Effective and accessible health communication media interventions are increasingly recognized as key strategies for increasing basic health literacy and promoting healthy behaviors.1–5 Researchers have thus called on professionals in the related fields of health communication, health education and health literacy to join forces in developing interventions that are compelling and effective for promoting behavior change.6 A growing body of research also emphasizes the need to design communication interventions that are accessible across diverse global audiences.1,3,6,7 Key solutions could lie in designing interventions for “glocalization”, the adaptation of global content for local resonance.8
Research suggests that health communication for global health literacy promotion needs to take into account cultural factors that may influence health in different target audiences. Thoughtful integration of these determinants has been identified as a cornerstone of effective interventions.3,9,10 If our goal is to promote health literacy globally, including reaching marginalized audiences, we must design health communication interventions from the outset with an appreciation for global cultural variation.9,11,12
Socio-cultural considerations influencing message design, narrative, and visual elements require close attention when designing animated health communication interventions.13,14 Prior research on the use of animated videos to promote agricultural knowledge gains in low- and middle-income countries (LMIC), showed high long-term retention of information (98%) and solution adoption (89%).15 This research underscores the potential of animated videos, dubbed in local languages, to cost-effectively reach a broad range of global learners, including those facing literacy barriers and geographic isolation.16
The Pilot Intervention in South Africa
In 2018, we created a video-based maternal child health communication intervention in collaboration with the South African National Department of Health. Our shared goal was to design and produce a series of story-based, short videos aimed at improving health literacy on key maternal-child health topics. The videos were also intended to optimally engage a broad spectrum of parents and caregivers across this culturally diverse country.14 In designing this intervention, the team faced several challenges:
1) We needed to effectively communicate key health messages, while overcoming literacy barriers and facilitating easy translation into different languages.
2) Our animation design prototypes needed to be universally acceptable while maintaining viewer engagement.
3) Since data costs in South Africa remain high, the videos needed to be small (2–10 MB) to facilitate equitable access for all communities.
4) To help viewers identify with characters and settings, we needed a protocol for glocalization, ie: localizing content that had been created for a broad, global audience.
A collection of existing approaches, combined with contemporary digital solutions, allowed us to address these challenges:
1) The use of narrative has shown great promise in the field of health communication, especially for populations with diverse literacy levels. Entertainment-education, storytelling, and testimonials are increasingly being deployed to communicate health messages, persuade and motivate behavior change.4
2) Universal design for learning (UDL), a theoretical framework originally developed to accommodate those with learning differences, has been successfully applied to the design of culturally inclusive health literacy interventions.3
3) The digital simplicity of vector-based, two-dimensional character animations facilitates compression into small files and optimization for mobile viewing.
4) The children’s entertainment-education industry has demonstrated the great potential for glocalizing video content by capturing local, community voiceovers to enhance viewer identification with the content. Research documenting the glocalization of Sesame Street by the Children’s Television Network, in the 1970’s, demonstrated the power of a structured approach to local language dubbing. This involved collaboration with in-country educators and local voice artists, facilitating the global scaling of this iconic television series. 17,18
We integrated these approaches to facilitate glocalization, by featuring local voices,19 designing simple, vector-based characters for accessibility across audiences and integrating narratives in an entertainment-education approach. A major, underlying goal was to enhance emotional appeal and character identification, highlighted as important strategies in the behavior change, communication science, and education literature.17,18,20−23
Following the launch of our pilot intervention24, we received requests to adapt some videos in the series for use in rural China, Guatemala, and Burkina Faso. While we had gathered in-country feedback from diverse local audiences during the development of the initial intervention in South Africa, we recognized a shortage of research on visual design preferences for health communication across global audiences. In this study, we use a mixed-methods approach to gain a broad sense of global design preferences, as well as a more nuanced understanding of those preferences. We summarize feedback from participants in 73 countries on a set of geographically and culturally non-specific prototypes. We also present novel content development considerations that have already served to inform the design of a globally scalable corona virus disease (COVID-19) prevention intervention and could serve to inform similar interventions in the future. Especially in the midst of a global health crisis, the COVID-19 pandemic, the need for evidence-based, globally scalable, accessible and compelling health communication media has become increasingly clear.