To be face-to-face with the people you’re designing with, to sit in the spaces they sit, and to listen intently as they spell out their greatest hopes and frustrations to you, a curious stranger, is a great privilege. To do so from a place of sensitivity to the extractive nature of research, and respect for the communities you’re working with, is a great responsibility.

When we visited Ghana’s Ashanti region back in February, we had the immense responsibility and privilege of working with Ghanaian communities to understand the landscape in which adolescent girls were seeking mental health and sexual reproductive health services.

We visited the adolescent services of clinics, and interacted with proud, well-intentioned health workers. We connected with teenage girls, some of whom had sought out mental and reproductive health services before, and many more who had never accessed these services before. Despite their mental health struggles and fears of unplanned pregnancy, the girls we spoke to shared a number of factors that prevent them from getting the support they seemed to want and need.

Our conversations and the spaces in which they took place helped us paint a picture of the many paths adolescent girls in this region find themselves barreling down when they lack financial support, emotional support, or both.

In our previous article, we broke down the decisions these girls make and the barriers they face along the way. In this article we’ll be unpacking the behavioural insights we gleaned from our research and how we worked with Ghanaian girls to turn those insights into actions using a behavioural design process.

What is behavioural design?

We see behavioural design as the gifted child of behavioural science and human-centred design. With parents who oftentimes sit at opposing ends of the table, behavioural design blends rigorous exploration of the drivers behind behaviour with creativity and deep empathy for people. Combining the best of these disciplines creates a participatory research and design process, where we listen to, learn from, and work with people to develop solutions that acknowledge their real lives and work towards their ideal futures.

The steps we took, with the people we took them with, led to three robust and thoughtful prototype packages that help Ghanaian youth get the mental and sexual health support that they deserve.

Before the actions: Collecting Insights

Through our primary research, we identified a number of hypotheses that might lead an adolescent girl to engage in actions that put her health and well-being at risk. For some girls, it starts at home.

On a tight leash

Some parents believe that keeping their daughters on a tight leash will prevent teen pregnancy, while other parents can’t afford to pay their school fees, forcing their daughters to drop out and seek out other means of support. Whether girls feel trapped in their homes or forced to leave them, we found that parents and their teens were struggling to effectively communicate about important topics. Our research helped us unpack why:

Unsupported adolescents don’t seek care

Our research revealed that adolescents who feel they can’t turn to their parents for support for their mental and sexual health concerns, may also be deterred from seeking clinical support due to:

Health workers aren’t able to provide mental health care

For adolescents who do seek out mental health services, they are often unable to find the support they need. We discovered that health workers are unable to offer adequate mental health support due to:

Confidentiality is key

For adolescents who do seek out sexual and reproductive health services, we found that they are often deterred by the lack of confidentiality:

Those who do seek care still face hurdles

Although unintended pregnancy remains a concern amongst adolescents, we found that adolescents do not access sexual and reproductive health services for prevention due to:

Inviting Action: Ideation

Armed with insights from our field research, we worked with UNICEF Ghana and Ghana Health Services to facilitate a two-day co-design workshop. At the start of our workshop, few participants understood how they could translate valuable insights from our research with adolescents, health workers, parents, and influencers into better, more supportive health services. With Ghana Health Services leading the charge, we brought people from a variety of regions and backgrounds into the behavioural design process, supporting them with tools to imagine creative opportunities for the healthcare system to better involve and serve communities.

We offered questions to help inspire their ideas:

• How might we design mental and reproductive health services that ensure the dignity, privacy, and confidentiality of adolescents?
• How might we create an environment in which adolescents are able to access mental and reproductive health information when and where they need it ?
• How might we equip health workers to better anticipate and meet the unique reproductive and mental health needs of adolescents?
• How might we enable adolescents to have a voice in the design of mental and reproductive health services so that they better meet their needs?

One team wondered, “How might we get condoms to adolescents outside the health facility?”

This question led to a prototype of a condom vending machine; a box constructed from cardboard, masking tape, and colourful paper that allows participants to visualise and interact with a solution for accessible contraception. Placing these vending machines in public spaces frequented by adolescents — grocery stores, malls — meets young people where they feel most comfortable. By removing human interaction and stocking the vending machines with other goods like juice and candy, adolescents can use the machine without fear of judgement.

This discrete solution doesn’t just help the sexually active fly under the radar, it also helps unplug the radar. The fear of being seen as sexually active deters many adolescents from seeking out contraception and other important sexual and reproductive health resources. Offering condoms in the public realm can help shed light on the prevalence of sexual activity within the community. These vending machines help communicate that grabbing a condom is as common as grabbing a soda. This helps to normalise safe sex in communities where keeping these subjects in the dark is causing a lot of harm.

The co-creation session demonstrated the joys of collaboration and the boundless creativity of community members when given the tools and platform to create. The ideas that emerged underscored what our insights revealed: the hidden opportunities outside the clinic to support adolescents in accessing the support they need. The details and thinking behind these prototypes would serve as ingredients for the final prototypes to be tested with adolescents and health workers in Ashanti.

Activating the actions: Developing prototypes

Brimming with inspiration from the co-design workshop, we analysed the qualities of the prototypes and worked with Ghana Health Services to align on clear objectives to guide the development of our final prototypes. Ultimately, adolescents needed safe, inclusive, free, and easily accessible health services. So we aimed to design prototypes that could (1) support adolescents to advocate and access such services and (2) encourage community health workers and counsellors to support and enable adolescents to access them as well.

One of the biggest findings from our behavioural mapping and co-creation session uncovered was the opportunities outside the clinic to impact adolescents’ emotional and physical wellbeing, so each prototype package focuses on a different stage of a girls’ decision-making journey.

The Parent Package

A major finding from our research is that adolescents’ ability to advocate for their mental and physical wellbeing starts at home. If adolescents can’t effectively communicate with their parents about these topics, their ability to make healthy choices is severely diminished. But the lack of trust between parents and adolescents takes effective communication off the table.

But what if we put it back on the table? We designed a board game that offers parents and adolescents entry points into topics that matter to them and rewards them for tackling harder conversation topics like pregnancy, depression, health needs, money, reputation. The game is just one product in a suite of tools to help parents and adolescents communicate about difficult topics in a safe and structured way. The family package features a check-in guide to help facilitate these conversations as well as physical conversation cards and a digital SMS system that provides parents with prompts to help jump start them.

By encouraging families to have regular discussions about sensitive topics, the parent package seeks to build trust between parents and adolescents. These tools are designed to help parents understand how they can support and empower their adolescents to make positive choices, and help adolescents feel more comfortable seeking the support they need.

Early testing has shown promise with both parents and adolescents, saying it has sparked discussion, empathy and shared time together.

The Community Package

Through our conversations with girls, we discovered that a major barrier to health-seeking behaviour is a lack of “self-efficacy” — the perception that one has no control or power to influence one’s own future. When adolescents encounter hardship, they feel trapped and unable to overcome their circumstances. Feelings of hopelessness can be detrimental to an adolescents’ mental health and trigger actions that negatively impact their futures. How can we help adolescents realise their agency and understand that decisions regarding their reproductive health can negatively impact their future?

Creating opportunities for girls to break cycles of harm requires support that goes deep. We designed a community-based Cognitive Behavioural Therapy and mental health support protocol to equip health workers, even without formal training to support adolescents to navigate difficult emotions, set goals for the future, and find healthy coping mechanisms. The protocol outlines training and treatment and includes physical self-care sheets, referral cards to refer adolescents to coaching, and pins that adolescents are awarded after completing the coaching.

We tested the protocol document with eight community health workers and all agreed that CBT training is necessary and beneficial.

“It will equip us as CHWs to help others. Most adolescents who are timid and cannot share their problems would be contacted and assisted.” — CHW

The Health Facility Package

Who is better placed to ensure that adolescent health services are safe and inclusive than the people delivering the services themselves? How might we make it easier for health workers to incorporate mental health counselling into their existing service routines for adolescents?

We designed three checklist tools that can make it easier for health workers to check-in with adolescents about their mental health during consultations:

1. An emotional thermometer or feelings wall is a visual tool that puts emotions on a scale to help adolescents identify and communicate their emotions to health providers.
2. The five fingers tool uses each finger to signify a different emotion, allowing adolescents to communicate their feelings with their hands. The five fingers are also a tool to help adolescents practise a breathing exercise, offering five steps to slow down, observe, and focus on your breath.
3. The body scanning tool utilises an image of a body to facilitate discussions about various feelings and their physical manifestations. Health workers can ask adolescents to point to different body parts (e.g., head, heart, eyes, legs) to gauge their thoughts, emotions, sleep patterns, and physical activity levels.

When tested with a group of twenty health workers and adolescents, they were praised for making conversations about mental health easier, providing guidance, and organising knowledge.

“Yes, the images are a representation of how I see myself. The happy image reflects the first time my mother took me to the airport. The sad image reminds me of the day I was wrongly accused of stealing my grandma’s money.”
— Adolescent

Next Steps

We’re taking insights from our testing with adolescents, parents, and community health workers to make our prototype packages better suited to the needs of adolescents, health care workers, and families in the Ashanti region. One of the most exciting findings is that these packages have the potential to have much greater impact. Ghana Health Services will be supporting the development and leading implementation of these prototypes, with plans to expand country-wide.

