Situated in Southwest Mozambique, Gaza Province has been described as being "suspended in time." Vastly agricultural, Gaza is known for two things: extensive cereal and rice cultivation, and its high HIV prevalence. Around one quarter of the adult population is HIV-positive. Among adolescents, Gaza also sees very high rates of unplanned and early pregnancy.

When adolescents and young women (14-24 years) enter the health facility to inquire about family planning methods, healthcare workers find themselves providing extraneous, confusing information strictly according to their tools and their training. Patients are left making a choice that may not be informed enough to make, adopting a method that may not meet their needs, not fully aware of the effects it might have on their bodies, and having an overall unsatisfactory experience.

In late 2018-2019, our team worked in five public clinics and three private clinics in Gaza to address the challenge of improving the counseling experience for adolescent girls and young women. Through immersive research, our insights led us to three primary points of intervention: the pre-counseling experience, the counseling experience (for both new-users and repeat or second-time patients), and the moment a patient decides which method to uptake. When prototyping, we focused on ideas which would improve the patient's experience at each of these points in their journey through the clinic.

To address these, we sat down with providers and users to collaboratively design ("co-design") a set of tools and techniques to improve the consultation experience. We introduced a revised version of the 50+-page script that the providers used to reference during consultations. We worked closely with the providers to design a process for helping adolescent girls and young women better understand risk during pre-counseling. If the patients understood their risk, the providers noted, they would be in a better position to make an informed choice about their contraceptive method. At the point where a patient decides on her contraceptive method, we also saw an opportunity to acknowledge the importance of it and asked providers to begin congratulating and celebrating that moment with the patients.

Choosing a method is not only about the method itself, of course. It's about the patient feeling assured, informed and confident enough to make a decision that will affect her future. It's about the patient feeling like she's done something to protect herself. And that she can do this alongside a genuine ally, who understands her specific experiences, preferences and needs, and advises accordingly.

This project has improved the way that Gaza-based healthcare providers offer consultations, and we are so proud of that. Moreover, it has humanized and personalized the process of taking up a contraceptive method, as it should be. By leveraging providers role in counseling through a personalized approach, it has enabled a shift in the space--the counseling experience--which was previously considered to be a provider-centric space to one where adolescents' needs and expectations are fulfilled while at the same time equipping them with trust and confidence.

INTRODUCTION

"Malaria can kill you. HIV won't."

Situated in Southwest Mozambique, Gaza Province has been described as being "suspended in time." Vastly agricultural, Gaza is known for two things: extensive cereal and rice cultivation, and its high HIV prevalence. Around one quarter of the adult population is HIV-positive. Among adolescents, Gaza also sees high rates of unplanned and early pregnancy. In general, there is a dynamic landscape of public and private clinics who serve adolescents. However, these services are not perceived as desirable or useful to most adolescents. This, precisely, is where our project was situated.

Interestingly, due to decades of de-stigmatisation campaigns focused on HIV, many people, including adolescents in Gaza proudly exalt: "Malaria can kill you. HIV won't." They also perceive the risk of contracting HIV as plausible for others but not for them. Adolescents sometimes conflate products which prevent HIV with those that prevent conception, or they perceive the risk of contracting HIV as being related to the risk of getting pregnant, given both can come via injection. Condom use is also rarely prioritized, especially when it comes to married young women: "I have a husband, so we don't use such things."

Despite these widely-held beliefs, when adolescents and young women (14-24 years) enter the health facility to inquire about family planning methods, healthcare workers find themselves providing information strictly based on their tools and their training. Patients are left making a choice that may not be informed enough to make, adopting a method that may not meet their needs, not fully aware of the effects it might have on their bodies, and having an overall unsatisfactory experience.

UNDERSTANDING THE PROBLEM

"These girls don't pay attention to anything. Later, they come back.."

Too often, we see health sector interventions which privilege technical, product-focused information rather than crafting a message that allows the user to understand the product, see value in it, and ultimately feel confident in choosing it. In late 2018-2019, our team worked in five public clinics and three private clinics in Gaza to address the challenge of improving the counseling experience for adolescent girls and young women.

We spent one month wholly immersed in these clinical contexts, identifying the areas where provider behaviour translated to poor patient experience and how such a poor patient experience would then lead to ill-informed decision-making or lack of uptake altogether. Our team experienced the end-to-end counseling process, like any other patient. With the sun beating down on our faces, we waited on the small wooden benches (or for the private locations, plastic chairs) outside of the counseling room. This portion was sometimes social, sometimes not, with other women coming and going as they had time and interest. It sometimes lasted close to an hour, and then the moment would happen: you were called in. The healthcare provider would allow a member of our team to follow another patient, who consented to us observing her consultation experience. Once you were inside the small, hot, windowless room, the healthcare provider would furiously flip through their 50+-page "script," providing a wealth of information about all available contraceptive methods, their side effects, their years/months of protection, etc. Patients were asked to constantly repeat the information and to nod as a sign of confirmation, which they did systematically. According to providers, "If you repeat the information enough, they'll get it." While informative, few patients left feeling informed.

