Messy but Worth It: Human-Centred Design as Applied within a Successful Vaccine-promotive Campaign

"...careful curation and close engagement within radical circles throughout revision and iteration can support product creation and help to develop a meaningful and successful intervention."

Human-centred design (HCD) is an approach to problem-solving that prioritises understanding and meeting the needs of the end-users by enabling a variety of stakeholders to cocreate effective solutions. While HCD is, in theory, a straightforward process, practitioners often struggle to navigate an excess of (often conflicting) ideas and to strike a balance between problem-understanding and problem-solving. This research team recently drew on HCD to develop a vaccine-promotive campaign that proved successful in a randomised controlled trial (RCT). This practice paper outlines the team's experiences with HCD, describing one workaround they employed (i.e., radical circles) that helped them overcome the complexities and iterative tensions inherent in HCD.

Project SALUBONG (see Related Summaries, below) sought to gain a better understanding of the current state of vaccine hesitancy in rural and urban areas in the Philippines. Vaccine confidence has declined in the Philippines following a dengue vaccine controversy in 2017 that led to a decline in vaccine confidence and uptick in vaccine refusal. As a result, the country lost its 19-year polio-free status, and there were measles outbreaks across several islands in 2019. The project aimed to codevelop an intervention to bolster vaccine confidence by using local narratives, designing and refining an HCD-driven intervention, and working with end-users and stakeholders (policymakers, community leaders, health promotion, and communication specialists). The team defines end-users as individuals receiving the service (caregivers and their families) and those delivering vaccinations (healthcare workers).

Following the principles of HCD, the project employed an applied, mixed-methods approach over four years beginning in 2020. However, due to the COVID-19 pandemic, the team had to forgo in-person data collection. In the spirit of HCD, they did not initially know what the intervention would entail. Instead, they developed its flow through these steps:

• Step 1: Empathise - The team first conducted remote in-depth interviews (IDIs) with Filipino policymakers (n=19) to understand general challenges for vaccination campaigns. Findings implied that widespread vaccination panic fosters public scepticism and is exacerbated by contextual and political influences that put pressure not just on vaccine confidence but also on health programmes more generally. They then then performed remote IDIs among vaccine hesitant (n=44) and vaccine accepting (n=11) caregivers, yielding stories that served as the intervention's backbone during the predevelopment phase. Based on these insights, they  developed a storyboard (i.e,, a sequence of illustrations that present a narrative) that depicted end-users discussing vaccines with healthcare workers and that could potentially be printed as educational pamphlets or converted into radio scripts or short animated advertisements, depending on user preferences.
• Steps 2-3: Define and ideate - Overlapping with Step 1, this phase entailed focus group discussions (FGDs) among caregivers who described themselves as either vaccine hesitant (1 FGD, n=5) or vaccine accepting (4 FGDs, n=22) and community health workers. The team observed that caregivers are drawn into their responsibility of becoming a good parent, which included ensuring that their children are free from vaccine risks. Healthcare workers, on the other hand, were more focused on upholding their responsibility to maintain the health of the general community, which, in some cases, resulted in healthcare workers pressuring families to vaccinate. These opposing perspectives led to tensions within and across parties. All respondent types highlighted a need for the storyboards to be tailored to the Filipino cultural context, and to feature characters of various ages, incomes, ethnicities, and household compositions.
• Step 4: Prototype
  • The team conducted IDIs with midwives and community health workers to ask for their feedback on the preliminary storyboards and visual analogues of the stories. Based on these inputs, the design team converted the storyboard narratives into a short-animated video. During this phase, the team saw a significant influx of ideas, characterised by the presence of unclear feedback, conflicting ideas and viewpoints, a wide range of potential solutions and downsides, and meticulous scrutiny of user personas, among other factors.
  • To mitigate this "overcrowding", the team engaged in a process that started with an individual envisioning a challenge, problem, or hypothesis, followed by two designers (pairs or sparring partners) engaging in criticism (i.e., attacking each other's ideas or hypothesis, comparing or combining different ideas). The pairs then assemble into larger groups, called "radical circles", wherein people with divergent opinions and identities are asked to critique the proposed idea, challenge conventional thinking, and create innovative solutions. Due to logistical challenges during COVID-19 pandemic, the radical circles were conducted using a combination of remote FGDs and in-person IDIs.
  • Following the radical circle sessions, the team further refined the intervention video and began to incorporate intricate details and codevelop the iterated characters of the storyboard. They also engaged in debriefing sessions to underscore insights gleaned from the meaning-making approach: Rather than concentrating on the traditional health promotion message of "vaccines are safe, free, and effective", they added a new meaning and value to vaccines, which centred on empathic components of love and devotion for children. At the end of this phase, they finalised the intervention, a 5-minute animation 'Salubong: Building Vaccine Confidence, which features narratives of Filipino families' experiences with vaccines (see video below).
• Step 5: Testing - The team tested the developed intervention against a control video in a RCT involving 719 caregivers of small children. (See Related Summaries, below.) In short, the intervention proved beneficial in shifting caregivers' beliefs and expectations towards childhood vaccinations, and respondents who had previously delayed or refused a vaccination for their children reported an increase in vaccine confidence post-intervention.Qualitative results indicated that intervention characteristics related to improving accessibility (subtitles, content summaries, social media shareability) and credibility (institutional logos, trusted messengers, in-person interaction) were the most crucial for viewer satisfaction.

Table 2 in the paper outlines challenges and mitigations across the phases of HCD. The streamlined bullet points are meant to inspire workable solutions in various contexts.

Reflecting on this experience, the team explains: "Radical circles provided a space for those who held opposing or critical viewpoints about vaccines to discuss and share in a diffusing environment. The acceptance of tension broadened our design process; we devised an intervention that gently critiqued the rigidity and lack of human care within the health system, but we did this in a manner that was attuned to Filipino perspectives and respectful of challenges healthcare workers themselves face....These approaches enabled us to create credible, resonant stories and characters to deliver these messages potentially contributing to the ultimate success of the final intervention in pilot-testing..."

In addition to radical circles, other practices that could show promise in addressing the challenges of HCD include design charettes, speed dating, and world cafés, among others. In addition, design thinking tools such as mind maps (www.xmind.com), affinity diagrams (www.lucidchart.com), impact and feasibility matrices, and the use of miro software (www.miro.com) could be advantageous for the organisation and prioritisation of ideas.

In conclusion: "HCD is complex, messy and time-consuming but creates a design space where end-users' demands and experiences are acknowledged and prioritised. Radical circles can assist in managing the complexities encountered and can reimagine meanings. It is crucial, however, to be aware of the limitations of HCD and to make concerted efforts to overcome them by including many viewpoints, expanding the scope of the questions and striking a balance between usability and other considerations."