STAY SEXY, STAY HEALTHY, GET CHECKED Designing a Youth-Friendly STI Testing Experience
A collaboration between the Baltimore City Health Department, the Johns Hopkins Center for Child and Community Health Research, and the Center for Social Design at Maryland Institute College of Art
2 Stay Sexy, Stay Healthy, Get Checked
STAY SEXY, STAY HEALTHY, GET CHECKED Designing a Youth-Friendly STI Testing Experience
Layout design & content by Maria Garcia, Devika Menon, and Rachel Serra With editing help by Irina Wong
Contents 06
Introduction
08
Foreword
09
Design Challenge
10
STI Statistics
12
Human-Centered Design
14
Phase One
16
Research
28
Synthesis
32
Ideation
34
Prototype
38
Narrowed Focus
40
Phase Two
42
Sexual Health Messaging
52
Testing Experience
64
Conclusion
66
Class Reflections
68
About the Grant
70
Partners
71
Credits
72
Appendix
74
Stay Sexy, Stay Healthy Campaign Materials
82
Clinic Space Materials
Stay Sexy, Stay Healthy, Get Checked 5
Introduction
Foreword Jacky Jennings, PhD, MPH Director, Johns Hopkins Center for Child and Community Health Research
Suzanne Grieb, PhD, MSPH Research Associate, Johns Hopkins Center for Child and Community Health Research
Baltimore has a long history of epidemic and endemic rates of sexually transmitted infections (STIs) and is a city with racial and ethnic disparities in STIs that are two to four times the national average. Young people in the U.S. represent 50% of all new STIs, while in 2012, young people in Baltimore represented 70% of new STIs reported to the Baltimore City Health Department (BCHD).
To identify and implement interventions addressing social determinants of sexual health outcomes in Baltimore, the CARS project worked with a Youth Advisory Council (YAC), an energetic and engaged group of young people from areas in Baltimore most impacted by STIs. During the first year, a needs assessment was conducted in neighborhoods most impacted by STIs to identify needs, strengths, and gaps that influence STI transmission, and the YAC conducted a root cause analysis to identify and prioritize social determinants of health to address. Through these processes, the YAC elected to prioritize increased access to STI testing by their peers and the promotion of a more positive culture around STI testing.
To address this issue, BCHD and the Johns Hopkins Center for Child and Community Health Research (CCHR), in collaboration with the Maryland Institute College of Art (MICA) Center for Social Design, received a three-year grant from the Centers for Disease Control and Prevention (CDC) in 2014 titled Community Approaches to Reducing STIs, or “CARS.” The CARS project aimed to develop interventions to reduce STIs by addressing youth-prioritized social determinants of sexual health outcomes, with an emphasis on STIs. “Social determinants” are the circumstances in which people are born, grow up, live, work, and age. They also include healthcare programs and systems. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. While personal behaviors are important for the transmission of STIs, an emerging body of evidence suggests that social determinants are key factors in contributing to endemic rates of STIs and racial/ethnic disparities in local communities.
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To aid in the development of interventions striving to promote STI testing among young people in Baltimore, the YAC and partners collaborated with an interdisciplinary team of students at MICA’s Center for Social Design. Together, they researched attitudes about STI testing among Baltimore youth, identified opportunities for intervention, and created youth-centered design solutions to improve the testing experience at local BCHD STI clinics and promote positive sexual health messaging through social media and in schools. This book shares elements of this process, conducted through a Practice-Based Studio course offered during the 2016-2017 academic year at the MICA Center for Social Design.
DESIGN CHALLENGE:
HOW MIGHT WE increase access to STI testing and normalize testing for Baltimore youth aged 15-24?
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STI Statistics Although many low-cost and no-cost STI testing options are offered locally, Baltimore City continues to experience high rates of
STIs among young people, particularly among African American youth.