On average, consultations with first-time users would last for a period of 45 minutes. The patients were inundated with information that did not take into account their lifestyles, their preferences, their fears/concerns, etc. On average, consultations for second-time or repeat users would last for a period of 15 minutes. This was due to primarily to the provider not recognizing the patient's need to be counseled through a decision to potentially shift methods. These patients have often experienced adverse effects (e.g. pain, weight gain) and they are in need of clarity, reassurance, and advice as they consider a change of method.

Most importantly, what this four-week immersion revealed to us was not that healthcare providers lacked knowledge about the methods (as is typically the assumption), but that there was no intent in how that knowledge was being transferred - and more importantly, translated and adapted - to suit the needs of the patient.

The problem space became clear.

DEFINING THE COURSE OF ACTION

"I have a husband, so we don't have to use such things."

While this project focused on improving the patient experience to increase the adoption of contraceptive methods, we realised through our research that that chain reaction starts with a genuine behaviour change on the part of the healthcare provider.

Behaviour change is a complex topic, one where the solution is specific to the social and systemic context of the user. For that reason, we invited the providers and with patients to act as the designers. We held 'co-design' sessions in which we worked closely with them to identify clear opportunities for design. These opportunities led to ideas for potential solutions, and those ideas were then developed into low-cost 'models', or prototypes, that could be tested in-situ.

This co-design-rapid prototyping-testing process is something ThinkPlace has used in relatively low-resource contexts where there is very little time to turn around a final solution. The process also allowed us to quickly learn how much users' stated behaviour aligned with their actual, observed behaviour.

A CHANGED EXPERIENCE

"I know I've decided but, what if it's not right?"

Our insights led us to three primary points of intervention: the pre-counseling experience, the counseling experience (for both new-users and repeat or second-time patients), and the moment a patient decides which method to uptake. When prototyping, we focused on ideas which would improve the patient's experience at each of these points in their journey through the clinic.

For pre-counseling, we wanted to isolate the concept of risk. Risk - risk of contracting HIV, risk of unplanned conception - is an abstract concept that was clearly difficult for patients to comprehend. Risk is also subject to bias and perception, leading patients to assess their risk level subjectively rather than objectively, from a medical perspective. A misinterpretation of one's risk can leave patients feeling uncomfortable or shameful about their lifestyle choices.

To counteract this, we worked closely with the providers to design a process for helping adolescent girls and young women better understand risk during pre-counseling. Details on this activity are included in the attached PDF.

Once in the consultation room, we introduced a revised version of the 50+-page script that the providers used to reference. When co-designing this new tool with the healthcare providers, we asked them to eliminate all information which was not used or irrelevant to the consultations. They eliminated a whopping 35 of the 50 pages.

The revision was referred to as the Minha Escolha ("My Choice") booklet, which provided information in a highly visual, highly consumable way. This information was also visualised through two personas and visual pathways that the provider could follow, noting when to ask specific follow-up questions, when to pause and allow her to provide more information, etc.

At the point where a patient decides on her contraceptive method, we saw an opportunity to affirm the importance of it and asked providers to begin congratulating and celebrating that moment with the patients. We found that this gave girls a sense of not only affirmation but also confidence that this was the right decision.

HELPING HER FIND HER CONFIDENCE

"I know what I want and why I want it."

Choosing a method is about the patient feeling like she's done something to protect herself. While she chooses it, she can also stay informed about reversing it, changing it, and interrogating it for as long as she likes. And that she can do this alongside a genuine ally, who understands her specific experiences, preferences and needs, and advises accordingly.

The Minha Escolha ("My Choice") booklet has been finalized and distributed as the Enfermeira Nota20 ("A+ Nurse") booklet. It has led to shorter, more fulfilling consultations for adolescent girls and young women. Before this project, consultations with first-time users lasted about 45 minutes on average. With the booklet, the poster, the pre-counseling interventions, and the congratulatory moment introduced, consultations with first-time users are now lasting 25 minutes on average. This is due to the fact that providers now only share tailored information after listening to their questions and concerns. Before this project, consultations with repeat or second-time users lasted 5 minutes on average. This is because very little consultation was offered to the patient, as providers mostly insisted that any side effects or concerns were "normal" and the patient continued on as usual. Today, those same consultations last 15 minutes on average, as providers offer practical information and guide the patients through a change of method should they need it.

On our most recent visit to these clinics, we observed five girls visit the public healthcare facility to get general medical services. The following day, providers were happily surprised to see the same five girls return to the facility and two of those girls had brought a friend with them. It was clear to us how much the clinic had created value for these girls, as they and their peers were craving accurate and clear information about their health.