against mosquitoes in a humorous, comic-based approach.
- Little Mosquito, Big Problem aimed to increase malaria risk perception by appealing to both the head and heart through statistics and testimonials.
- Don’t Give Me Malaria, Man focused on the human’s role in malaria transmission and the impact it could have on the entire camp/community.
Each had a campaign name, slogan, and simple accompanying visual to test.
2. Malaria trainer support materials were developed as a job aid for volunteer testers to provide basic information on malaria to miners and to improve the accuracy and quality of the service provided. The materials also included maps and a directory of trained testers throughout the area.
3. A comprehensive RDT branding strategy was created to increase the visibility of and trustworthiness in MOH-approved testers, services, and products. It included a consistent visual element to convey the availability of free malaria testing and treatment services.
4. Standardization of the RDT program was a partnership between MOH and private importers of malaria supplies intended to standardize RDT kits and treatment supplies to increase the accuracy of malaria test results.
5. The treatment adherence idea started as a simple pill box container that split daily doses into separate compartments and included additional information such as when to take each dose.
6. Collaboration with private sector transportation was envisaged as a coordinated network of transportation companies (e.g., boat, plane, car) to facilitate movement of supplies and reports to and from camps to minimize stock-outs, enhance reporting, and reduce un-reimbursable out-of-pocket expenses from local/volunteer staff.
7. MalaApp was a phone app designed to improve the ease, speed, and quality of reporting; improve testing and treatment services; and reduce stock-outs. The prototyped app was meant to help testers easily and accurately fill out necessary documentation, report stock-outs, request supplies, and contact other testers. The app also included educational information on malaria transmission, symptoms, how to use LLINs and the recommended malaria treatment.
8. The Malaria Fighters Training of Trainers Network was an updated structure for the RDT program, with current testers serving as trainers and supervisors for new testers, building a network in which the health workers would support themselves, decentralizing training and increasing the number of active testers.
Prototype Testing
Based on the feedback received, prototypes were either refined, combined, tested with additional audiences, discontinued, or new ideas generated. The image below shows how the prototypes evolved throughout this iterative process of refining, prototyping, and testing.
Refining Our Prototypes
Five design prototypes emerged as the most desirable. The five prototypes were further reviewed and refined into the following solutions:
1. The Little Mosquito, Big Problem (LMBP) creative concept was most preferred by miners for the SBC campaign since it was easily understood, humorous, and captured their attention best. The “Don’t Give Me Malaria, Man” concept, which examined the human element of transmission, was found to be stigmatizing by some and the “Go for Gold” concept was confusing to miners as they did not understand the intended economic angle
2. Testers preferred the Rapid Counseling Cards (RCC) – a stack of color-coded counseling cards with a checklist that would allow them to counsel clients only on topics relevant for their needs. Testers felt the job aid in the form of a flip chart was too cumbersome for their busy schedules so the RCC was designed smaller and with the accompanying checklist to tailor the counselling to each client. The counseling cards have an image on the front and pertinent information about malaria prevention, transmission, and treatment on the back. The counseling checklist also represented an attempt to collect more information about the content of discussions between testers and clients that could in turn be shared with VCS staff and used to develop effective interpersonal communication strategies for testers.
3. The branding of malaria testing and treatment services with the use of a flag intended to raise the visibility of free, MOH-approved malaria testing and treatment services under the Ministry’s RDT program was widely appreciated by testers. The branding package also includes a tester’s toolkit and certificate of completion of the RDT training. The toolkit will include the rapid counseling cards, a laminated card with the treatment regimen for different types of malaria, referral forms to be used in cases of stock-outs, and a flashlight to help testers read cartridges in the evening. It will also contain malaria test kits, treatment, gloves, and reporting forms provided by VCS.
4. Two products, collectively known as innovations in treatment adherence, work together to simplify treatment, provide treatment reminders, and encourage treatment completion. Pill cases to improve adherence were found to be bulky. Miners preferred a lighter and more compact tablet strip that separates daily prescribed dosages in individual packets. Each packet would also include a visual representation of how parasites in the body are decreased each day the treatment is taken. A second product - a wristband that uses an audible reminder to indicate when the user should take their treatment, would accompany the tablet strip.
5. Improvements to the current RDT program - the Participants, Content, and Logistics (PCL) approach - was favored over the MalaApp and Malaria Fighters. The PCL approach would address the scaling up of testers, antimalarials, and other malarial commodities in difficult to access mining areas. It includes hubs for distribution, reporting, medical supplies, and training facilitated by a mobile brigade. RDT testers will be supported by implementing a referral form that caters for stock-outs and cases that testers are not equipped to manage.
Breakthrough ACTION Guyana piloted the rapid counseling cards and counseling checklist, branding for malaria testing and treatment services and small components of treatment adherence (treatment adherence handouts) and PCL approach (referral forms) in Regions 7 and 8 over a three-month period (June-August 2019). In each pilot area, persons received training to be new RDT testers while active testers in the areas received refresher training.
During the trainings, testers were oriented on how to use the rapid counseling cards and counseling checklist, branding materials, treatment adherence handouts, and referral forms. Immediately after the orientation, focus group discussions were conducted to elicit initial feedback on the materials.
Intermittent supervisory visits were conducted by Breakthrough ACTION and VCS during the pilot period to monitor the use of the materials, collect completed forms and checklists and coach testers on the use of the new products and processes.
The RCCs proved to be more effective as a training tool since testers grasped the content quickly during training and were able to counsel patients without relying on the cards. Additionally, the treatment regimen guide, treatment adherence handouts and referral forms were well accepted and utilized by testers and will be implemented at scale.
Following the SBC Flow Chart, the project team is implementing the Apply phase which focuses on the evaluation, implementation and scale of the final interventions.
During the Apply phase, Breakthrough ACTION Guyana will asses the final solutions for feasibility and sustainability in partnership with key stakeholders for the project - MoH, PAHO/WHO, and USAID. Adaptations of the “Little Mosquito, Big Problem” campaign; rapid counseling cards; branding malaria testing and treatment services; innovations in treatment adherence; and the PCL approach are being implemented at scale across Regions 1, 7, and 8.
For More information
More information about key insights is available in the Breakthrough ACTION Guyana Insights and Design and Test Report, which provides an overview of all activities completed during the Define and Design & Test Phases. Key findings are consolidated and presented alongside opportunities to take forward to the Design and Test Phase.
Acknowledgements
We would like to acknowledge our Ministry of Health partners in Guyana, in particular the Vector Control Services team (Dr. Horace Cox, Dr. Neil Trotman, Dr. Helen Imhoff, Dr. Kashana James, Dr. Michael Marks, Dr. Dexter Browne, Mr. David Williams, Ms. Charmaine Semple, Ms. Nathalie Griffith, and Mr. Royan Teixeria) and the Public Relations and Health Promotion Unit (Mr. Terrence Esseboom, Ms. Nickishaw Khan, Ms. Shivhana Bruce, and Ms. Shabana Shaw). We would also like to thank Dr. Quacy Grant.
We greatly appreciate the support and participation of the United States Agency for International Development, in particular Ms. Rebecca Minneman. We would also like to thank the organizations that participated in the Design & Test Workshops, including the Pan American Health Organization, the National Mining Syndicate, the Guyana Geology and Mines Commission, and the Guyana Women Miners Organization.
Last, but certainly not least, our heartfelt thanks goes to the miners, camp managers, and malaria testers in Regions 7 and 8 who provided their invaluable time and feedback, making this a true co-creation process.
Credits:
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