Rate of Gonorrhea Cases Per 100,000 Persons Baltimore City 2013 Age Groups
Cases
Rates
0-4
0
0.0
5-9
3
8.1
10-14
47
136.5
15-19
529
1,343.2
20-24
687
1,257.3
25-29
389
649.9
30-34
187
375.6
35-39
104
283.1
40-44
63
167.9
45-54
116
137.5
55-64
28
38.6
65+
4
5.4
Total
2,158
346.6
Rate of Youth 10-19 with Gonorrhea and Chlamydia by Race Baltimore City 2009 (Age-specific rate per 100,000 population)
10
All
Black
White
Gonorrhea
1234.5
1329.8
141.5
Chlamydia
4778.9
5589.1
449.9
Rate of Reported Gonorrhea by Census Tract, Aged 15-24 Years Old Baltimore City 2013
Legend Rate per 100,000 Population n = 200 Census Tracts Quartile 1: 0.0-354.6 Quartile 2: 354.7-1013.5 Quartile 3: 1013.6-1811.6 Quartile 4: 1811.7-4923.1
Rate of Reported Chlamydia by Census Tract, Aged 15-24 Years Old Baltimore City 2013
Legend Rate per 100,000 Population n = 200 Census Tracts Quartile 1: = 0.0-2066.1 Quartile 2: 2066.2-4898.6 Quartile 3: 4898.7-7092.2 Quartile 4: 7092.3-15671.6
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Human-Centered Design Human-centered design is a problem-solving tool that is structured, intentional, collaborative, and design-driven. It looks at old issues in new ways and is grounded in human empathy. Most importantly, it focuses on people, their experiences, and their behaviors. The Center for Social Design utilizes a humancentered design to understand and define social problems, identify opportunities and generate ideas, and make tools that support positive change.
SOCIAL PROBLEM
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Frame & Plan
Our process includes six interwoven phases: Frame & Plan Organize existing scientific data and research associated with the problem. Facilitate discussions to better understand key data and research and to appropriately scope the engagement. Research Understand the culture and context of the problem by understanding the culture and context of the people involved. Talk to, observe, and learn from stakeholders to locate needs and assets to support.
Research
Synthesize
Synthesize Compile observations and research findings. Embrace unexpected insight, ideas, and inspiration. Find appropriate opportunities for intervention.
Prototype Make tangible representations of ideas and give them form. Prototype with people to better test assumptions, lower risk, align partners and stakeholders, and reveal potential problems early.
Ideate Generate as many ideas as possible and defer judgment (no bad ideas). Be visual with idea generation and share openly. Draw concepts, not outcomes. Document the process and routinely combine and refine ideas.
Implement & Iterate Test, iterate, and develop prototypes in context. Document and collect feedback to inform strategies and solutions that are more likely to be adopted and align with target behavior and outcomes.
Ideate
Prototype
Implement & Iterate
SOCIAL CHANGE
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Phase One
Research As social design students, we recognized we were not experts on sexual health and testing in Baltimore, so we used a variety of methods to conduct research and immerse ourselves in the current state of STI testing in the city. We started by listening to Baltimore-area researchers, Baltimore City Health Department staff, clinicians, sexual health educators, peer navigators, clinic staff, and public health experts. We went through the process of getting tested for STIs ourselves and toured clinic spaces to better understand the testing environment. Most importantly, we worked directly with Baltimore youth. We designed and distributed surveys to ask youth about their current testing experiences and the barriers and motivations to getting tested. We attended a local conference for high school students, the Baltimore Youth Sexual Health & Leadership Conference, to speak with students about their testing preferences. Additionally, we worked closely with youth programs, specifically the Youth Advisory Council (YAC) and Wide Angle Youth Media. With these students, we gathered key insights on the topic, brainstormed possible solutions, and asked for feedback throughout the design and prototyping process.
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Various photos of the class learning about STIs, touring clinic spaces, organizing research, and brainstorming.
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Youth Perspectives To better understand youth perspectives on sexual health, STIs, and STI testing, we asked youth the following questions:
What motivates you to get tested?
What are your barriers to getting tested?
My support network (friends, family, partners, etc): A member of a youth’s support network suggested testing, making them feel emotionally supported to do so.
Fear: • Uncertainty about what to expect • Dread of discomfort/pain during the test • Distress about potential positive test results • Anxiety about others knowing about testing
My doctor: Doctors are often regarded by youth as trusted resources and authority figures.
Pride: • Resistance to admitting they are experiencing STI symptoms • Defiance against the need for outside help
Having unprotected sex: A personal experience might expose youth to a higher risk of STIs; as a result, they decide to get tested. My personal health: Health and well-being are important to youth as they think about their present and futures.
