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Design thinking and health communication: learning from failure

Priyanka Dutt

Country Director, BBC Media Action India

What do you do when your audience is difficult to reach, tough to keep engaged and doesn’t understand concepts you take for granted? Priyanka Dutt offers some words of advice from her team’s experience of running a health communication ‘laboratory’ in Bihar, northern India.  

Anyone working in international development will attest that human-centred design (HCD) has been a ‘trending topic’ in recent years. Design thinking has been applied to a range of challenges, from supporting democratic transition in Libya to building an all-terrain wheelchair for under $200. Melinda Gates even hailed HCD as the innovation changing the most lives in the developing world.

But what exactly is design thinking? It involves bringing together multi-disciplinary teams – think creative writers working alongside ICT specialists – to address challenges through rapid prototyping and repeated testing. At the core of HCD is building empathy with the people you’re designing for with the overarching aim of producing something genuinely valuable to them.

Marrying these principles with our own core value of putting audiences at the heart of everything we do, we decided to set up a ‘laboratory’ in Bihar, in northern India, which aimed to improve child and maternal health through communication. We saw Bihar as a great site for HCD-style innovation because it offered us the scope to test and fine tune new ways of using communication to promote healthy behaviours for women and children alike.

Bihar is home to 29 million women of reproductive age, who give birth 3 million times every year. And although Bihar’s maternal mortality rate has declined in recent years to 93 per 100,000 live births, it is still well above the Sustainable Development Goals target of 70. As for the communication challenges, less than a fifth of these women watch TV and only 12% listen to the radio.

Yet the lab’s early creations achieved a great deal. Over 50,000 people have graduated from our Mobile Academy training course, which is delivered through mobile phone audio messages. The course teaches health workers how to communicate more effectively to persuade families to lead healthier lives.

We also produced a set of cards and audio messages delivered via mobile phone – called Mobile Kunji – for health workers to use during their visits with families. The evidence shows that families subsequently asked health workers more questions and were more likely to follow advice on preparing for birth, family planning and how to feed babies.

Rethinking strategy: learning from failure

High on our early successes, we set about developing Kilkari (a baby’s gurgle in Hindi). This programme sends weekly audio messages about pregnancy, child birth, and child care, directly to families’ mobile phones, from the second trimester of pregnancy until the child is one year old. The aim was that Kilkari would be listened to across Bihar, by the most vulnerable families, with the greatest need and least access to information and services.

Drawing on lessons from two similar services from around the world, Mobile Midwife and BabyCenter, in addition to our own prior experience in Bihar, we were confident Kilkari would be a success. Just to be certain, we ran some tests before rollout and found that we had failed in our vision – and spectacularly so. We weren’t getting through to our main audience, women, as we weren’t using the right channels and language.

In the end, we went back to the drawing board on Kilkari four times, simplifying and stripping down the content time and again, until we got it right. Through repeated prototype-test-redesign cycles, we made the vitally important discovery that our basic assumptions about our audiences were wrong. So we went back to basics and asked ourselves the following questions to push us to rethink our strategy:

1. Is the content relevant and easy to understand?

We discovered that our content confused the audiences we were targeting, who didn’t understand even simple Hindi words like health (swasthya). Men understood more than women – likely due to their greater literacy and mobility – but Kilkari’s female focus meant that this wasn’t particularly helpful.

Audiences also struggled with other concepts we take for granted. They mainly think of time in mornings, afternoons, evenings and nights, but we’d referred to hours and minutes in our programming, time references which simply don’t exist for them. 

Finally, we also found that the speed and style of content used for Mobile Kunji and Mobile Academy was overwhelming for Kilkari’s audience. For example, dramatising content confused our listeners, who didn’t understand why there were so many people on the phone, all talking to them at once. We needed to have a single voice and a single take-away, simplified to the most basic information audiences needed.

2. Are we getting through to our target audience?

We primarily wanted to reach women, but discovered that it was mainly men who owned phones with the credit needed to receive messages from Kilkari, a paid subscription-based service. 

In response, we used tactics to prompt men to share information with their wives. For example, calls were scheduled for the evening when men were more likely to be at home, increasing the chances that they’d pass on what they heard. 

To drive up subscriptions, we also ran promotions targeting men, which presented the Kilkari subscriber as a smart and engaged role model father, who cares about the health and well-being of his family.

3. Can we do more to keep our target audience engaged? 

We did a big marketing push for Kilkari, partnering with phone companies to promote the service at 20,000 shops. This went hand-in-hand with community outreach through songs, street theatre, films, quizzes and much else. As a result, we initially got a lot of subscribers, but the drop-out rate was high, suggesting that the service wasn’t relevant to those signing up.

Applying HCD principles, we redefined our audience and rapidly tested solutions to come up with a new and improved marketing strategy. We partnered with community health workers, who were already in contact with the families expecting babies we were trying to reach and so could help us promote Kilkari to its intended audience.

We incentivised health workers by offering them free mobile talk time for every subscription they secured, and gave them even more minutes if subscribers stuck with the service for more than two months.  

In the end, our total number of subscriptions dropped slightly, but those who signed up did so for the long haul – our dropout rate fell to less than 10%.

From lab design to adapting for scale and sustainability

Ultimately, the lessons we learned from our mistakes paid off. Flash forward to January 2016, when the Indian health ministry began its national roll out of an adapted version of Kilkari. Kilkari is currently listened to by 1.6 million families in 11 states across India, every week. In a survey of Kilkari’s listeners, three out of four women said they frequently followed advice they’d heard on the service.

We’ll remember Kilkari as the project that taught us the most, not just about how to design for our audiences but also about the value of learning from failure. There’s also the long-lasting satisfaction that comes with finally getting it right.

If you want to find out more about how BBC Media Action used media and communication at scale to improve maternal, newborn and child health, go to our digital platform, Global Health Stories.

Priyanka Dutt is Country Director of BBC Media Action’s India office. Priyanka’s most recent publication is Rethinking communication for child and maternal health, which reflects on BBC Media Action’s Shaping Demand and Practices initiative to improve family health in Bihar, northern India. She tweets as @priydee