Using Human-Centered Design to Develop, Launch, and Evaluate a National Digital Health Platform to Improve Reproductive Health for Rwandan Youth

Nicole Ippoliti; Mireille Sekamana; Laura Baringer; Rebecca Hope

doi:10.9745/GHSP-D-21-00220

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FIGURE
Overview of Phases of HCD Phases, Data Collection Objectives, and Methods Throughout the Design, Pilot, and Implementation of the CyberRwanda Project
Abbreviations: HCD, human-centered design; RCT, randomized controlled trial.
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Conducting design research of reproductive health content with adolescent girls. © 2016 Laiah Idelson/YTH
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Rough prototype of Shop interface. © 2018 Caroline Wong/YLabs
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CyberRwanda web app loaded on a tablet. © 2020 Oscar Muhire/AfricaMile

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TABLE 1.

Distinctive Approaches to Designing With Youth

Term	Definition
Youth-led design	Young people make the decisions on which problem statements to focus on. They are facilitators and designers of the solution development process, either with or without guidance from an adult team.
Youth-driven design	Young people’s voices and perspectives drive the decisions about the interventions and approaches that will affect them and their communities. Young people are actively involved in the decision-making processes and lead key project activities.
Youth-centered design	Youth are the audience of focus for the intended intervention or approach. They participate in the design process by providing data, input, or feedback to an adult design team. Typically, they are not part of the team that decides on the intervention or proposed approach.

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TABLE 2.

Selected Design Research Methods Used for CyberRwanda

Method	Examples of How They Were Used for CyberRwanda
Card sorting	Participants ranked cards with different images of people in order of preference (e.g., people they trust most with sensitive information or who they would ask for information on reproductive health). Additional prompts and discussion informed the initial design of the characters who deliver information in the webcomic.
Vignette cards	To explore provider knowledge and biases, pharmacists and clinic staff were asked to opine on which family planning methods and reproductive health services might be “appropriate” for different mock clients.
Role play	Role play was used extensively to understand taboos and stigma that youth held in discussing their reproductive health with others, including peers, providers, teachers, and parents, and prompt discussion on how to address these challenges. Dialogues also helped inform the style and tone of conversational content for the webcomic.
Codesign activities	Workshops gather audiences of focus to take part in the creative development process of brainstorming ideas for a specific design challenge and then bring them to life by creating rough representations of their solution idea. Youth were asked to develop paper prototypes of their own campaign addressing adolescent pregnancy in Rwanda to prompt further discussion on messaging, content, and digital and nondigital delivery channels (e.g., social media, magazines, and school lessons).
Surveys	Rapid, small sample surveys were used during design research to capture baseline knowledge, demographics, and technology usage among participants.
Journey mapping	Participants drew their journey maps, setting different life milestones and their expected timeline for their achievement.
Mystery clients	Mystery clients are trained community members who visit services or facilities in the role of the patient or client and report on their experience. Mystery clients were used to explore the service experience for young people requiring different products and services at pharmacies.
Observation	Observation was a critical method used to understand the level of privacy, dignity, and comfort for young people accessing health care services. In schools, observation of teachers, equipment, and classroom spaces helped us test assumptions around using school laptops to deliver CyberRwanda. Observations that existing laptops were not easy to use by untrained staff and did not afford privacy led to a pivot to instead use tablets in kiosks or school clubs.
Personas^a	Personas were used to better define potential groups of users with shared characteristics regarding knowledge, needs, and access to technology.

↵^a Personas are adapted from World Health Organization (WHO). Digital Implementation Investment Guide (DIIG): Integrating Digital Interventions Into Health Programmes. WHO; 2020. https://apps.who.int/iris/rest/bitstreams/1303132/retrieve.

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TABLE 3.

