The SBC Flow Chart (Figure 1) is an integrated, trans-disciplinary approach that aims to gain a deep understanding of the full scope of the problem (Phase I: Define), translate problems into solutions through iterative cycles of design (Phase II: Design & Test), and implement programs more nimbly, using real-time monitoring to adapt and course-correct (Phase III: Apply). Project teams leverage different disciplines in the application of the SBC Flow Chart based on the specific needs of the project. Breakthrough ACTION Guyana’s approach relied heavily on HCD methodologies in order to put the audience at the center throughout, generate a wide range of ideas not limited only to social and behavior change communication (SBCC), and co-create and rapidly iterate low-fidelity prototypes.
HCD shares similar inspiration from social science disciplines such as anthropology, sociology, psychology, and human factors design. While HCD offers an opportunity to rapidly and directly synthesize findings from field data collection, there are some deviations from typical socio-behavioral science approaches to problem solving. Given the exploratory nature of HCD work, especially in the Define phase where formative research occurs, there tends to be a lack of hypothesis-driven science research and a lack of clear documentation as to what happened and the rationale behind each decision, though this varies between projects (5). During the Design & Test phase, in which users test solutions that further iterate, the process tends to have less focus on an auditable and replicable process compared to projects led by socio-behavioral sciences (10). Given these challenges, the authors employed health research reporting guidelines for HCD projects to encourage replicability and proper dissemination for this manuscript (11). Throughout the project, the team documented the process using reflection sessions after it completed each phase.
This article highlights the implementation of two of the three SBC Flow Chart phases—Define and Design & Test—in the context of malaria reduction among gold miners in Guyana.
This research received public health practice ethical approvals from Johns Hopkins University and the MoH in Guyana. For both the Define and Design & Test phases, two teams of seven people—each consisting of experienced social scientists from Breakthrough ACTION, the MoH VCS and PR/HPU, and design specialists (e.g., visual designers, design strategists)—conducted field research in Regions 7 and 8.
Interviews and focus group discussions (FGDs) were held in areas accessible and close to Puruni (Region 7) and Mahdia (Region 8). Details of the field site visit are documented further in a previously published article (12).
Define Phase
The Define phase included a comprehensive review of the literature, an Intent Workshop, and the deepening understanding component (field-based research).
Literature Review
To gain a further understanding of the malaria situation in Guyana and its surrounding countries, a review of existing literature was conducted to identify malaria knowledge, attitudes, and practices; behavioral barriers; and gaps in information, social, and cultural context of mining communities in the priority regions. An initial search was conducted using PubMed, EmBase, and Google Scholar for peer-reviewed journals on the aforementioned topics in Guyana and the Amazon Basin. Country-level documents, project reports, and other grey literature were also collected for Guyana and surrounding countries. The search yielded limited documents and was therefore expanded to include other low- and middle-income countries not located in South America. A total of 40 relevant malaria-related documents were found: 24 specific to Guyana and 16 focused on other countries. The results of the literature review demonstrated that gaps in malaria knowledge around transmission, prevention, and treatment exist and there are opportunities to correct misunderstandings and improve behaviors. Literature review results confirmed information that was already known by the team regarding access to malaria testing and treatment services. It also highlighted additional topics to explore as part of future research.
Intent Workshop
The Intent Workshop aimed for the core design and research teams to gain a high-level understanding of the malaria and mining context in Guyana and to agree upon the project purpose in the short, medium, and long term. The main output at the end of the workshop was a draft intent statement. Achieving this objective required the involvement of key stakeholders at the workshop. Twenty-four participants were drawn from the MoH, Ministry of Communities, Ministry of Indigenous People’s Affairs, mining organizations (e.g., The National Mining Syndicate; Guyana Women’s Miners Organization), Merundoi (nongovernmental organization that specializes in behavior change communication), PAHO/WHO, USAID, and Breakthrough ACTION.
During the one-day workshop in October 2018, participants deliberated over several key issues in small groups and in plenary. These included understanding the current state of malaria in Guyana and the desired future state. Presentations by the MoH, Breakthrough ACTION, and participants' experiences working in the mining sector of Guyana aided the discussions and allowed for fruitful conclusions to such questions as: What does the current state mean for stakeholders? What will success look like for the project in the short, medium, and long-term?
Deepen Understanding
In this stage, the project conducted field research and data processing. The results were used to harvest/validate insights and develop design artifacts.
Prior to the Deepen Understanding stage, Breakthrough ACTION Guyana conducted mobilization visits in both Regions 7 and 8. The purpose of these visits was to identify existing mining camps and meet with camp managers to inform them about the research. When meeting with the camp managers, researchers specifically inquired about the best time to speak with the miners. A schedule for the teams traveling to each region was developed so that interviewers would not show up at the mining camps unannounced, and at an inopportune time for the miners.