These promising solutions would not exist without guidance from and close collaboration with our Ghanaian researchers, Ghana Health Services, UNICEF Ghana, and adolescents, parents, teachers, health workers, and community members in Asante Akim South and Adansi South. Their willingness to be open with us and to this process allowed us to find hidden opportunities for impact and forge solutions that bring insights into actions that can improve the wellbeing of adolescent girls across Ghana. We look forward to sharing preliminary results and key learnings with the colleagues and community members who invested their time and creativity into developing these initial prototypes. Stay tuned for updates!

Written by Ghana Health Services, UNICEF Ghana and Common Thread.

There are certain things girls would rather not talk about with their parents — crushes, periods, sex, financial troubles, emotional turmoil.

It’s often easier with friends, but there is only so much a 15-year-old girl can do to support her friend through an abusive relationship, an unplanned pregnancy, or debilitating depression. Who can girls turn to for answers when their families and friends are unable to give the information and guidance they need to weather the storms of adolescence?

Over the years there have been an increasing number of initiatives that seek to make mental, sexual and reproductive health services more accessible to youth — especially in contexts where these topics are taboo. For example, in Tanzania, combining contraceptive counselling and entrepreneurial skills-building is helping adolescent girls understand the role of contraceptives in achieving their future goals. In Zambia, Adolescent Wellness Days are inviting adolescents into health facilities every month to participate in individualised consultations and informative games on family planning, HIV, nutrition, and malaria. In Uganda, family planning for adolescents is being reimagined by providing youth-friendly services in an environment that inspires trust and comfort and empowering girls to refer their friends.

In 2012, Ghana ratified its Mental Health Act. The widely lauded legislation set out parameters for a new system of mental health care in Ghana, including protecting the rights of people suffering from mental health conditions, and the creation of a dedicated Mental Health Authority. But the Act did not include detailed plans for how to support adolescent mental health.

Last year, Common Thread joined UNICEF and Ghana Health Services on a journey to understand the environment in which adolescents in Ghana’s Ashanti region seek out mental health and sexual and reproductive health services — what drives them to do so (or not), and what factors impact their ability to have their needs met.

Understanding an adolescents path to, and away from, the clinic

“If a girl walks in, they are likely to get a pregnancy test. 3 out of 5 girls who come to this facility are pregnant.” — Health worker

We began by looking at the existing research on services for adolescents in Ghana. We reviewed over 20 studies to get a better understanding of how these services were being delivered by health workers, accessed by adolescents, and perceived by these groups and their communities. We found that multiple contextual factors can impact whether adolescents seek services: self efficacy, trust, and the physical and emotional environment of health facilities.

Girl talk

Through the leadership of Ghana Health Services, we connected with health facilities, schools, and communities across two districts in the Ashanti Region: Asante Akim South and Adansi South. We worked with Ghanaian researchers to ensure that the adolescents, parents, health workers, community leaders, school teachers and administrators we were speaking with were met with familiar faces — ones that spoke their language and understood their social and cultural nuances. We employed methods like card sorting, role play, and journey mapping to understand the behaviours, barriers, and emotions that emerged around accessing and providing adequate support for mental, sexual and reproductive health. Methods like these offered participants a visual, a scenario, or a written prompt to help them ease into more sensitive topics. These considerations were essential to building an atmosphere of safety, where stakeholders could speak openly and honestly about their dreams, perspectives, and lived experiences.

And they did.

Girls shared some of the challenges they face at home: parents who can’t afford to send them to school or firmly believe that confining them to the home is the only way to prevent them from becoming pregnant. These environments have made girls desperate for independence. Girls with families who can’t financially support them might drop out of school or take matters into their own hands, turning to older men to fund their education, often in exchange for sex. Adolescent girls who find themselves in these situations may become unintentionally pregnant.

We asked girls to draw what good health looks like to them. Their sketches depicted health as financial stability, access to technology, personal space and books, and a strong support system of friends and family to lean on. To these girls, this is what paves the way to a bright and successful future. To them, that is good health.

“We need understanding from our parents and a supportive environment. Parents should understand that we need time, space, and money to achieve our vision.” —Adolescent girl

What happens when girls lack financial support?

“It’s different for boys and girls. For girls, because their parents don’t support them, they have to fend for themselves. For boys, they work on farms to support themselves. Because girls have to fend for themselves, they end up getting pregnant.” — Community leader

“Girls are brought to communities where there are schools and left to fend for themselves, they are then forced to be in relationships where they can cohabitate and have their educational needs catered for [by] these boys and thereby get pregnant” — Community leader

“In this community, there was one girl who was 12–14 years old. She was getting financial support from her uncle so she was forced to sleep with him and became pregnant. When we found out, we told the family, but they told us just to leave it and not report it. The girl is not being taken care of by her mother and the uncle has also run away.” — Health worker

But even when girls do feel financially and emotionally supported by their parents, pressure from their friends sometimes leads them down paths to transactional sex and accidental pregnancy.

What happens when girls lack emotional support?

No matter what has led these girls to a place of physical or emotional distress, they deserve to have access to high-quality health services that respect and respond to their physical and emotional needs. We need to understand what barriers stood in the way between girls and the support they needed.

What gets in the way of girls accessing these sorts of services?

We found that stigma around mental health and sexual activity has really poisoned the experience of these services. Many girls shared stories of being judged and yelled at by health workers. Even the layout of clinics can deter girls from seeking out services. In one health facility, the area that provides health resources and services for adolescents is located within the reproductive care unit. Many girls worry about being seen using these services, in fear the news may travel back to their parents.

“If an adolescent comes for an abortion, we counsel them on the dangers of abortion. Only if they refuse our counselling, they will get an abortion. But mostly they will attempt an abortion at home. Two weeks ago, an adolescent came in with her mother because she was pregnant. The mother told us the girl had taken some medications and was in severe pain.” — Health worker

“Adolescents think their relatives will see them [at the health facility]. Usually they will only come to us when we go into the community. Some also feel shy because they don’t want the nurses to know. They think the nurse will say they are not good.” — Health worker

Many of the health workers we spoke to felt inadequately trained to address mental health issues, or believe that their methods were helping girls steer away from unsafe behaviour. But in reality, the way they were delivering services may be leading girls and their peers to steer clear of the clinic.

Turning her words to action

The challenges ahead were many: How can we equip health workers to provide adolescents with quality, confidential, and responsive care? What are some ways we can ensure adolescents have the support they need from their families to access health services and make decisions that give them opportunities for a bright future? How can we encourage communication between adolescents and their parents? How can we reduce the stigma around seeking mental health and reproductive health services?

First, we needed to address the communication chasm between parents and their children. The team looked at what was working in the community already, and what could create safe space and stimulate difficult conversations. Pregnancy, depression, health needs, money — could we stimulate regular and productive dialogue around these topics free of fear or judgement?

Next, we needed to equip health workers with skills and tools to support young girls through their mental health challenges. Health workers told us they lacked the time, knowledge and resources to address these needs. Adolescents told us they often felt judged and poorly supported when asking for mental health services. Reproductive health and mental health were conflated, often incorrectly linking mental health challenges with pregnancy and other sexual health needs. How might we make it easier for health workers to integrate mental health into their work?

Ultimately, good communication and improved services can only go so far when girls feel that their fate is out of their hands. How might we help girls develop a greater sense of agency and control over their health? Adolescents told us of the stigma related to reproductive and mental health services and that they often felt powerless to change their situation — their life path. To address this area, we need to equip young people to value self-care, support them to plan for their future, and help unravel mental models that limit their ability to believe that change is possible.

We looked outside the health clinic for inspiration to support girls’ mental well-being and empower them to make healthy decisions.

Our curiosity matched with the determination, imagination, and knowledge of our partners, Ghana Health Services and UNICEF Ghana, led to the design of three early prototypes that lay the foundation for a world where adolescents’ feel safe to access inclusive and high-quality mental and reproductive health services. These prototypes were shaped and tested by adolescent girls, their caregivers, health workers and community leaders in Ashanti.

Co-creating solutions that address the root of the challenges adolescent girls face, with the perspectives and hands of the people who endure and fuel these challenges, would not have been possible without a process that seeks to understand a persons’ behaviours and motivations, and centres their desires, priorities, and experiences.

When girls are given the opportunity to share their hopes, experiences, and ideas for service improvements, we get to see adolescent clients for who they are outside of a service interaction: girls who want to hang out with their friends, succeed in school, and want agency over their future, but struggle with shame, fear, and pressure from their parents and friends. We get to reframe their “issues” as opportunities, and empower them as designers. Through behavioural design, girls and their communities can inspire and direct the change they want to see.

To explore our ongoing prototypes and learn about how we went from insights to actions, click here.

Written by Ghana Health Services, UNICEF Ghana and Common Thread.

How wayfinding can help the vaccine opportunistic

By UNICEF Ghana and Common Thread

KUMASI, GHANA — With COVID-19 vaccine becoming increasingly available, Ghana has shifted its focus from vaccine procurement to vaccine uptake. As of February 25, 2022, less than 16% of Ghana’s population was fully vaccinated against COVID-19. Despite having enough vaccines to inoculate 88% of the population with at least one dose, only about half of the country’s available vaccines have been administered.

How might we explain this gap between supply and vaccine coverage? Are people in Ghana hesitant to get vaccinated? Do people have difficulties accessing vaccination services? Or, is it something else?

