From Insights to Actions
Putting the experiences of girls at the heart of health service design in Ghana
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:
- 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.
- 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.
- 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.
