Kenya has the fourth-largest HIV epidemic in the world, with a prevalence rate of 6%. This means that there's about 1.6 million people living with the devastating HIV infection, with Female Sex Workers (FSWs) being one of the most affected groups. While Oral PrEP is a viable HIV prevention option, our research - which included a combination of both in-depth exploratory research and behavioral insights research - was able to understand the latent motivators, decision-making pathways, and behavioral norms that can be optimized for this purpose.

So many traditional communication strategies are grounded in harm reduction theory where the objective is to use fear-based messaging to reduce harm immediately. For this project, we took a different approach. We utilised a unique research strategy and methodology where we designed not only at the individual level (using aspirational messaging to encourage adoption and retention) but also designing at the broader peer group and community level (stimulating long-term social norm change). Human-centered design is predominantly a qualitative process, which seeks emotional understanding of the users for whom it is creating value and drives an action-oriented, creative process from this strong emotive foundation. For this reason, we engaged FSWs very early in the process, and even trained some of them to conduct research in an environment that was familiar to them and their peers. Complementarily, behavioral economics supported a more data-driven approach to understanding the psychology behind human attitudes.

In the process, we gained qualitative insights by exploring the contexts in which FSWs expose themselves to risk and make decisions. This research phase informed the creation of a quantitative tool used for segmenting the target population into clusters based on self-reported sexual behaviors, decision factors and objective-subjective risk levels. Following which, we defined the identified personas in the quantitative data to make population level inferences and provide clues on ideal intervention strategies.

We ran several co-design sessions around the country, invited members of the relevant communities to design with us, including members who resembled the key personas we identified and subject matter experts. At the end of this process we generated a diverse range of concepts, then chose the most promising ones to build and test. Some examples of these are stickers featuring the slogan "Sex Work is Real Work", providing a call to action to inquire more information about PrEP, that were pasted inside matatus (minibuses) that routinely passed hotspots or places where brothels are common in Nairobi. They were intended to legitimize the sex work profession and engage the FSW by appealing to her directly, in a bold and unapologetic manner. This simple intervention was able to catch the attention of FSW who take matatus to and from work on a daily basis.

The types of interventions we co-created and tested with FSWs achieved individual, social and structural change. Our communication strategies focused on influencing the FSW as an individual and her decision-making process, as well as social behavior change interventions using the principles of the Diffusion of Innovations theory.

The government of Kenya recently introduced Oral Pre-Exposure Prophylaxis (Oral PrEP), a method which uses antiretroviral drugs to protect HIV-negative people from getting infected.The drug reduces the risk of HIV infection by taking one pill once a day.

The key goals of this project were to understand and develop new communication strategies targeting FSWs (as well as other key target groups) across five regions in Kenya, to increase the uptake of PrEP.

What was so unique about this design research and strategy?

An integrated approach utilizing Human-Centered Design and Behavioral Economics had the ability to help us understand the 'world' of the FSW, at a deeper level, and think about not just individual adoption, but wider social norm change and sustainable long-term diffusion of PrEP.

ThinkPlace's strength lies in the deep, personal understanding of users through a qualitative research approach. Our partner, The Busara Centre for Behavioral Economics; added rich quantitative data to our segmentation of the population of FSWs and in the prototyping phase.

Taking an exploratory approach to uncover insights.

A day in the Brothel and at the Hotspots: We spent full days and nights shadowing FSWs both inside brothels and in the street at designated "hotspot" zones. This immersion allowed us to naturally observe what a typical day looks like for them, including the flow of clients in-and-out and the decision-making processes the women took to determine how clients are assigned.

Peer interviewing: Understanding that research involves gaining access and building trust, we engaged FSWs to conduct research in an environment that is familiar to them. We trained them on effective research methods and also on how to achieve the objectives of this research phase.

Activity-themed interviews: We often design bespoke techniques and tools for our research. For this project, we needed to understand healthworker bias around serving FSWs, so we challenged a group of FSWs to create a model of the "ideal sex worker-friendly health center" using Lego blocks. As they participated in this activity, we understood barriers and enablers for themes such as accessibility, privacy, and service delivery.

The role of Behavioral Economics

After this first round of qualitative research, Busara classified FSWs into segments using a machine learning approach (an appropriate unsupervised learning clustering algorithm). The tool identified the key features that differentiated FSWs across segments given a user-inputted set of features observed. These features were the relevant data collected as part of a quantitative survey, as well as behavioral indicators uncovered by the qualitative research (risk aversion, subjective and objective perception of HIV risk, etc.)

This input was fundamental in the development of our 4 personas (key archetypal users that represented the needs, values, and behaviors of larger groups of FSWs).

Design- Led Behavior Change

We identified a hierarchy of barriers which had to be addressed in order to increase adoption of PrEP. Since one cannot effectively change people's behavior with only rational mechanisms, such as incentives, it is necessary to induce changes in unconscious behavior. The challenge was to create "decision architectures" to positively take advantage of the unconscious forces of FSWs minds.