Kumasi is Ghana’s second-largest city and historic capital of the Ashanti Empire. It’s here where we discovered one possible explanation. Many people that we spoke to were not vaccine hesitant but rather, vaccine opportunistic. If vaccination services were clearly visible, available and easy to access, people had no objections to vaccinating.

Like all of us, we found that many people we talked to were generally willing to get the COVID-19 vaccine, but they often had multiple competing priorities and were therefore unlikely to go out of their way to find a vaccination site. It was a question of prioritization, convenience and perceived cost.

In other words, if someone was at a market and happened to hear an announcement giving the location of a nearby vaccination site, that might be enough to get them to get the vaccine then and there. Someone who is vaccine opportunistic would therefore be unlikely to actively search for a vaccination site without being prompted or shown the way.

UNICEF Ghana and Common Thread* collaborated with local civil society organisations (CSOs), and the Ghana Health Services (GHS) to help make vaccination as salient and easy as possible. Our 2-month project included a rapid assessment to help us develop a solution that prioritised vaccine opportunists. Our prototyping efforts focused on prompts for vaccination, support for finding such services, and information to help prime people for what to expect. The goal was to reduce friction so that individuals would need to exert as little effort as possible to get vaccinated.

One way to help people find and access certain locations and services is through an approach called wayfinding.

Wayfinding

Wayfinding is more than just signs. When done well, it’s an information system that enables people to move through their environment to a desired destination with ease. The best airports help us all make sure we know where we are, where we’re going, and what to expect when we get there. Wayfinding can be used to:

Effective wayfinding is logical, consistent, and considerate of its environment. Tools that are often used to create effective wayfinding systems include:

• Colours
• Symbols and icons
• Effective language
• Sound
• Light
• A designed environment (e.g. paths and rails)

The best wayfinding systems should be able to effectively guide people through their physical environment and enhance their understanding and experiences within these spaces. In doing so, they can both increase the efficiency of a process and improve the overall experience of users. Beyond providing direction, when wayfinding is used to guide a user to a particular public service, it can, at the very least, inform people of the existence of the service and may therefore act as a visual prompt for people to access it.

Existing wayfinding at vaccination points was inconsistent, lacking information and did not engender trust or confidence in the service being provided.

Although a wayfinding system alone may not increase COVID-19 vaccination rates, a consistent visual marker for a service may help establish familiarity and confidence in the service. By being located at strategic points of a person’s daily routine and eventually their journey towards receiving a COVID-19 vaccine, wayfinding could prompt a person to decide to get vaccinated, to direct people to convenient vaccination sites, and to inform people of what they can expect before and throughout the vaccination process. Setting expectations of the requirements and steps of the vaccination process can reduce any potential friction that might cause a person to abandon ship before getting vaccinated. Such communications should include information about requirements (paperwork, age), cost and expected wait times.

What we did

Before designing a wayfinding system, we needed a better understanding of COVID-19 vaccination in Ghana, particularly in the Ashanti Region. Our background desk research and multiple consultations with key stakeholders led us to Kumasi, an urban area with a high population density and unvaccinated population.

In order to get a more complete picture of the journey to vaccination — and all the potential barriers along the way, we spoke to vaccinators and people receiving their COVID-19 vaccines at static and mobile vaccination sites. We visited three different vaccination sites: a workplace booster campaign at the Bank of Ghana, a static vaccination site at a Kumasi Municipal Authority (KMA) clinic, and a mobile vaccination site at Kumasi City Market. Interviews revealed little resistance to vaccination, and we saw that periodic market announcements drove more people to the vaccine site.

Armed with our insights from the field, we brought people together to learn more. We held a day-long co-design workshop with regional level stakeholders from Ghana Health Services, UNICEF, implementing partners, and civil society organisations in Kumasi. Our goal was to collaboratively brainstorm and iterate on potential wayfinding solutions to help the vaccine opportunistic get fully vaccinated. We collaborated on our mission to reduce uncertainty towards the vaccination process, cue people to get vaccinated, and instil trust and confidence in the vaccine and the vaccination process.

Our team returned with key insights and ideas for effective wayfinding systems. Our design team went to work leveraging recognisable colour schemes that built upon the national vaccination card and the green and gold of Ghana Health Service’s ‘Good Life’ brand. They created mock-ups with critical messaging around how to prepare for the vaccination process.

Once the prototypes were developed, we moved on to testing. We built a rapid field testing kit and engaged our in-country partners, The Light Foundation, Theatre for Social Change, and RISE Ghana to get feedback from vaccinated and unvaccinated adults in Kumasi on the messaging, look and feel of our prototypes. While the people we spoke to were generally receptive to the ideas, we gained valuable insights on how to ensure the messaging and imagery were culturally relevant and impactful for Ghanaians.

Our findings revealed that messaging was helpful and understandable. Feedback underscored the need to translate the messaging into Twi (or other local languages, as appropriate) and adapt the hairstyle and clothing of the woman illustrated to resonate with the community in which the sign is placed. Wherever possible, information on wayfinding materials should be adapted to include the particulars of the vaccination site, especially their hours of operation.

The UNICEF team will take this feedback forward by working with health authorities in Kumasi to invest further in learning how renewed wayfinding and investment in reducing friction for opportunistic vaccinators will impact vaccination rates at these sites. This rapid and practical process has piqued the interest of partners in Ghana, who have become curious about how community-driven solutions and behavioural design can support improved health services for the people of Ashanti.

*Common Thread is a behavioural design company that aims to support people to make better decisions about their health. Want to know more? Reach out to us at hello@gocommonthread.com.

Healthcare workers are critical for COVID-19 vaccine rollout. They are the backbone of routine immunisation services and highly influence whether a person will vaccinate or not. But the voices that carry the most weight are not automatically the biggest advocates.

The COVID-19 vaccine rollout has shone a spotlight on mistrust in vaccines among healthcare workers at a global scale. Healthcare workers, like the rest of us, worry about vaccine safety, fall prey to misinformation, and have varied levels of trust in the government.

Healthcare worker hesitancy to vaccinate is not a new challenge, but the COVID-19 pandemic has introduced new complexity: an aggressive vaccine roll-out, high-risk of exposure and more pressure for healthcare workers to have all the answers for an increasingly skeptical public.

A literature review conducted in April of 2021 found that among 76,471 healthcare workers across the globe, 22.51% reported that they were hesitant to receive the COVID-19 vaccine. A survey of 6,043 Arabic-speaking healthcare workers living in and outside of Arab countries found that only 26.7% accepted the vaccine, with the leading barrier to acceptance being fear of side-effects. Another survey found concerns over vaccine risks and mistrust among healthcare workers in Romania, Croatia, Greece, and France — all the countries in the study.

These statistics are dangerous given the high level of public trust in healthcare workers.

How can immunisation programme managers better understand healthcare worker hesitancy in their contexts?

COVID-19 vaccine roll-out and preparing for the next pandemic starts with building demand for vaccination and increasing trust within our healthcare workforce. But measuring demand and hesitancy in the healthcare workforce and the wider population is complex. So how do you spot it?

By diving into the data. Social and behavioural data on healthcare workers offer clues as to what groups are more likely to be hesitant to the COVID-19 vaccine. Early data collection on 12,000 healthcare workers in the UK suggests that pregnancy, belief in COVID-19 conspiracies, lack of vaccination against the flu, a prior infection with COVID-19, lower health literacy, and higher economic security are all factors that can potentially make someone less likely to accept the vaccine to protect against COVID-19. These factors ring true for hesitancy in the general population as well. Data like this can help you identify potentially hesitant groups so that you can co-develop interventions tailored to their needs and concerns.

Understanding healthcare worker hesitancy in your own context starts with determining what you already know. Exploring previous research on general healthcare worker vaccine demand can provide a wealth of insight into what behaviours breed hesitancy in your context. Gathering lessons and indicators from previous health crises can also help you construct a better picture of what hesitancy looks like in your context.

Build on this existing knowledge by conducting your own research. You can explore different methodologies to fit within your budget — including rapid qualitative insights — or simply having regular conversations with healthcare workers. Whatever method you decide best suits your situation, ensure that you are collecting data regularly to stay on top of shifts in attitude.

Want to learn more about specific actions you can take to build trust of health workers and reduce healthcare worker hesitancy in your context? Contact us.

Today is Earth Day. Compared to other calendar markers, Earth Day feels relatively untouched by the pandemic. It’s a day typically celebrated outdoors, in our minds and hearts, through our deeds and donations. But as we celebrate the second Earth Day under Covid’s reign, the intersections between human health and planetary health are impossible to ignore.

In order to protect human health, we need to protect our planet. Covid is the most devastating reminder of this in recent memory. But it isn’t the only one.

Our global embrace of fossil fuels, deforestation and industrial farming practices have turned our air supply into an enemy, driven our climate to extremes, and made us more vulnerable to death, infection, food insecurity, record-setting natural disasters, and the next era-defining Disease X.

Human behaviour has rapidly accelerated climate change, but can human behaviour slow it?

Yes. In 2018, the Center for Behavior & The Environment at Rare identified 30 actionable steps that individuals and households can take to help reduce our carbon footprint. This list features the usual suspects: composting, ride-sharing, and solar-paneling, alongside a host of land use and agricultural recommendations.

