Amplify Trusted and Familiar Sources

Channels of communication that include trusted and familiar sources should be used to amplify health messaging and seeking but with appropriate moderation and regulation.

The Challenge with Centralized Health Messaging §

We needed local ways and forms of communication, the presidential address and radio announcements were not enough. Each community has their own way of accessing and spreading information.

55 year old respondent from KwaZulu-Natal, South Africa

Our research highlights a number of factors that make it challenging for distant authority figures to effectively communicate health messages.

These authority figures are at times not trusted by members of communities who may not believe that these authorities have the community’s best interests at heart. This is especially true for marginalized populations, such as transgender communities, who often face stigma and discrimination.
At times, centralized forms of communication can appear insensitive to local contexts — with people being unable to contextualize these messages to fit into their lives; this makes it difficult for them to act on these messages.
Centralized communication tends to be one way and does not facilitate dialogue, which can be a crucial component of effective communication.

We get information through miking (public announcement). Announcements on sputum test (TB), eye treatment. This and that. Look, they give information through mike announcements and all. But if I don’t go to them, how will I understand the information?

An elderly TB patient in Dhaka, Bangladesh

Amplifying, yet Moderating Trusted and Familiar Sources §

Familiar and trusted sources, ranging from friends, family, and neighbors to community leaders and health workers are effective channels of messaging as these sources are generally trusted, understand the local context and are available for dialogue.

In this hospital we have had field staff who have worked in the community. They can reach people door to door. They can tell pregnant women and others too about coronavirus.

Ward Nurse, Narayanganj, Bangladesh

However, these individuals may not be equipped with the right knowledge and in such cases may end up doing more harm than good. On the other hand, the lack of right knowledge does little in curtailing the ability and urge of these actors to engage in health related messaging and dialogue within their influence circles. During the COVID-19 pandemic, disinformation and conspiracy theories, often propagated within these familiar channels, led to confusion and mistrust. As such, public health cannot ignore these actors, especially those who have larger influence circles, and needs to engage, inform and moderate them.

Engaging trusted members of the community to inform the design and delivery of digital health messages, from testing content, to recording audio or video clips, to championing a digital platform, can all ensure that messages are culturally relevant and increase trust and engagement.

A global study (Mason et al., 2022) conducted to assess factors of scalability of digital tools in LMICs during the COVID-19 pandemic identified 3 main lessons for launching and scaling digital interventions in health:

User-centered design is key to the widespread adoption of digital tools in health.
Strong, country-led partnerships between community-based implementation organizations or other private stakeholders and the government ministries or public stakeholders are essential for scaling up digital tools successfully.
Using adaptable digital tools enables implementers to focus on the content rather than the technology.

While these levers can enable greater effectiveness and scale for digital health interventions, especially for low-middle income countries, there remain challenges in sustainable financing, business models, or methods to evaluate impact rigorously, which should be considered for long-term sustainability¹.

Online Communities and Role of Digital Tools §

Communities need not only be geographically localized and online communities are increasingly influencing health behaviors. These communities, which have lower thresholds for engagement when compared to physical ones, provide opportunities for cost-effective interventions from public health actors. Digital tools can effectively support health systems by facilitating immediate widespread distribution of information. In the near future, as internet access becomes more ubiquitous and as more and more individuals immerse themselves in online communities, it is quickly becoming imperative for public health systems to frame approaches to participate in these communities.

Findings from a systematic review of literature shows online communities supported patient empowerment by helping the patients become engaged and have the possibility of being equal contributors in the patient-provider relationship. The main findings indicated that online communities supported patient empowerment in the way of meeting emotional needs of handling conditions and the possibility of patients becoming equal contributors to the patient-provider relationship. Such communities provide patients and caregivers with new resources, offer new insights to non-patients, challenge traditional power dynamics between patients and clinicians, and form part of a growing trend in data collection.

Provocations §

When targeting a specific health seeker group, how might we identify and tap into online communities that influence their health behaviors?
How might we reach individuals and communities who are digitally disempowered and excluded?
How might we create and incentivise a steady decentralized cohort of good faith influencers within communities and empower them with the right knowledge from a regulated source?
How might we promote good faith influencers, while delegitimizing bad faith ones?

Mason, Caitlyn, Siobhan Lazenby, Rachel Stuhldreher, Meredith Kimball, Rebecca Bartlein. 2022. "Lessons Learned From Implementing Digital Health Tools to Address COVID-19 in LMICs." Frontiers in Public Health.
https://doi.org/10.3389/fpubh.2022.859941

Innovations §

Examples of pre-existing movements and interventions that utilize this principle in their design
- Kollyani : Community led health program
  
  A community led the process to establish a formal primary health care set-up at an accessible distance from the villages, with support from Concern Universal Bangladesh, 3 local NGOs and some active community members. The executive committee from the villages identified tribal women willing to work for the clinics. In addition, several village volunteers were attached to each of the clinics working for health education and health promotion. With financial support from the NGOs involved in implementation, the initiative maintained sustainability through a revolving funds approach. In this approach, the Kollyani community received drugs from manufacturers, with the help of seed money from NGOs, which they recovered by charging a lower than market rate to the patients in the community. These funds were rotated between the medical supplies and daily needs supplies like soaps, detergents, etc. that enabled project sustainability along with the government support to these clinics in family planning, antimalarial drugs and malaria testing.
  
  Sustainability of the Innovation
  The intervention was sustained without external support with the introduction of a user fee in the clinics. A flat user fee of 5 taka or $0.07 was levied with exceptions for disabled and financially weak community members. It also tried to cut costs by collecting drugs from manufacturers that produce them at low cost. While drugs and other medical supplies were subsidized, the clinics revolved funds between these medical supplies and daily needs supplies, as described earlier. There were also investments made in income generating activities within the community that further helped with financial sustainability. The active participation of community members in activities like knowledge building and adopting positive health seeking behaviours towards health also helped with the sustainability of the project.
- Mom Connect
  
  Mom Connect is a promising example of integrating self-care into digital tools is the use of two-way messaging in maternal health. Under the stewardship of the National Department of Health and a group of committed partners, Praekelt.org has developed a platform that serves approximately 65% of women n the country; 81% of users shared messages with family and friends, 70% wanted more messages per week. MomConnect is a multi-faceted programme that creates demand for maternal health services as well as improves the supply and quality of those services. It includes stage-based health messages developed by the National Department of Health with support from expert partners at Baby Center, a text-based helpdesk that provides answers to pressing questions, a library of health information accessed via a USSD menu, and a service rating feature that allows subscribers to report on the quality of services they receive at facilities.
  
  Over 95% of clinics and health facilities in the country are participating in the programme, allowing over 2 million pregnant women and new mothers to become MomConnect subscribers. Aside from the sheer scale of the programme, one of the most notable achievements is the high level of engagement elicited from subscribers. Over 27% of subscribers have completed service ratings and more than half a million messages have been received and processed by the MomConnect helpdesk. With MomConnect, pregnant women and new mothers from low-income groups across South Africa could access critical information about pregnancy and infancy for free via SMS by subscribing to the service. However, MomConnect could not sustainably expand its services with SMS due to its prohibitive costs, character limits and inability to deliver rich content. To solve this challenge, Praekelt.org turned to WhatsApp, which agreed to help deliver its services using the WhatsApp Business API at a reduced monthly operational cost.
Concepts §

Artefacts embedded within Project ARC's 'Stories of the Future' that represent the values of this design principle