In this stage, research depends on the ability to conduct quasi-ethnographic, personalized, in-depth discussions with members of relevant stakeholder groups. The process uses interview techniques that are common in various forms of qualitative research but emphasize the importance of collecting personal narratives that reveal stakeholder experience and desired future states. The skills needed to conduct these kinds of interviews do not come naturally to most people; skilled qualitative interviewers often have years of training and experience. However, one mandate of the Breakthrough ACTION Guyana project was to build the capacity of local partners to carry out high-quality SBC programs. While some of the Guyanese counterparts had extensive experience as field supervisors and outreach workers, none had any training in qualitative research, hence the need for a capacity strengthening workshop. As part of the capacity strengthening workshop, the teams who would conduct discovery research in Regions 7 and 8 participated in sessions on the differences between qualitative research and other types of information gathering, the structure of an in-depth interview, the importance of a respondent-centered mindset, rapport building, mindful listening, the use of open-ended questioning techniques, probing, and research ethics. Participants then practiced conducting interviews with each other using the interview guides.
Field Research
Two research teams of seven people each, including staff from Breakthrough ACTION, central and regional VCS, and MoH PR/HPU who participated in the capacity strengthening workshop, conducted research activities during a one-week period in October 2018 at mining communities across Regions 7 and 8. In Region 7, research focused on two major communities and six mining camp areas, while in Region 8 the team focused on one major population center, four mining camp areas, and a rural health post. A total of 108 people (miners, camp managers, health testers, regional administration, media professionals, and hospital staff) from these communities were interviewed (Figure 2).
The objective of the deepening understanding interviews and FGDs was to understand the experiences of each stakeholder group around malaria-related behaviors. Separate “lines of inquiry” (or interview guides) were developed for each stakeholder group so that conversations would be relevant to each context. For example, the lines of inquiry for miners focused on understanding a standard day of work in the mines, perceptions about personal health including preventing and coping with malaria, as well as their relationships with camp management and health services. For camp managers, the lines of inquiry focused on the context of the camp, their relationships with miners, the challenges malaria poses for their professional life and the business of mining, and their role in protecting the health of their workers. For the volunteer RDT testers, discussions focused on how they perceive their role as a tester, how they relate to and communicate with miners who come to them for services, the challenges inherent in their work including reporting requirements, and their relationship to the health system that provides testing and treatment supplies, training, and supervision.
Interviews and FGDs were conducted in available spaces where some degree of privacy was possible at camps or in the larger communities. Each interviewer was supported by a note-taker/observer who also operated a handheld audio recorder. Prior to initiating each interview, the purpose of the activity was explained and consent was sought from all participants to conduct and record the interviews. Field teams took photos and recorded general observations of the field sites to document findings relevant to the lines of inquiry. At the end of each day, the interviewer and observer transferred their notes and observations onto a summary sheet, reviewing the recordings if necessary, and capturing the highlights of each conversation, including: the respondent’s personal motivations in daily life; challenges they face; things that give them satisfaction in their life; perceptions about malaria testing, treatment, and adherence; and any initial insights or interesting findings worth noting.
Data Processing
At the end of the week, the research team in each region met for a daylong session to compile the findings across all of the interviews. First, the team transcribed highlights of the interviews onto colored Post-ItTM notes, with one finding per note. Findings were color-coded by stakeholder groups. Findings could include quotes, paraphrased comments, observations, facts, or initial insights. The goal was to get information out of research notes and researchers’ heads and physically onto the wall where it could be processed collectively.
After extracting the findings, each research team worked together to group the information by sub-themes through an iterative process of clustering, discussing and comparing clusters, then reclustering until all findings were located in a larger map of themes and concepts. The two regional teams used slightly different approaches: Region 7 grouped findings irrespective of stakeholders (that is, combining similar or related findings across stakeholder groups), while Region 8 grouped findings and created theme clusters within stakeholder groups. Examples of sub-themes included such things as malaria knowledge, care-seeking behaviors, motivations to enter into mining, misconceptions about malaria, and other health concerns. A total of 92 themes and sub-themes were generated across the two regions. Each step of the clustering process was photographed in order to allow retrospective examination of how the clusters emerged and changed and to identify the final insights. The physical artifacts (flipcharts covered with clustered Post-ItTM notes) were rolled up and transported back to Georgetown, where an Insights Validation Workshop was held.
In Georgetown, each research team reviewed the other team’s data and collapsed common sub-themes into broader themes across regions. Some sub-themes remained specific to a stakeholder group while others were crosscutting. For example, all of the sub-themes on malaria knowledge, knowledge about malaria transmission, and malaria symptoms were collapsed into a broader “Malaria Knowledge” theme. Afterward, team members focused on one theme and individually reviewed the findings associated with each sub-theme to identify key ideas that were representative of the broader theme (e.g., a compelling quote from a stakeholder). Initially, the research team generated 14 themes. These themes were later consolidated into the 11 themes that correspond to the insights presented in this report.
Insights Harvesting and Validation
After finalizing themes, researchers (typically from two different regional research teams) worked in pairs to review findings and generate preliminary insights related to a particular theme. An insight has three distinct characteristics: (1) it comprises two or more disparate pieces of information (2) that combine to shed new light on a situation (3) in a way that suggests opportunities for action to collectively generate, develop, and prioritize ideas around how to improve malaria testing and treatment among miners in Guyana.