But will cutting ties with the meat industry and converting the single-use plastic obsessives in our lives really make a difference?

Yes and no.

These individual behaviours have the potential to reduce our projected emissions over the next 30 years by over a third. However, that level of mitigation would require a global commitment to uproot our current practices and fully adopt these 30 commandments. You and a couple eager neighbors alone won’t save the planet. But if a collective shift in individual behaviour can make a dent, imagine what an unbending, unanimous change in both systemic and individual behaviour could do.

While the pandemic has taken so much away, it has given the world something incredibly valuable: a moment of revision. In the wake of Covid, governments are reimagining economic, energy and public health policy for a greener future. For the first time, we see climate considerations being made across all sectors. The status quo is slowly turning green.

These developments won’t be transformative unless institutions and individuals work in tandem to bring climate to the forefront of everyday decision-making.

At Common Thread, we understand that human behaviour lies at the centre of public and planetary health, these increasingly inextricable domains.

So we’re looking at climate change.

We’re learning from people at the forefront of climate action. We’re listening to the communities most vulnerable to climate change. We’re on the lookout for opportunities to apply our experience in behavioural design to help turn this pivotal moment into sustained momentum towards cleaner, greener pastures. Most of all, we’re here to help. Because if behaviour connects us, it can be what protects us.

We’re spending this Earth Day in admiration of how far we’ve come, and in preparation for all the work we have left to do. We hope you step outside and join us.

By Sherine Guirguis, Co-Director of Common Thread

Common Thread puts people at the centre of Public Health. Find us at: gocommonthread.com

“I’m pretty sure I had Covid last October. I never get sick, and this was bad. I couldn’t go to work for 3 days. I don’t need the vaccine. I’ve already got the antibodies.”

That’s my Uber driver, Terell, telling me why he feels safe shuttling people around every day. And why he won’t be taking any Covid vaccines when they come out. Terell is African American, which statistically makes him 5 times more likely to be hospitalised with Covid. His wife has Diabetes. And although he hasn’t been tested for antibodies, he doesn’t think a vaccine will give him any more protection than he already has. As for his wife, the fact that she never got infected, even throughout his own “illness”, is just a testament to her incredibly strong immune system.

The rumour mill around Covid-19 has been vibrant, no matter where in the world you live. Rumours and perceptions that circulate in Bucharest, where I live, are almost identical to the ones I heard this summer in New Jersey, where I met Terrell. Most people I have encountered on both sides of the Atlantic believe Covid-19 is real — they just think the Government or the Scientists have exaggerated its prevalence for political gain. Friends and family members in the US told me the same stories as swim instructors and teachers in Romania. “A family friend passed away last week, but he died of a heart attack and the hospital classified his death as Covid-19.” I have heard variations of this one numerous times. “They’re just trying to get the numbers up.” “We went out last night without masks and everyone’s fine this morning.”

A WAR ON TWO FRONTS

Covid-19 is the perfect storm for misunderstanding, rumours and fake news. The disease is new, it’s invisible, unpredictable, and its progression feels out of our control. Adding fuel to the misinformation fire, most public health advice throughout the pandemic has been confusing and overwhelming.

People are home, surfing the web and communicating via WhatsApp and social media, trying to fill in the gaps. While most of this web-surfing and social media sharing is rooted in genuine searches for information, the phenomenon has exacerbated what behavioural scientists call ‘Group Polarisation.’

Essentially, people will find the views they’re looking for online and once in the company of similar minded people, become more extreme in their views, even if they’re incorrect.

The situation is so widespread that the World Health Organization has given it a new name. An Infodemic is ‘an overabundance of information — some accurate and some not — rendering it difficult to find trustworthy sources of information and reliable guidance.’

“We’re not just fighting a pandemic; we’re fighting an infodemic” — WHO’s Director General, Dr Tedros Ghebreyesus.

So it’s really quite logical that the next stop on the Covid-19 infodemic train is the imminent Covid vaccine. Many people are anxiously awaiting the vaccine, pinning their hopes for “normalcy” to its rapid release. For others, the Covid vaccine is just the latest prevention tactic that seems politicised, confusing, and potentially more hassle than it’s worth.

COVID IN THE TIME OF HESITANCY

The hesitancy towards a Covid vaccine is an indicator that vaccine hesitancy — once reserved for fringe anti-vaxxer groups — is now moving into the mainstream.

“A lot of people you never would have imagined are now saying that maybe the anti-vaccination lobby has a point.” - Heidi Larson, Director of the Vaccine Confidence Project at London School of Hygiene and Tropical Medicine.

In April, a social media campaign #africansarenotlabrats trended fast and wide across social media channels, signalling a loud declaration from African citizens that they would not be testing the vaccine for the rest of the world. Protests continue in Africa against Covid vaccine trials, demanding that a long history of medical experimentation end now.

In the US, recent polls suggest that as few as 50% of Americans plan to get a Covid vaccine. A survey in the UK found that only 30% of British people are positive they’ll take the vaccine.

A vaccine has myriad benefits. But Covid-19 will be difficult to contain and stamp out if large portions of the world’s population won’t take a vaccine.

So what can governments do in the face of this unprecedented resistance to the only viable medical solution on the table?

Here are five suggestions that could potentially end the pandemic:

All of these things can and should be done now, before a vaccine has even been released.

1. Focus on the positives:

Find the people who have clearly said “yes” to a vaccine now — and make sure they get vaccinated. For this group of early adopters, policy makers must do everything possible to move their intention to action.

As Common Thread knows from research on broader vaccine acceptance, resistors are hard to budge, though it is tempting to tackle them first. But trying to sway this group will not yield great benefits. Policymakers should simply try to limit their influence.

Focus strongly on getting a vaccine to everyone who wants it. For the ‘wait and see’ group who will be watching for more evidence once the vaccine is in the market, make sure the case for efficacy and safety is clear and incontestable. They are likely to come around.

2. Make it easy:

Studies of annual flu vaccination campaigns show that even people who intend to get the flu jab often don’t get around to it because…well, life kicks in. To make sure life doesn’t get in the way of Covid vaccination, health officials can help make sure that people who want to get vaccinated don’t procrastinate, forget, or get caught up in a Zoom fog on their way to a clinic.

Public Health Managers can adopt behavioral science’s “make it easy” mantra to Covid vaccination. Set up clinics in workplaces, pharmacies, public areas, shopping malls and other community gatherings. Making it easy also has an added benefit of making it visible — helping to further cement vaccination as something everyone is doing.

3. Put people at the centre of the vaccination effort:

As we know from previous outbreaks, people respond to risk in dramatically different ways. Context, income, education, culture, social norms, and competing risk all play a huge role in determining how people will respond and comply with health advice. These variables and their priorities are constantly shifting.

For policy makers who are just trying to stay on top of the latest scientific evidence, people’s behaviour can seem like an unpredictable black box of obfuscation. But people — if engaged and employed as partners — can be powerful assets to leverage in an outbreak.

Dr. Mike Ryan, WHO’s Executive Director of Health Emergencies is a Common Thread hero for combining empathy with sound public health strategies that promote real community engagement and dialogue.

4. Speak the (emotional) lingo:

The anti-vaxxing narratives are diverse, creative, and widespread. Their angles range from safety, to the perils of capitalism, to the benefits of alternative medicines, to immunization as a conspiracy theory. Other hesitancy narratives for Covid vaccine play to people’s genuine concern over the speed of vaccine development.

Regardless of the content, anti-vaxxing narratives employ personalised, strategically-placed messages that tap into people’s emotions. By contrast, pro-vaccine groups generally have one simple message: vaccines work and save lives.

Public health campaigns often employ dry medical facts and stick to traditional channels to get their message out. To drown out the anti-vaxxing narrative, the alternative needs to be stickier, more creative, more emotional, and more widespread. People remember good stories that make them feel things. With hundreds of thousands of lives and jobs lost to Covid, and so much more at stake, there is no shortage of emotional fodder for the Covid vaccine story. Policymakers need to leverage it.

5. Design for women:

Women form 70% of the global health workforce, but are “underrepresented in leadership positions, clustered into lower-status, lower-paid jobs and commonly subject to harassment.” Across the world, women and girls perform more than 75% of total unpaid care work, making them most likely to serve as the primary caregivers for family members who have been affected by Covid.

In the United States, women make approximately 80% of family health decisions. Yet health programmes and emergency response plans are primarily designed by men, for other men. Want to ensure people take the Covid vaccine? Convince women it’s a good idea, and then help them secure it for their families.

This means placing women at the top table of strategy and programme design, and understanding what they need to make the right choice.

“The pandemic has finally opened our eyes to the fact that health is not driven just by biology but by the social environment — and gender is a major part of that.”

And Finally…

The history of pandemics and how they ended has demonstrated that humanity has so far prevailed when facing a challenge on a global scale. But the world didn’t have the internet in 1918 during the Spanish Flu. We didn’t have organised anti-vax movements, or legitimate looking social media feeds.

Arguably, there wasn’t such distrust in public health organisations when childhood vaccinations for Polio, Measles, Mumps or Rubella first became available. Human behaviour is what is spreading this deadly, raging virus. It should be a given for people to be at the heart of our future solutions to consign Covid-19 to history.