Money: • Uncertainty about payment method for STI testing/services • Confusion about health insurance coverage • Unfamiliarity with free testing services Transportation: • Uncertainty about transportation options to and from the testing site Shame: • Feeling ashamed of having sex • Feeling ashamed of the need or desire to get tested Past testing experience: • Unpleasant previous experience with wait times or clinic staff discourages youth from trying again Lack of support network: • Absence of trusted older mentor figures to discuss sexual health with
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What does sexual health mean to you?
“Knowing the outcomes of your decision, keeping up with physical sexual health, and being aware of your sexual agency.”
“Being educated on your body and sexual relationships with others and knowing how to prevent catching diseases.”
“Staying safe. And making sure your body is healthy before, during, and after sex.”
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Journey Maps To better understand what STI testing is like for Baltimore youth, we each got tested for chlamydia and gonorrhea. Through these experiences, we gained firsthand insights into the testing process and a strong sense of empathy. As part of the project, we created journey maps to track our touch points in the process, from friendly interactions with security guards to long wait times. After creating our own journey maps, we worked with the YAC to also map their testing experiences. Five YAC members got tested, then worked closely with a MICA team member to visualize their experience and also identify touch points.
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JOURNEY MAPS: A visual representation of a user’s journey through any given process (e.g. baking cookies, getting tested for STIs, etc.). Journey maps are a way to gather user actions, barriers, and bright spots all in one place. As interventions are being developed, it is helpful to reference journey maps to identify where in the process the intervention would occur and how it relates to the overall journey.
MICA student journey maps.
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On the way to the clinic
The waiting room Watching the video
Getting
Tested
Meeting the
Doctor 2017
Leaving the Clinic Going homeÂ
YAC member journey maps.
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Youth STI Testing Experience Using the individual journey maps, we created one comprehensive visualization of the STI testing experience for youth. This graphic shows key steps in the process and highlights moments that matter along the way.
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Personas While we knew the community was, in general, Baltimore youth aged 15-24, we recognized there was a spectrum of individuals within that range. We created different personas to capture the varied perspectives in this community.
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Primary Community: Youth who understand the value of STI testing, but hesitate to get tested for various reasons. Secondary Community: Youth who do not currently need to be tested for STIs, but will need to address their sexual health in the future.
PERSONAS: Representative users based on research and interviews. Referencing these personas throughout the process help us make sure that our work is responding to real user needs.
2
mmunity
ey & Harry
ut getting tested
Secondary Community
Motivated Michelle & Malik
Healthy Henry & Heather
Neutral Nancy & Nick
• Wants to get tested, but is unsure of where to go
• Gets tested regularly and for all STIs
• Neutral on the issue because they have not had sex
• Doesn’t have transportation
• Knowledgeable about healthy sex, STIs, and testing
• Feel that this issue does not apply to them YET
e to get
l clinics
• Has distrust for local clinics
riends and
• Has a solid support system, but they do not talk about sex, STIs, or testing
• Has regular doctor’s check-ups • Has a support system that openly discusses sex, STIs, and testing
o do for their concerns m testing
Likely to Get Tested
Not Sexually Active
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Synthesis Through our research we gathered a large amount of qualitative data to sort through and synthesize. We grouped our findings into the following action-oriented themes: • • • • •
Feeling shame Seeking confidentiality Inciting fear Lacking trust in institutions Navigating policy
From our themes, we then crafted insights to highlight areas of tension and surprise.
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INSIGHTS: Short and concise statements that reveal something surprising and unique. They are a way of distilling a large body of research into key findings and identifying opportunities for design interventions.
Insights Stigma The stigma around STIs can be just as harmful to an individual’s health as the infections themselves.
Anxiety & Fear Despite the high availability of testing options, anxiety and fear about the process and outcome can prevent youth from getting tested.
Wait Times Even with positive patient-doctor interactions, wait times for service and test results are strong influencers on feelings of anxiety and fear during the testing process.
Peer-to-Peer Communication Youth have a strong preference for receiving information from peers, but peer-to-peer information is not always accurate.
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Design Principles & Values Based on our research, we developed a set of values and design principles to guide ideation. The most important takeaway from these values and principles is that what is good for Baltimore youth is good for everyone. We suggest that moving forward, Baltimore STI clinic spaces, processes, messages, and services are designed with the city’s youth population as their primary users.