In our hierarchy of barriers, the top of the pyramid was what we could have the most direct influence on and what we started addressing first in terms of our subsequent communication strategies for all of our personas.

Clinic visit and testing:PrEP adoption is not possible without an in-person visit to a participating health facility. If an FSW thinks she is going to be judged at the health facility, she would probably decide to avoid it.

Product awareness:Not knowing about PrEP is an obvious but critical barrier to uptake.

Financial access:Directly and indirectly associated costs with PrEP enrollment (transport fare, productivity lost due to the potential side effects, etc).

Valuing your sexual health:Conceptualizing personal HIV risk, and then subsequently prioritizing it above external influences.

Ability to make decisions about your body:Those who do not have the authority to make proactive decisions about their bodies and sexual partners.

Highly protected against HIV or no risk at all:No risk of HIV infection is a direct barrier to PrEP adoption, as a person that is not at risk has no utility for protection.

Second qualitative research immersion and prioritization based on risk

Once we were aware of the main barriers to be addressed by each of our personas, we conducted a second round of deep dive qualitative research to answer the unresolved research questions. We also conducted shadowing peer educators - PEs (trained individuals conduct sessions with their peers to improve knowledge and attitudes that reduce the risk of acquiring HIV).

Communication Insights

1. For FSW who work full-time in brothels or at hotspots, sex work is their profession. They want this to not only be acknowledged, but also accepted.

2. The transmission of time-consuming information is ineffective while FSW are on-the-job. Most often, the only idle time they have is in between clients. The consumption and full comprehension of information, however, is unlikely during this same window.

3. FSW that are mothers typically report that their primary behavioral driver is the need to earn and provide for their children's future.

4. Some brothel owners are unwilling to share PrEP information in places visible to clients, fearing negative impact overall business. Some, however, are open to conversation and since they have one of the highest rates of contact with FSW, they are effective messengers and reinforcers of PrEP messaging.

5. Camaraderie is particularly evident in the peer-to-peer networks that exist at "hot-spots" throughout Nairobi and beyond.

Having FSWs design alongside with us

We ran several co-design sessions with FSWs who represented our key personas and subject matter experts. At the end of this process a range of concepts were generated, then prioritized and built. Together with Busara, we conducted user testing of the concepts including RCT style testing, phone sensing to track user's behaviors and iterated based on the outcomes.

Solution approach

SEX WORK IS REAL WORK

This strategy targets not only FSW who have an attitude to avoid contracting HIV (Lulu and Anna Personas) in order to achieve a high level of success or improve their current situation in life, but also FSW who have the ability to speak openly about their lifestyle with others.

Messaging

Prove to me (by design) that you understand me: FSW respond well to messaging that shows that we understand their lifestyle, the challenges that they face, and the preferences that they have.

Voice and Tone

A confident FSW to the world: The tone of messages should be as if they are being spoken, in the first person, directly from an FSW herself, talking to the world. Therefore messaging should be clear, firm and should not coddle the FSWs sensibilities but reach out to her in a way that is real and respectful.

Imagery

FSWs want to see more imagery, language, and depiction of FSWs that are successful in their work and their personal lives. There is a strong undertone of professionalism and the need to be legitimized among FSWs. Being direct about PrEP as it relates to the empowered, professional sex work is critical in catching their attention.

Most FSW who are mothers explain their roles as sex workers in direct relation to their children, therefore PrEP should be introduced as a compliment to healthy sex work and fiercely loyal motherhood.

Channels

1. Using a trusted, free message delivery channel such as Whatsapp is an effective way to connect with FSWs.

2. Since FSWs spend a lot of their time in hotspots and brothels these areas and are prime for receiving information in their down time.

3. Unapologetic and direct communication within public transport demonstrates that the brand supports their movement and is not afraid to let the public know.

4. Interpersonal Communication and leveraging on the PE's network.

5. Getting pimps and managers of brothels on board is a key to success for any intervention.

Interventions currently being piloted across Kenya

Reimagining the PE's Network

Start with recruitment. The peer network is only as successful as the people who run it. Building a strong network starts from the very beginning, with recruiting PEs that are fit all eligibility criteria.

Make IPCs more experienced and target their messaging

Supporting PEs in their work with a digital tool: PEs are not necessarily clinicians, and therefore cannot always answer technical and specific PrEP questions in the field. They need to be provided with reliable and consistent support so that they can answer questions in real-time.

PrEP package: Currently PEs find it challenging to relay details about PrEP in a quick and user-friendly manner, while convincing peers about why it may be a good idea for them. This kit included a conversation starter tote bag and smaller kits that will not only help PEs do their job better, but also FSWs.

"Bring the clinics to me": Implementing mobile clinics that visit brothels

Many FSWs are generally either at work or home and do not have the time, money or inclination to travel to clinics within their area. FSWs are more likely to uptake if we remove the barrier of distance and time.