Sherine Guirguis is Co-Director of Common Thread — an emerging leader in behavioural science for global public health. Before starting Common Thread, Sherine held senior behaviour change positions with the United Nations for over 15 years. She has lived and worked in four continents, and is widely published in the realm of public health and social and behaviour change. She has designed and implemented large-scale social and behaviour strategies to rid the world of polio, respond to the Indian Ocean Tsunami, and halt West Africa’s Ebola outbreak. She is a busy mom to twin toddlers, and is often running after (or away from!) her kids.

If you’re interested in insights from the fields of global health, behavioural science and designing for change, check out Common Thread’s Newsletter, The Stitch, or find out more about what we do at: gocommonthread.com

How could public health use social media more effectively — from adapting scientific messages to ‘flatten the Covid-19 curve’, to using trusted stories to change behaviour and #StayHomeSaveLives?

By Mike Coleman, Co-Director of Common Thread: Putting people at the centre of public health.

We reached out to NYU’s Vice Provost of Educational Technologies, and distinguished internet and social media theorist Clay Shirky to ask him about social media, science and stories - and the role they all need to play in public health initiatives.

Our original interview preceded the outbreak of COVID-19, but the messages for public health communications are even more pertinent now, when a pandemic is no longer a foreboding warning, but a grim reality.

MIKE: Have institutions overlooked the opportunities that social media can bring to public health? And what are they missing?

CLAY: People spent so long assuring one another that social media was just going to be unimportant that when it turned out to be something that people would forego food to have, the totality of the importance of communications to the human condition has only just started to sink in.

The thing for public health people to understand about social media is it has a politics, but the politics isn’t left versus right, it’s insurgents vs incumbents.

The internet increases the ability of dispersed or disorganised groups to communicate with each other…and it’s become clearer than ever that the days of only one answer are gone and that trust adheres more to the people you know than the institutions you don’t.

MIKE: How does social media challenge official public health communications from governments or other institutions?

CLAY: I am not a public health person so the work I have done has always been in concert with someone who can translate. Whatever the long term values of the internet are for public health the short term question of ‘what do we do about this?’ comes up all the time. The news is mostly bad for traditional organisational methods.

What we thought was trust in institutions was mainly an information vacuum.

We’ve discovered that when they’re given no choice, people say they trust government or other institutions more than when there is a choice.

MIKE: So what happens when there is a choice of public health communications?

CLAY: When you add the internet to a communications situation to people with a set of goals or beliefs that are somewhat out of sync with the mainstream you get all these ‘insurgencies’ which are not necessarily political and certainly not violent.

The anti-vax people in the United States is an insurgency.

The internet benefits polarisation over moderation — in part because whoever it is at an extreme is almost by definition ‘locked out’ of access to the regular organisational and broadcast tools of the media — and now has this new capability.

The challenge is in adapting to a world where people on the ground not only have access to the tools of coordination they also often have access to tools of better coordination than the institutions.

MIKE: So what could the future hold for social media during a disease outbreak?

CLAY: Longer term the internet increases the flexibility of communications and co-ordination for everybody.

The internet holds out the possibility for public health that rapid, adaptive responses are seen not as unprofessional or outside the bounds of the larger organisations, but as something where those organisations can have units that respond like that or even more likely, those organisations know units that can respond like that.

We’re seeing places where the ability to respond to these situations, improvisationally at first, turns out to be a useful complement for the larger more organised responses.

MIKE: How should public health organisations be using social media? How can they get the science across to people through these formats?

CLAY: People look for comforting stories — we all do.

The ability to communicate with people has obviously exploded this century but it has begun with communications gaps. It’s only now that public health experts are realising that they can’t compete against a local story with science.

Instead there are places where they are saying I can go in with biomedical information and a story — it’s not science vs stories, it’s stories as the way that people who don’t have any sense of science can think about the world and still integrate new practices into their life.

MIKE: How can a national or global health message cut through to something that’s heard locally?

CLAY: You will have to work pretty hard to arrive at the point of asking, ‘How can we identify locals who will help us intervene?’ or ‘How can we talk to people who will tell us what story will make the scientific message palatable in this context?’.

The disconnections between the ‘globals’ and the ‘locals’ does not need to be as bad as it currently is and there are ways to develop a sense of ‘Here’s how I would operate on the ground if there were a disaster there’ — so that when the time comes and you are in a particular place you are not operating without local knowledge.

MIKE: How can we help public health organisations to adapt their culture and messaging?

CLAY: All large organisations are resistant to change but whereas commercial organisations are better at adapting to change in times of plenty — profit, plenty coming in, investing in new ideas, taking the long view — crises cause commercial organisations to freeze because everybody’s trying to preserve short-term cash flow.

Non-Profits have almost the inverse position, we are very complacent and self-unmoving when things are fine, but during a crisis, they can be surprisingly adaptive, in part because the demand for our services and our income are not completely tied together.

My bet for public health and for public health communications is that one crisis at a time these organisations are going to adapt. If we don’t adapt these tools and techniques we will not be able to deliver what we have promised and if we do we may actually not only be able to catch up but do better than we were doing.

Clay Shirky is an American writer, consultant and teacher — on the effects of the internet on society.

You can find Mike’s full interview with Clay along with other experts we’ve interviewed for our newsletter The Stitch on our SoundCloud channel

Common Thread has also produced a blog specifically looking at how human behaviour can help ‘flatten the curve’ of coronavirus cases and deaths.

See…

A Behavioural Guide to Covid-19

USEFUL LINKS & FURTHER READING:

Clay Shirky’s Medium site.
Clay’s Website
Clay Shirky on TED

Establishing the Truth: Vaccines, Social Media, and the Spread of Misinformation — Katherine J Igoe, Harvard T.H. Chan School of Public Health

Like everyone on the planet, we were left reeling at how quickly the world changed. For Common Thread it really hit us in mid-March. We were a week away from a meticulously planned four-day Human Centred Design Workshop on ‘motivating health workers’ for new members of the PATH Living Labs team in Zambia, when non-essential travel was cancelled.

By Mike Coleman and Amaya Gillespie, Common Thread: Putting people at the centre of public health.

If nothing else, HCD is about connecting with people in their element, understanding their context to co-design solutions that work. But what now? HCD without humans? No context. No-one in the same room. And… no time.

After weeks of planning, research and design, we had one week to re-imagine and create a workshop with participants from Living Labs Kenya and Zambia, and facilitators and speakers logging in from the US, Austria, Romania, the UK, Ireland and Australia.

In just a few weeks this has become an old story. We all have an embarrassing Zoom anecdote at the ready: maybe it’s screaming children and an important presentation, or a stray wine bottle left from the night before in the background of a ‘home office’, or cringe-worthy audio from that person in your last meeting who clearly did not know they were off-mute. Yawn. Ho Hum.

We seem to have seamlessly gone from virtual virgins to digital demons in a matter of weeks.

But like many of you at the time, we didn’t have all the answers. We dismantled the agenda and adjusted our mindset, our technology, our approach and even our ambition. We took some key HCD principles to heart: experimentation, iteration and a bias to make something.

This is what we learned.

1- Double the prep

You need more time. Prepare for everything. You simply don’t have the option of dashing out to get coloured pens during the lunch break, or deciding to take a flagging group outside to work under the trees for a session, or even stepping across the room to change the mood with a different ice breaker.

We asked ourselves a lot more “What if” questions than we normally would — not only to make sure that Plan A went well, but to also have Plan B, C, and D available, just in case.

Preparation is everything. Embrace the format — work through more scenarios than you think will happen, and work out what really needs video interaction, and what could be shifted to just audio, self-directed or off-line learning.

2- Hone the Methodology

Switching to an online format is as much about mindset as actual methodology. Everyone involved was encouraged to embrace a spirit of experimentation. That meant expecting surprises, delays, changes to the agenda and format. Maybe it’s the COVID-19 context, maybe this group was just amazing, but they were open, and trusted us enough to join us for the ride.

Develop new norms: When you are working online, many of the usual ice breakers won’t work as well. You won’t have as much non-verbal communication and the usual banter of face to face interaction which helps to create psychological safety and a healthy dynamic.

We had to find more ways to say, “We see you and we hear you.”

Normally you wouldn’t want participants talking to each other during a presentation or panel, but we encouraged it with the video chat function and using WhatsApp in parallel. In effect, this doubled the check-ins and feedback to create more empathy and connection and to replace in-room verbal and non-verbal cures and interaction we were missing.

Having your own sign language can also help to compensate for the limitations of video conferencing. Asking participants to show how they feel with a thumbs up or down signal, or something in between is an easy way to assess whether the instructions are clear or the team is ready to start, or finish. Though you can use emojis and other digital options, we felt that any physical action that linked participants to us and within the room was critical and an emoji is a poor substitute.

Whatever it is, the key is that everyone agrees on the same system of gestures or triggers, whatever you choose to use.

Variety and Learning Styles: Keeping people energised for eight hours in a face to face workshop is hard enough, but it’s not worth staying glued to a screen for that long — and probably isn’t necessary either. We shortened the screen time for sessions, gave assignments in between, ensured lots of change and movement, and changed speaker regularly.

Instead of 4.5 normal workshop days, the online version was converted to five 3.5 hour sessions, plus a half-day field research visit, all over the course of a 10-day period.

While we included a variety of “inhale moments” (brief presentations, new experts or guests) we were careful to balance these with longer “exhale moments” (group work, hands-on) for online format.