Design Principles: Serve as an ally to Baltimore youth: Prioritize the lived experience of youth over adult expertise. Normalize STI testing: Incorporate sex-positive thinking and destigmatize STI testing. Turn barriers into opportunities: Rethink the negative connotations of STI testing and leverage them to discover bright spots. Make interventions sustainable and structural: Design for the long term and be realistic with resource constraints.
Values:
Sex Positive
Comforting
Confidential
Youth need sexual health care experiences to move away from being punitive or judgmental and towards being supportive and positive.
Clinic spaces and testing can feel “cold” and “scary” to youth.
Youth and clinicians have different definitions of confidentiality. Clinicians follow HIPPA, but youth want to feel “invisible.”
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DESIGN PRINCIPLES: Provide a north star for projects and teams. Keeping these principles in mind during the process helps to insure all design decisions stay true to the project’s values and reflect real user needs.
Timely
Enjoyable
Transparent
Delays and wait times will discourage youth from completing testing.
This is often the first time young patients are interacting with the clinic and STI testing—a positive testing experience will help establish trust and promote future visits.
Youth want to know what the entire testing process will be like before they go.
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Ideation After sharing the research and insights with the health department and other partners, we re-framed these challenges into “how might we?” statements that present opportunities for design. Using the “how might we” statements we facilitated two brainstorming workshops: one with youth and one with adults. Our goal with these workshops was to generate as many ideas as possible with our workshop participants. We were shooting for a quantity, not quality, of ideas. After the brainstorming, we asked participants to vote on their three favorite ideas. This exercise helped us prioritize ideas to prototype.
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“HOW MIGHT WE” STATEMENTS: Questions that turn tensions and bright spots into opportunities for design. The questions prompt growth and change in addressing insights from the design research. By re-framing the problem into “how might we” statements, we allow the brainstorming process to be simultaneously focused and generative.
Images from brainstorming workshops.
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How might we create transparency around the testing process to reduce anxiety and fear in patients?
Ideas from the brainstorming sessions.
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How might we cultivate positivity and comfort during the wait times of the testing journey?
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Prototyping Using the top ideas from the brainstorming sessions as a starting point, we created a first round of low-fidelity prototypes.
PROTOTYPES: Tangible and low-fidelity mockups of ideas. Translating ideas into 3-D form gives designers a chance to test ideas with users, collect feedback, and improve the idea before too much time or money is invested.
Tap It, Test It
Love Yourself Campaign
“Tap It, Test It” is a mobile website and app that guides youth through the testing journey, from thinking about getting tested to completing their appointment with their provider. It also provides links to other sexual health resources.
“Love Yourself” is a sex-positive and stigmafree ad campaign to encourage youth to get tested, relating STI testing to taking care of one’s health and future.
Pre-test
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Teen Help Desk
Post-Testing Celebrations
The Teen Help Desk leverages youth preference for peer-to-peer conversations about sexual health by placing trained peer navigators in clinics. Youth can visit the desk while they wait or after they see a clinician.
Certificates of testing and thank you boxes with fun surprises activate the post-testing experience and destigmatize testing.
Testing
Post-test
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Feedback Workshops We returned to Wide Angle Youth Media to share the prototypes and collect feedback from youth. The youth shared their thoughts on which ones they liked the best and why. Some of the most commonly liked ideas were custom condoms, virtual clinic tours, providing alternate services in the clinic, and having activities while waiting. We also shared prototypes with the CARS team and a peer educator at BCHD’s Druid Hill Clinic who works to educate youth that come to the clinic. We incorporated their feedback into the next round of prototyping. Using feedback from the presentations, two areas of focus were identified for research and ideation in phase two: 1. Sexual Health Messaging: Designing sex-positive messaging to encourage youth to get tested. 2. Testing Experience: Creating stigma-free and supportive clinic spaces to ease anxiety and fear.
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Sharing prototypes with youth at Wide Angle Youth Media.
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Phase Two
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Sexual Health Messaging In our research, we often heard that negative language pushed youth away from getting tested. We saw fear tactics as a contributer to low rates of youth getting tested in Baltimore. Before youth even get to a clinic, they feel shame and are intimidated. We saw an opportunity to re-frame the language used and to craft positive sexual health messaging in order to increase awareness of testing options, reduce the negative perceptions and stigma of getting tested, and demystify the testing process.
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SEXUAL HEALTH MESSAGING CHALLENGE
HOW MIGHT WE craft positive sexual health messaging with Baltimore youth?