Development of Design Artifacts
After crafting and refining the insights, the Breakthrough ACTION Guyana team reviewed each insight individually to identify one or more “design opportunities.” These opportunities frame the specific challenges proposed in each insight and are presented in the form of a question that starts with, “How might we…?”.
“How might we” (HMW) questions help a design team think about the opportunities and challenges implied by an insight in a constructive way. A well-crafted HMW question does not suggest only a single solution. It should be aspirational and encourage a broad range of answers that point toward potential solutions to a particular challenge. Moving into the subsequent Design & Test phase, the HMW questions provide a quick and effective way of translating insights into ideas, concepts, and solutions that can be prototyped, co-designed, pilot tested with stakeholders, and ultimately implemented.
The team created other design artifacts such as personas and journey maps for miners, camp managers, volunteer testers, and community health workers. Personas are key archetypal users that represent the needs, goals, values, and behaviors of larger groups of people (13). In this case, they allow us to understand our target audiences in a real and human way. Personas allow us to make evidence-based decisions, which means that all persona information is derived directly from our fieldwork. Acting as stand-ins for real people, personas are tools that help guide design teams in asking the right questions, generating insights, and ultimately making decisions about the functionality of a solution.
Journey maps illustrate the experience pathway or “journey” of a persona from their individual perspective and allow us to highlight pain points and opportunities for intervention (14,15). Journey maps tell the important stories of our personas in a way that places them within a broader ecosystem of interactions between people and systems; they help us to consider our personas within their unique context, rather than in isolation. Most journey maps include a timeline, opportunities for intervention, and elements of the persona such as pain points, thoughts, and feelings. Journey maps are useful during the Design & Test phase because they help us to keep the experiences and interactions that influence behavior at the forefront.
Design & Test
Stage I of the Design & Test phase included an Imagine Workshop which used HWM questions in the development of prototypes, while Phase II included the testing of prototypes and the decision-making process used to prioritize solutions.
Design & Test Stage I: Imagine and Refine
Imagine Workshop
The Imagine Workshop 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 use of MoH services.
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.
The Imagine Workshop began with a recap presentation of the 11 insights that emerged from the Define phase. As each insight was presented, workshop participants were asked to consider:
- What is new or interesting?
- What are the initial ideas that come to mind?
Objectives of the Imagine Workshop include:
- Review and refresh insights from Define stage
- Immerse the workshop group in the research findings
- Move into “idea generation” frame of mind
Use of HMWs and Development of Prototypes
During the workshop, participants were divided into five groups. Each group was given two insights and corresponding design challenges framed as HMW questions that were previously developed. These questions were used to guide the generation of new ideas for possible interventions. In all, more than 790 ideas were generated and then later collapsed into eight broad categories. From the vast set of potential solutions, the Breakthrough ACTION team examined trends and themes and clustered similar ideas into refined groups of concepts. The concepts identified were then distributed to the groups of workshop participants who further developed the ideas by merging smaller ideas and adding details where necessary.
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 allowed the team to test the idea with real audiences quickly and cheaply.
A prototype might take many different forms. It is important to note that the prototype might look quite different to what the idea would look like in reality, if it were implemented. A prototype is useful as long it allows us to learn about the idea by proving or disproving our assumptions.
Low-fidelity prototypes were constructed from craft materials such as Play-Doh, colored paper, markers, and string. Some used digital mockups and photoshopped images.
Design & Test Stage II: Prototype and Test
Prototyping and Field Testing Methodology
Two teams using a similar composition to the research teams during the Define phase returned to Regions 7 and 8 for prototype testing in March 2019. The interventions were tested with a total of 145 persons including miners (56), malaria testers (20), camp managers (15), community members (32), health workers (15), regional administrative officials (5), and others (2). On each day of testing, users were given the opportunity to interact with the prototypes and provide feedback on the ideas. Inquiries and observations were made about their initial thoughts and reactions to the interventions; what they liked and didn’t like about each one; whether they thought the intervention was useful; how each intervention could be improved, and any other suggestions they wanted to share. Based on the feedback received, prototypes were either refined, discontinued, or new ideas generated. Throughout the process, researchers followed two prototyping principles: (1) the greatest value should be created for the user with the smallest input of resources, and (2) prototypes should be put in the hands of the user (for testing) as quickly as possible.
Decision-Making Process
The project team aimed to identify the most promising ideas that could improve malaria testing and treatment-seeking behavior. Over the course of one week, the two teams adhered to the following methodology:
- Refine: Develop the ideas into something we can build by identifying assumptions and designing the finer details of the concept.
- Prototype: Build ideas into tangible low-fidelity models that can be physically taken and tested within communities.
- Test (Monitor & Evaluate): Give users the chance to interact with the prototypes and provide feedback on the idea. At this stage, some ideas will possibly be identified as undesirable, infeasible, or inappropriate, and will be discontinued.
- Imagine: Generate new ideas based on new findings and results of testing our assumptions. Reflect on what was learned the previous day, and decide how that will affect the ideas in development.
This methodology was continuous to give space for iteration of the prototypes with the target audience throughout the week.