Cycling through divergent (e.g. going wide, generating lots of ideas) and convergent methods (going deep with a few ideas) also engaged a wide range of learning styles and helped to keep things interesting.

Offline to support online: One invaluable adjustment that we made soon after the switch to a virtual workshop was to develop a ‘Playbook’ for participants.

The Playbook included all of our planned activities, plus additional reference and resource materials. Participants arrived on the first day with Part 1 (the first 3 sessions) printed and waiting for them. Part 2 was modified as we went and finalized before the final sessions. The Playbook anchored the participant experience during the workshop, provided key signposts and highlighted what was important at each stage of the process. Critically, it also provided a valuable offline resource in case of any technical blackout or glitch.

The Playbook facilitated additional self-paced learning outside the workshop — a take home reference which participants could annotate themselves and return to over time. We also thought it looked kinda cool and sent a message: this isn’t a regular workshop.

Overall, the approach meant that while technology was critical, it was not the only mode of delivery.

The spacing between sessions, sometimes as much as three days, also gave groups the flexibility to catch up or complete activities and assigned homework while juggling normal work demands, and gave the facilitators flexibility to adapt content and methodology along the way.

3- Make the Technology Work for You

Remote delivery requires early decisions about what platforms will be used. We needed to consider not only how to facilitate the actual online workshop, but also the communication, planning and information sharing before, during and after the workshop. We focussed on free (or already in use) and easy to use platforms and applications that would be accessible and effective for our participants.

We used Zoom, using the chat and breakout rooms constantly.. The breakout function was particularly useful, not only for focussed group assignments (just like a ‘normal’ workshop), but also for allowing fairly seamless toggling by the facilitator between the smaller working groups.

The main workshop space in a conference room in Lusaka, Zambia had a microphone and a single video camera. The quality and positioning of the camera and audio was an issue especially for those joining remotely.

As such, more effort (and time) is required to build the rapport that normally develops in face to face workshops.

For general documentation, Google Docs worked well, but to share outputs easily and in real time, Miro boards were a great way to summarize the day’s events, capture images of the work in the room, and to build a sense of a coherent whole to the workshop. Most participants were able to use the Zoom video format throughout, but working with Miro strained some internet connections in Zambia during online sessions.

WhatsApp was useful for group discussion and team building between screen sessions, and for sharing comments and photos throughout the workshop. During the field trip to a local hospital, it also helped the Facilitation Team to connect with the participants as they did their field work.

We also used WhatsApp to communicate between facilitators and avoid broadcasting to the entire workshop.

In short, choose complementary technologies. We didn’t find a single solution. Think carefully about what’s done best online with video, and what’s best on other channels. Build in the time to practice, or create team-building, energizing exercises to help people practice in a low-stress environment.

4- Rethink Roles

Be ready to define key roles more fully for the online format. For example, where facilitators and some participants are together and some dispersed, you will need to be particularly clear on who is doing what both in the room and online, as there isn’t much wiggle room for negotiating things on the run without interrupting the whole process.

Lead and Support Facilitators: Consider having lead and support roles when you try the online format. The support facilitator can take more responsibility for time keeping, taking notes, monitoring online chats and feedback, uploading to the Miro board or preparing for the next session. This set-up also provides a much-needed second voice to spark people’s attention again.

IT & Technology: If you can, splurge for a dedicated IT support person (not a participant doing double duty) during any online experience, and particularly using multiple platforms across multiple continents, with participants with different technology capacity and bandwidth.

There will always be lines dropping out, video pixelation, interrupted audio feeds, and formats that don’t speak to each other, no matter how many times you trial the system. In these moments, there is nothing like having an IT guru to minimise that awkward dead spot with a work around. Even when not in the same room, they can be a neutral voice to interrupt the flow to advocate for better sound, video, or use of a particular technology.

Admin & Coordination — In any process the unsung hero is usually the admin person who coordinates all those details like invitations, passwords and accreditation, transport for field visits, timing and connection for guest presenters and participants, and most important of all — coffee breaks and lunch — even if those who join remotely will miss out!

You might say all of this is obvious for any event, but when things go wrong during an online workshop, there is nowhere to hide — no unplanned coffee break while the microphone is replaced, no sudden energizer ‘onstage’ while the next speaker is located ‘offstage.’

What now?

While a degree of spontaneity and pace can be sacrificed online, at the same time a motivated group ready to embrace an experimentation mindset, and keen to learn something new can be surprisingly forgiving.

The nature of the COVID-19 crisis itself has stimulated a new level of interdependence and understanding that we are ‘all in this together’ and need to collaborate to make it work. This changes the dynamic in ways that the usual workshop interaction might not achieve.

So what would we do differently now? Hard to say. The world was different just a few months ago. Common Thread’s plans to increasingly explore virtual opportunities and methods to reduce our climate impact, to reduce costs, and to embrace technology are now on the fast-track. Virtual collaboration is at the centre of our work with clients, our company planning and team building, and even our research is rapidly shifting to virtual channels.

With our Zambia colleagues we are working on a refined HCD process mixing virtual, in-person and self-guided user research. Already we’re seeing the benefit of looking at the world from the user’s eyes directly.

We expect to continue innovating, and developing new HCD field tools in this post-COVID world. But we are also keeping a half-packed bag ready in the closet for that day when we can finally get back to Lusaka.

If you’re interested in insights from the fields of global health, behavioural science and designing for change, check out Common Thread’s Newsletter, The Stitch, or find out more about what we do at: gocommonthread.com

Watching the Covid-19 pandemic unfold has turned all of us into recipients of the very things Common Thread usually advise others about: public health policy, outbreak response, risk communication, and behavioural strategies. Covid-19 has democratised disease — and people — perhaps more than any other experience in our lifetimes.

By Mike Coleman and Sherine Guirguis, Co-Directors of Common Thread: Putting people at the centre of public health.

These past few weeks have certainly been the most effective exercise in empathy-building we’ve ever been a part of.

As professionals and as citizens, it’s been a fascinating, at-times scary, and mercurial couple of weeks. We’ve seen the impact of fact vs fear-based communication, and watched the ways in which we — and those around us — respond. We’ve seen misinformation and myths come into our homes and inboxes every day and have had to decipher fact from fiction, at times with great difficulty. We’ve confronted our own trust in Government and International Organisations, and questioned their ability to make decisions on our behalf — vacillating between wanting them to be more forceful and nudgy, and wanting more autonomy on the length of our daily walks.

We realise these are strange, scary times, and people are acting scared and strange.

If you need a break from rooftop aerobics, operatic arias, and your kids (let’s be real), we’ve pulled together a few of our very favourite resources to help you better understand the most important resource we have to fight this pandemic: people and their behaviour.

Before the world went on lockdown, Common Thread was gearing up for an exciting year. Our organisation began expanding and we are increasing our strength in public health, anthropology and behavioural science.

We’re also working with wonderful new clients like PATH to harness the power of HCD (Human Centred Design) for frontline health workers, and in new countries like Ethiopia and Namibia to understand barriers to civil registration, including amongst refugees. We’ve been filming in rural Balochistan, in Pakistan, to better understand journeys to health, and have just finished delivering a five session HCD workshop in Zambia and an outbreak communication course with NYU — both 100% virtually.

This pandemic may be the single largest behaviour change effort in history.

We’re all doing things differently and at Common Thread we are trying to be mindful of what we can learn from all this. Our (unfortunately!) prescient interview with Dr Jonathan Quick, author of The End of Epidemics in our last Medium piece still rings hauntingly in our ears: the last century is riddled with cycles of public health panic, followed quickly by complacency (repeat — rinse — repeat). Fingers crossed things are different this time.

Building A Wall Won’t Prevent A Global Pandemic

So here are a few of our favourite resources, and you can also check out our Field Notes page on our website, Twitter and Instagram for more updates.

Stay safe and stay healthy, friends.

Sherine and Mike

The Stories We Can’t Stop Talking About…

Who Let the Virus Out?

If you’re still not clear how a few cases of Coronavirus managed to explode into a full blown Pandemic, despite draconian social restrictions that are the envy of all Western Democracies, watch this infographic.

Are we too “Loose” in the West?

First of all, get your minds out of the gutter. “Loose”, in a Covid-19 context, refers more to your fondness of democratic norms than anything else. The differences between individualistic and collective cultures on behaviour has long been a focus of study for behavioural scientists, particularly as it impacts behaviours like immunisation. In the context of the coronavirus pandemic, this same phenomenon — and where you stand on the cultural spectrum of looseness — could mean the difference between being able to flatten the curve, or not.

Hand Sanitizer, Masks, and….Toilet Paper?

If you’re looking for a nerdy analysis of why every shopping cart you saw last week was overflowing with toilet paper, there’s a perfectly (ir)rational explanation: “There are at least three factors driving our response — scarcity, social proof, and regaining a sense of control.”Even behavioural scientists themselves couldn’t resist the social pressure to stock up.

The Research We’re Curious About…

Behavioural Sightings at the World Health Organization

The World Health Organization wants to know what people know and think about COVID-19. This unprecedented inquiry into human behaviour led by the world’s largest organization of doctors and epidemiologists is like a coming out party for the newly established Behavioural Insights Unit at WHO/Europe. They’ve made their research tool free and accessible to everyone, and are also offering support to countries who want to use it. You can download the tool and find out more about it here.