Craft:
Positive Sexual Health:
With Baltimore Youth:
Make sure every single component of the message, from the language to visuals is carefully crafted to meet the expectations of youth.
Convey the importance of sexual health through positive language.
Ensure that this campaign for youth is co-designed with youth to capture what they want to see in Baltimore.
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Research Since we set ourselves to design a new message, we needed to explore the array of sexual health messages and see how they are displayed in Baltimore. We spoke with Dr. Kathleen Page, Baltimore City Health Department’s Director of STD/HIV/ TB Clinical Services, about how her team at BCHD’s Eastern and Druid Hill Clinics select materials about STI testing. Her conversation led us to dive deeper into existing messaging that aims to raise awareness about sexual health and analogous health topics. We conducted a messaging audit and organized ads according to these themes: • Fear-Based • Destigmatizing • Sex-Positive • Humorous • Clinical In order to determine if a campaign would be successful with youth or not, we analyzed it based on content, language, relevance, and design. As a team, we critiqued what we had found with Charlotte Hager, BCHD Family Planning Program Manager. All this analysis was helpful, but we were missing youth voice.
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To fill this gap, we facilitated workshops with the YAC and youth at Wide Angle Youth Media. We first gave them a short survey to fill out, containing five questions about sexual health and testing options they would or would not use. After this, we asked for their feedback, positive and negative, about existing ad campaigns. We found that youth preferred the campaigns that were sex-positive, visually appealing, and informative, with clearly stated information about where to go, when to go, and the cost upfront. The ones that youth did not like were posters that looked outdated, or that you could “find in your school.” They also responded negatively to campaigns where the humor and silliness outweighed the importance of the message.
“I think this might encourage people, seeing that they don’t need to pay for the test.”
“The image distracts me from the actual message.”
Analyzing other sexual health campaigns and talking with youth and Baltimore City Health Department staff.
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Design Principles After talking with youth about existing sexual health campaigns, we asked them to design their own. We gave them blank mock-ups of Instagram posts, Facebook banners, Facebook posts, billboards, and bus station ads. We asked the youth to think about what kind of message around sexual health and testing they would respond the best to, and what words were most important to highlight. While Facebook is still a popular social media method, the Instagram post mock-ups were the most commonly chosen background option. Out of the feedback and quick message designs we collected from youth, we created a set of design principles, to guide the creation of our own messaging campaigns.
Youth created campaign ideas.
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Sexual Health Messaging Design Principles
1
Communicate sex-positive and stigma free values: Use messaging and visuals that tackle stereotypes, combat stigma, and remove judgment.
2
Include simple language that is easy to digest: Use engaging language and provide clear information in a simple presentation.
3
Establish expectations about the service: Share cost and insurance details and tell youth up front what will happen at the clinic.
4
Provide information about resources: Explain where to go and how to make an appointment.
5
Be relatable to youth: Show a realistic view of life and use familiar messaging.
6
Create a visually appealing system: Use an unexpected approach to attract young viewers.
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Prototypes Using the youth-created campaigns, we developed refined campaign prototypes. We shared these prototypes with the YAC for another round of feedback and revision.
From a visual perspective, the “Stay Sexy, Stay Healthy” campaign was really successful amongst youth, but they felt the message needed to be stronger and provide more information.
The youth felt that the illustrated season campaigns were a bit “corny” with their language, and didn’t seem serious enough to make a change.
Ultimately, we focused on revising and expanding the “Stay Sexy, Stay Healthy” campaign to respond to youth feedback.
Seasonal Inspiration
Emphasizing Free
When working on messaging with youth, we noticed that several different students had made seasonally themed mockups.
In the design workshop with youth, we found that many students made “free” a main element of their designs.
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Youth Quotes
This mockup presented simple and straightforward details about clinic location and hours, and featured a youth quote.
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Stay Sexy, Stay Healthy, Get Checked “Stay Sexy, Stay Healthy” is a fresh and fun initiative to talk about and take care of their sexual health. It creates stronger connections between conversations about sex, health, and testing services. The initiative aims to increase the number of Baltimore youth, ages 15-24, who visit an STI clinic for the first time. This is part of taking more control of their own sexual health by knowing and taking care of their bodies and sexual relationships.