Prototyping Methods Used to Develop CyberRwanda

Methods of sharing prototypes used	Description
Paper prototyping: used to develop the initial design platform and subsequent iterations, content, and marketing materials (content, UI/UX, social media marketing strategy, promotional materials)	Paper and cardboard prototypes are used or co-created to create a quick but interactive physical representation of the product or experience.
Role play: Used in prototyping the end-to-end ordering experience	Participants are assigned certain scenarios and roles to help designers understand the interactions through observing the improvised scenario-specific performances.
Storyboarding: Used in prototyping workshops with pharmacists to walk through the potential value of the platform and pain points	Drawings or images displayed in sequence for pre-visualizing a new experience or service (e.g., a clinic visit).
Low- and high-fidelity interactive prototyping/digital prototyping: Used in the final stages of prototyping of the digital platform	Participants interact with an interactive prototype that has the look and feel of the final product.
“Wizard of Oz”: used to test a motorcycle taxi delivery service prototype	Participants interact with a digital product that appears to be computer-driven, when in fact responses are human-controlled. This method may intersect with others listed here.
Methods of eliciting feedback and preferences	Purpose
Ideation and co-creation: used to design and iterate on the cast of CyberRwanda webcomic characters, as well as developing storyline and content)	Participants generate entirely or partly new ideas for prototypes to test based on a design brief.
Elicitation: commonly used at the end of a prototyping session after showing multiple concepts	Asking the participants directly what improvements can be made to the prototypes to better reflect their needs and desires, what they prefer, and why.
Ranking: used to rank preferred channels of communication for young people to inform CyberRwanda marketing (e.g., posters, radio ads/shows, referral cards, and SMS alerts)	Participants vote and/or rank their preferred prototypes and top concerns.
Pre-/post-survey: this was used to evaluate knowledge improvement after interacting with an early prototype	Use surveys to evaluate change in specific indicators pre- and post-interaction with prototypes. The level of rigor may vary depending on the needs and the phase of the project. In early stages when testing low-fidelity, “rough” prototypes, these may help in rapidly deciding on prototype selection, but the sample size may not be powered appropriately. During the pilot, and implementation, and sometimes for live prototyping, an adequately powered sample is used.

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TABLE 4.

Key Findings and Iterations to Intervention Design of CyberRwanda

Key Finding	Iteration to Intervention Design
Supply-side barriers to quality care
Youth often saw health care providers as “gatekeepers” to accessing methods and were afraid about the questions they might be asked at health care facilities	We pivoted the platform away from simply linking to clinics to providing direct-to-consumer products and information directly in the hands of youth to reduce barriers associated with gatekeeping. Medically relevant screening is conducted at point of order to minimize bias-related barriers to FP/RH care and expedite the interaction between provider and youth. Youth can choose from a selection of pharmacists with transparent pricing.
Youth strongly preferred pharmacies as a point of access for contraception due to expediency and privacy	Deliver products and services via pharmacies: Young people’s priority concerns for privacy and expediency informed the pivot to supplying products via pharmacies instead of clinics, as originally planned. The platform also links to all public clinics in the intervention districts for longer-term methods.
Pharmacists lacked confidence in addressing young peoples’ SRH needs and had knowledge gaps on FP	Designed tailored training modules with and for pharmacists and pharmacy staff to address common misinformation, provide training on adolescent-friendly care, and support self-identification of provider bias to help providers improve access to care for adolescents.
Demand-side barriers to quality care
Program lacked content on economic opportunity and job readiness, making it less appealing to youth and less acceptable to parents	The webcomic stories and FAQs now include content on preparing for employment and address gender stereotypes on careers. The site links to job search resources. The site tagline is “learn about relationships, your body, and your future.”
Boys had clearly expressed needs for information on health, relationships, and reproductive health	Content, characters, and the direct-to-consumer platform were codesigned and implemented with and for young men.
Youth lacked access to trusted, nonjudgmental information in accessible language they could understand	Characters were designed with youth to represent trusted personas for young men, women, and parents. A webcomic format was introduced to deliver information in a compelling, locally relevant way, focused on addressing key behavioral barriers and social and environmental norms that stigmatized access to FP/RH services. All content was reviewed by gender and behavior change and validated by youth. Finally, it was approved by the National Health Communications Committee to ensure alignment with national guidelines.
Young people were primarily concerned with lack of privacy and confidentiality in accessing information and services	To minimize barriers to engagement and allay fears about confidentiality, no identifiable data were collected from youth, even though this limited the ability to track individual user engagement. All data from the CyberRwanda platform were gathered and stored in compliance with General Data Protection Regulation guidelines. The shop was designed so that users can order without supplying personal information, without needing to request the product in person from the pharmacist. An order code is provided, which is needed to collect their order, with an optional SMS to their phone.
Given low levels of knowledge on FP/RH, youth often seek help for a specific problem rather than a specific product	In the shop, we pivoted to include both products for quick access for informed users and added common scenarios as another pathway to access products on the platform for naïve users or users experiencing a crisis (e.g., “I had unprotected sex.”). When a user clicks on those scenarios, they access essential information and recommendations of products and additional services available.