Don’t Test Me

How quickly the Coronavirus can be halted is now almost entirely dependent on human behaviour. A new paper, which scoured 120 research articles in about a week highlights three factors that would make altruistic behaviour more likely: clear communication, feeling a sense of community and some form of punishment — social disapproval, for example — for those who break the rules.You may recognize some of them already being rolled out at a press-conference near you.

Cough this way, please

Your coughing could help epidemiologists better understand the distribution pattern and transmission potential of viral respiratory outbreaks in crowds. University of Massachusetts Amherst researchers have created an artificial intelligence device called FluSense which can analyze audio of people coughing in public places and turn it into actionable data. With the help of a relatively cheap microphone and thermal imaging data set up in a public area, FluSense can’t tell you if you’re sick as an individual, but it might be able to tell city administrators when a particular neighborhood is about to have an outbreak.

Sharing is caring

Collaboration amongst social scientists has arguably never been more important. This global list of social science research tracks new studies planned and ongoing about COVID 19. It includes published findings, pre-prints, projects underway, and those at proposal stage. If you want to collaborate with a group of social researchers, avoid duplication, or identify a critical gap you can fill, download the shared spreadsheet. Please share widely amongst your networks.

Lessons from the Behavioural and Social Sciences — now and later

This paper, hot off the press this week, was written by 36 authors from around the world and highlights work on navigating threats, social and cultural factors, science communication, moral decision-making, leadership, and stress and coping that is relevant to pandemics. Perhaps more importantly it highlights gaps that need to be urgently filled and the value of these lessons long-term: “Whether policy makers are trying to increase vaccination rates or reduce the harm of climate change, they will be fundamentally facing many of the same issues.”

The Lessons that are Sticking with Us

“I told you so” — said Bill Gates Never

Remember when Bill Gates told us we weren’t prepared for the next pandemic…..FIVE YEARS AGO? His TED Talk from 2015 feels like an eerie prediction into the future. Except it was based on science and data, so really it just feels like everyone ignored the data. The Bill & Melinda Gates Foundation tried once again last year. They,organized a pandemic simulation exercise at the World Economic Forum in October 2019 — just 3 months before Covid-19 took off in China. The key takeaway- we’re not ready. Anyone surprised?

Luckily for us, Bill Gates isn’t the “I told you so” type. Instead, the Bill and Melinda Gates Foundation is working with the World Economic Forum to set up a Covid-Action platform among governments, international organisations and the business community to focus on three priorities.

Hopefully the world will listen more closely this time.

Visual graphs are worth a thousand words

We know most people have their favorite data tracker for the outbreak (this is ours).

More than ever, we’re seeing how important it is to provide visuals and graphics to help people interpret numbers and science.

What started out as an exercise in counting numbers is now a plotting exercise reminiscent of your high school algebra class. Unfortunately, a lot of people don’t really know how to read graphs, and this innumeracy can lead to misinformation and misguided decision making.

If you’re graph literate, you can track how your country is flattening their curve with this nifty time series graph from Visual Capitalist.

#StandAgainstCorona

Knowing the impact of pledges on behavioural follow-through, a team of behavioural scientists launched the #standagainstcorona pledge . It’s a public commitment to carry out four life-saving behaviours. We took the pledge and so should you! Interested in the science behind the pledge? Check it out here.

Kids need to be entertained

Who knew? There’s no shortage of lists circulating amongst desperate parents trying to keep their kids entertained, mildly stimulated, and away from their Zoom cameras. This is one of the best lists we’ve come across, put together by a mom and former educator, and crowd-sourced by other parents around the world. It includes live virtual classes for all ages, museum tours, puppet shows, toddler concerts, art, magic classes and more. You’re welcome.

What’s distracting us from our work…

Note: This list is really, really long. Are we the only ones finding it hard to focus?!

The groceries no one wants to panic-buy

Wondering what’ll still be left on the shelves for your midnight grocery run? Chocolate hummus, chick-pea pasta, Dasani water (weird), and all the vegan food you could hope for are a good bet. These groceries are getting no love amidst the shopocalypse.

Dr. BJ Fogg is listening

Life looks pretty different now for most of us. If you’re taking a “one day at a time” approach, or frankly a “one hour at a time” approach, Dr. BJ Fogg has your back. Inspired by his book “Tiny Habits”, he and his colleagues offer daily Covid coaching sessions — or “tiny tips” as he calls them — for things like how to remain calm with kids, tools for seniors, and building healthy habits while working from home.

‘I’m no epidemiologist, but…’

If you’re tired of giving advice about COVID-19 that starts with that phrase, just stop right there. Don’t say another word. Shhh! Shush. Stop. Take this course from LHSTM first.

TED Connects with Bill Gates, Seth Berkeley and other smart people

This free, live, daily conversation series brings you real-time insights from some of the world’s leading experts on public health systems, vaccines, mental health, and human behaviour. It’s like having a private Zoom session with a celebrity. Insider tip: we logged in with Bill Gates this week and were way too excited to get a glimpse into his home office. Also exciting on the same scale, he was reassuringly optimistic about our prospects for beating Covid-19.

This Podcast Will Kill You

It won’t really kill you, unless you walk into traffic with your headphones on, but it covers so many things that can. Normally, each episode tackles a different disease, from its history, to its biology, and finally, how scared you need to be. Now, disease ecologists and epidemiologists Erin Welsh and Erin Allmann Updyke have created six chapters (and counting) dedicated to everything Covid, from the anatomy of the disease, to potential vaccines, to how to take care of your mental health.

Dr. Tedros on WhatsApp

OK, it’s not really Dr. Tedros personally on your WhatsApp feed, but it’s the next best thing. Text “hi” to +41 79 893 18 92 and get the latest numbers from WHO, information on how to protect yourself, frequently asked questions answered, mythbusters, travel advice, and more.

Behavioural Updates to Covid-19

For constant updates and links to the behavioural side of coronavirus check out this selection of articles and links the Behavioural Scientist collates and updates daily. It’s kind of like the Stitch, but more predictable and slightly more ambitious (read: impressive).

The Things We’re Laughing About

We’re all looking for ways to remove ourselves from our phones detailing new restrictions, and mounting case counts. Here are just a few of our favourite escapes. Please send us yours on Twitter (@gocommonthread) or hello@gocommonthread.com

Italian Mayors losing it over lockdown violators

Nothing can prepare you for this. It’s the best. Love to all our Italian brothers and sisters.❤️

When politicians show their funny side

If ye dinnae understand this, ye dinnae ken Scottish!

Toothpick prototype

No step is too small, no invention too basic, to halt Covid-19. This brilliant idea had a lot of harsh critics, but we still love it.

Behind every successful woman is a man without pants (sure to be our most popular link)

M-m-m-my Corona

Finally having too much time on your hands, a love of 80s music and semi-professional audio equipment pays off!

And finally, if you’re concerned you may have inadvertently stock-piled, this Coronavirus Poop Calculator here can show you how much poop you need to produce before you run out of stock.

This Medium piece was produced while…

Mike was keeping fit thanks to this video from a 75-year-old in Cork, Ireland, while holding family dance parties to newly-discovered Zambian music.

Sherine was earning a PhD in toddler arts and crafts, and resorting to this by evening.

If you’re interested in insights from the fields of global health, behavioural science and designing for change, check out Common Thread’s Newsletter, The Stitch, or find out more about what we do at: www.gocommonthread.com

P.S. — The Things Our Readers Are Suggesting

Thanks to those of you who’ve reached out to us with your own useful links and apps to help us with our behaviour…here’s one from the team at Am Mindfulness…keep them coming :)

Am Mindfulness is free for the duration of the outbreak to help with anxiety and depression induced by self-isolation, uncertainty and loneliness. Thanks for reaching out Avetis Muradyan!

As the world’s attention turns to the threat of the Coronavirus, we revisit our discussion on whether the world is prepared for the next global disease outbreak. The consensus seems to be we’re due a big epidemic — the kind that would fundamentally disrupt life as we know it. A pandemic could affect food supply, the global economy, energy, productivity, transportation, foreign relations, healthcare, and ultimately cause significant death on a global scale. Are we ready?

By Mike Coleman, Co-Director of Common Thread: Putting people at the centre of public health.

The Global Preparedness Monitoring Board published its annual report in September 2019 saying we’re not prepared for the global, catastrophic, biological risks that are upon us. They also said if a similar contagion to the Spanish Flu of 1918 occurred now it would be four times larger. That’s a terrifying prospect.

In December last year, we reached out to Dr Jonathan Quick, epidemiologist and author of The End of Epidemics for our year-end episode of The Stitch to ask him how we can minimize the risk of or even prevent the Next Big One?

He also discussed the role behavioural science, and those of us working in public health organisations like Common Thread can play.

Then, at the end of 2019, a cluster of cases of pneumonia with an unknown cause were reported from Wuhan City, Hubei Province, China.

We reached out to Jono last week to get his view on this new threat, and whether 2019-nCoV, as it’s been named, has the potential to become the Big One that he and other public health professionals have been predicting.

Coronavirus — The Latest

See the Latest Situation Reports for Coronavirus, from WHO.

Find out how to protect yourself from Coronavirus with the advice on the CDC site and see the WHO’s advice for the public to reduce exposure and transmission.