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The “Stay Sexy, Stay Healthy” campaign aims to make conversations about sexual health more comfortable, constructive, fun, relevant, and supportive. The goal is to make testing feel easier by making the clinic locations, testing process, and benefits clear. We wanted to expand this campaign to include all social media, print, environmental, and giveaway components and create seasonal messaging that aligned with the main brand.
Brand Visual Style We went for a brightly colored and confetti patterned look for the brand to produce a celebrator, youthful, and positive feel. With this brand, we want youth to feel: Relieved: “It’s okay to talk about sexual health.” Understood: “This is about my life today.” Informed: “Here’s the why, how and where about testing.” Supported: “You got this. We’re with you.”
Before getting burnt up this summer, get a free, simple, and confidential sexual health check. It protects the sexual health of you and your partners against sexually transmitted infections (STIs).
Eastern Sexual Health Clinic 620 North Caroline St. Mon & Tues: 8:30AM–5:00PM Thurs: 8:30–1:00PM 410.396.9410
No appointment necessary.
STAY SEXY STAY HEALTHY GET CHECKED
For more information visit: www.knowwhatuwant.org
#swimsuitseason #staysexystayhealthy
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Testing Experience People between the ages 15-24 make up about one-third of Baltimore City Health Department (BCHD) clinic patients. Of all young people getting tested at BCHD’s Eastern and Druid clinics in 2016, about 65% indicated that it was their first STI test. It is important that the clinics are attuned to youth’s needs and tailor their services to be more youth-friendly. Moving forward, a smaller group of students focused the next phase of the project at BCHD’s Eastern STI Clinic. Using our learnings from the first phase of the project, we developed a research plan for Eastern clinic.
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TESTING EXPERIENCE DESIGN CHALLENGE
HOW MIGHT WE make STI testing friendly and transparent for Baltimore youth?
Friendly:
Transparent:
Baltimore Youth:
Getting tested can be scary for a young person, and the people they interact with shape their experience and their likelihood to return. Youth also want testing to be easy to navigate and not feel like a homework assignment.
The testing process is complex. Youth want to know what is going to happen to them, who is involved and what is expected of them during STI testing.
One-third of BCHD clinic patients are youth and we want to make sure we stay grounded in what their needs, wishes, and challenges are.
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Testing Process In order to find ways to make Eastern Clinic’s service more youth-friendly, we broke down the testing process into key phases, steps, and moments for change.
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Using data from the youth journey maps, we could plot their experience over time, map what they were thinking, doing, and feeling, and identify key touch-points. By breaking down the service process, we could map out front stage activities that impacted the patient and backstage activities that helped make the service possible.
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Interviews We conducted in-depth interviews with clinicians, providers, and other staff at Eastern Clinic in order to learn how the clinic engaged with its patients, what made a good testing experience, and what reasons kept people waiting for long times. We spoke with: • Eastern Clinic’s Director • 4 Clinicians • 1 Hep-C Coordinator • 1 Registration staff • 1 HIV counselor • 1 DIS worker • 1 Lab Coordinator • 1 Youth who was tested at Eastern By synthesizing our research, we uncovered several new insights that shaped the direction the testing experience team pursued. We heard errors on forms create more work for staff and end up affecting the type of care a patient receives, retrieval of their results, and the amount of time they spend waiting at the clinic. We also heard how these errors due to incorrect triage lead to unforeseen changes in the patient scheduling system, which can force clinicians to accommodate more than one patient at a time. This can lead to patients waiting for longer periods than estimated and also result in patients leaving and/or deter them to come back. Ultimately, unsuccessful registration can have a ripple effect on the entire patient experience.
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This one overarching insight guided the work of the testing experience team. During registration there are a lot of opportunities to make or break how youth patients feel about their entire visit. We focused on the following three aspects of registration: 1. Forms: The process of completing registration forms. 2. Human Connection: Interactions between patients and all staff members. 3. Number System: How patients use the current numbering system at the clinic while they wait to get registered, visit a clinician, and receive results. With these three focus areas in mind, we crafted insights, brainstormed ideas and prototyped possible solutions for the registration phase of the process.