MIKE: So Jono, tell me about your views and experience during times of major health crises?

JONO: I had seen how long it takes the world of global health to get stuff done.

“Looking back over the last century of epidemics it was so clear that we would panic — globally as health providers and as a global health community — and then we’d fall back into the trough of complacency. That’s what I was worried about would happen after Ebola.”

What you typically have is outsiders starting to come in, people who don’t understand messages. Guinea was a classic example — their whole first set of posters said ‘Ebola Kills!’ People are in the community and they are seeing people dying. And then they say, ‘there’s no treatment’ — but there is treatment.

Treatment will reduce the mortality from 60 or 70% that you get in poor environments to 10% that you get in high income environments. Yes there was no medicine, or vaccine back then. But basic care — antibiotics for infections, hydration all those things — they were life-saving treatment.

So they messed up the messaging because they didn’t have that skillset.

MIKE: Could the Coronavirus become a major health crisis? The latest information is showing that it’s accelerating really quickly?

JONO: It is very concerning that this new coronavirus has spread in just four weeks to more than 20 countries in Asia, Europe, and North America. The mortality rate for the Wuhan coronavirus is currently estimated at 2 to 3% — less than the 10% for SARS or 30+% for MERS. But in just four days between January 31 and February 4 the number of cases in China doubled to more than 20,000. This far exceeds the global total for SARS of 8,096 worldwide.

Time is a critical factor in outbreaks, and if the response to novel Coronavirus among lower level officials had been quicker — particularly if it had kicked in before the start of the (Lunar New Year) holiday season — that could have made a significant difference and reduced the spread both inside and outside of China.

However, the global outbreak control community is quickly mobilizing.

The 2003 SARS outbreak spread to at least 4 continents and 27 countries within a matter of weeks. Lacking neither a vaccine nor an effective medicine, once mobilized, national authorities used basic public health measures and were able to eliminate this first new pandemic human virus of the 21st century within six months.

Some elements of China’s official response have improved dramatically since then including a possible world first — China has shared the genetic code of the novel coronavirus which has allowed labs anywhere to start working on a vaccine without the need for a specimen of the virus. Reporting to WHO and public announcements have also improved, as well as the establishment of a centre for disease control led by renowned virologist and immunologist Dr George F Gao.

MIKE: In an information vacuum, epidemiologists and communications specialists absolutely have to work together to get the message across.

So have we learned anything from the pattern of complacency and panic in a crisis between the West African Ebola outbreak and the current Ebola outbreak in North Kivu and Ituri provinces of the Democratic Republic of the Congo (DRC)?

JONO: The Ebola outbreak that we have now in the Eastern DRC is our first experience with conflict Ebola, really based on a long tough conflict, where trust is disrupted and everything else. I think many would agree we over-militarised in 2014 in West Africa — we panicked and finally sent the military and that wasn’t what turned it around. It was the community response.

In contrast, and some would disagree with this, but I think we are probably under-militarised the Eastern Congo right now.

It’s such a complex environment in the Eastern Congo right now as where the social fabric and trust is totally torn up by decades of civil war. That’s an area where I think the lessons and the tools and technologies that have come out of the West Africa experience are serving us well. But they can’t overcome the realities on the ground of disrupted, distrusting communities.

MIKE: What happens when there’s an erosion of trust with the state or anyone else perceived as delivering the health services and how can this affect the response on the ground?

JONO: The whole idea that as a country you can protect yourself by keeping to yourself is just an illusion.

“There are no walls you can build high enough…to keep out the flu virus or these other pathogens.”

MIKE: So how differently do we respond, or react in a crisis?

JONO: The brain works differently in times of panic. So the skills of delivering messages, the basic principles of communication in a pandemic — for government providers or anyone else — are to be first, be right, be caring.

There’s this panic and distrust that happens so that’s why being on the ground, in the community is a really important part. The other thing is the paradox of risk vs horror.

Ebola is a horrific disease — imagine blood coming out of the eyes and every orifice and that’s the reality, it’s horrific. But it’s never going to go global, yet it set Twitter records in August 2015 when the first two health workers were evacuated back to the hospital in Atlanta.

On the other hand, when the influenza outbreak in the US last year topped 80,000 deaths — more than the opioid epidemic which has gotten huge press — there was barely a blip.

MIKE: We talk a lot about community trust, but how important is trust between countries?

JONO: One of the things that will worsen any outbreak is when there’s a delay in responding to the outbreak because there’s a delay in reporting it. Countries are really reluctant to report outbreaks if it affects their economy. That’s why the SARS virus got to more than two dozen countries in a matter of weeks in 2003 because China wouldn’t admit it. Fortunately we moved quickly on that.

If countries are not trusting that the information they share about diseases or other things will be used by professionals in an appropriate way to do appropriate responses then they are going to be less likely to share it.

MIKE: Now we know that Coronavirus can spread between humans — could China be doing more to lock it down?

JONO: China is actually responding quite aggressively, especially in comparison to the 2003 outbreak of the SARS coronavirus. By the end of January, 17 cities and 50 million people had been quarantined. Early on Chinese President Xi Jinping told party, government, and health leaders the outbreak “must be taken seriously” and that “all levels should put people’s lives and health first.”

Since SARS, The Chinese Center for Disease Control and Prevention has become a highly professional organization under the leadership of Dr. George Gao. WHO was alerted, the new virus isolated, and the genetic sequence was shared so tests could be developed.

Once a new virus is confirmed, it takes rapid epidemic detective work to map patient contacts to confirm the actual source. Epidemiologists move from “what we see” to “what we suspect” to “what we know.” The critical factor has been daily information-sharing on cases, which has enabled the Chinese CDC, WHO, and others to confirm human transmission.

MIKE: Is the global health world prepared for another SARS like respiratory virus?

JONO: As a result of SARS — and accelerated by 2014 West Africa Ebola outbreak — the worldwide infectious disease capabilities to prevent, detect, and respond to such outbreaks has been considerably strengthened.

Through the World Health Organization and partners, we now have a rigorous tool to assess national readiness. The Coalition for Epidemics Preparedness, CEPI, is a novel epidemic preparedness partnership based in London which is catalyzing development of vaccines for viruses with a high epidemic potential.

“Despite these and other advances, the world is still highly vulnerable to another pandemic respiratory virus — a more contagious and deadly SARS-like virus, a pandemic influenza virus as in 1918, or a Disease X virus that we’ve never seen before.”

Less than one-in-three countries worldwide — including several in Asia and many in Africa — are not fully prepared to prevent and respond to new outbreaks. Investment in vaccine development is still lagging. And international travel, global warming, and a web of other risk factors are only increasing the chances for another global pandemic.

MIKE: What’s the real threat of an as yet unknown disease, sometimes called a Disease X?

JONO: Disease X isn’t some science-fiction futuristic thing.

Ebola was the Disease X of the 1970s. Never seen before and scared the heck out of people.

AIDS was the Disease X of the 1980s where you had this virus that took a while to figure out and these strange deaths that brought panic.

And SARS was the disease X of the 21st Century. So Disease X is a real issue.

The Coronavirus is a known epidemic risk, and therefore not properly speaking a Disease X. However, a distinctly new, deadly, and highly contagious coronavirus jumping from animals to humans — for which we have no surveillance system, proven medical treatment, or vaccine prevention — would effectively be a Disease X.

Similarly, the Zika virus that arrived in Brazil and other Latin American countries in the mid-2010s, causing an explosion of birth defects, had existed quietly in eastern Africa for decades. But it was a Disease X for the mothers and families of Latin America.

MIKE: What are your views on the behavioural science side of things when it comes to dealing with outbreaks of disease?

JONO: When you see people reacting in a way that doesn’t make sense you really need to understand how they’re making those decisions.

We know for example the whole idea that health people communicate with facts and information. When someone is not accepting the flu or measles vaccine you want to give them more information.

But we now know from research in politics and now in public health that there’s something called the ‘Backfire Effect’.

People who have ego invested in a belief — whether it’s that vaccines cause autism or that a particular candidate has a particular view on something — when you really provide the best facts and evidence, they hold on to their belief even harder and don’t change their belief.

So we really need to understand what are the pathways that we have to get people on board. It’s often getting the right communicator, but it’s also understanding what they care about, what they value and what they’re willing to base their decisions on.

Dr Jonathan Quick — A Brief Introduction

Jono has worked in around 70 countries. He spent 10 years running the World Health Organisation’s essential medicines programme in Geneva, during the time when increased access to HIV/AIDS medications was developing.

In the middle of the West Africa Ebola outbreak (in 2014–2016) he was working with a non-profit and grew concerned that the world had not woken up to the threat of global epidemics, which is when he decided to write The End of Epidemics.

This interview was brought to you by Common Thread

— a global public health, behavioural and communications organisation which puts people at the centre of public health. See: gocommonthread.com

If you’re interested in other insights from the fields of global health, behavioural science and designing for change, check out the latest edition of Common Thread’s Newsletter, The Stitch, or listen to the full interview with Dr Jonathan Quick and other experts in their field on our SoundCloud Channel.

Want to Know More?

Read: A World At Risk: Global Preparedness Monitoring Board’s 2019 Annual report on global preparedness for health emergencies.

Find out more about Spanish Flu in this podcast on Stuff You Should Know.

Learn more about The End of Epidemics and what can be done to stop the world’s next killer virus.