“The front desk staff couldn’t find my results because they had misspelled my name in their records when I had registered. What was supposed to take 2 minutes took about 10 minutes to figure out.” - Youth Patient
“If you get four patients back-to-back who are very complex cases - if you run behind on the first one, then you are definitely going to run behind on the next. (The staff) should know how to balance patients based on what is reported.” - Clinician
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Forms Patients fill out forms incorrectly because they are worried about privacy, have difficulty understanding the form, or have other concerns on their mind. Some staff described BCHD clinic patients as having an “Emergency Room” mentality, checking whatever box they think will get them the quickest appointment with a clinician. “A lot of people incorrectly fill out the registration forms because they just want to get it done. My perception is they just want to circle x, y, z because they want to get the heck out of there.” - Clinician Eastern Clinic sees patients with a wide range of literacy, language, comfort, and ability levels, which can affect the service they receive. BCHD must design a process for patients who experience a range of comprehension issues, or the stigma associated with STIs - or else these patients are less likely to return for results or future services. “I filled out the forms which felt like an essay. I don’t want something that feels like a homework assignment” - Youth Additionally, the scheduling system depends on the accurate allocation of patients. During the health history and review, clinicians often encounter situations when forms have obvious errors. Due to the frequency of errors, clinicians dedicate valuable time during a patient’s visit to check whether forms are filled out accurately.
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So we asked ourselves - How might we design a form that is difficult to fill out wrong? We brainstormed a wide range of ideas and came up with prototypes that we rated across a spectrum of low fidelity to high fidelity. Low fidelity meant something that was easier to implement using the resources at our disposal and high fidelity meant more resources were required but imagined future possibilities. Re-designed forms would be easy to interpret and would result in a more positive registration experience for youth. This in turn would lead to a more accurate and efficient triage of patients. Digital registration through swipe style forms on iPads. Another iteration of this could be ACASI: Audio Computer-Assisted SelfInterview Software, on iPads with headphones, to accommodate literacy and language needs. Registration booths provide one-on-one, confidential support through the registration process. It also builds moments of human connection into the testing process.
Top: Current registration form. Bottom: Redesigned registration form.
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Human Connection We know that most youth feel uncomfortable even accessing a clinic, so of course waiting rooms are full of stressful energy. For worried patients, ancillary staff members are the first impression and first resource for answers to questions. Through interviews, we learned that the front desk staff understood their role as linear—taking a piece of paper, entering it into the computer, and assigning it to the next clinician. “A lot of patients complain that registration is the worst part and after registration everything is great.” - Clinician There is a disconnect between the front and back of the clinic. Since they are not on the same page, varying expectations of responsibilities can lead to inefficient execution of roles. For example, when patients went to the clinicians as an “Express Tester” and then turned into a full exam, clinicians did not always call to notify the front desk. The front desk staff are often unaware of the need to assist or reschedule the following appointments. Because of this disconnect, patients are not always registered and scheduled appropriately and they experience long wait times. We found that while the front desk staff have the important role of making the first human connection with patients, yet their job requires a focus on more mechanical tasks. So we asked - How might we support the front desk staff in becoming stewards of the testing journey?
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We brainstormed a wide range of ideas and came up with prototypes that we rated across a spectrum of low fidelity to high fidelity. Personalized name plates invites interaction and humanizes the employee as patients recognize shared interests, common spoken languages, or other personal points to build human connection. Staff photo wall increases the level of familiarity and comfort between youth patients and the staff, leading to a more supportive and less anxiety-provoking clinic visit. Staff-led waiting space redesign lets the staff pick paint, music, and decor as a way to build autonomy through the creation of their space, thereby building ownership and leadership within a larger domain. A team of problem-solvers at the helm of the clinic could lead to improved outcomes across the entire patient experience. New job descriptions help value and understand the role of the registration staff. To create structural level change it might require a change in the way the position is communicated, understood, and valued by the BCHD team.
Welcome sign and photo wall prototypes for the front desk area.
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Number System The number system is one of the initial touch points of the service. When a patient comes in, they pick up a number if they are getting tested or a letter if they are collecting results. These numbers and letters are patient identifiers, and not an order for appointments. Moreover, since the numbers and letters are called out of order, the patients get frustrated when they see other patient numbers get called, “before them,” and they think they are getting skipped. “People don’t know the process, and when you don’t know the process you become anxious because you don’t know what’s next.” - Clinician Patients are unable to easily gauge their progress during the waiting period. This is a moment that matters; if people think they are going to be stuck waiting or cannot anticipate how long it will take, there is a higher chance of them dropping out of the process. “After waiting for an hour just to be called up to turn in my registration forms at Druid I lost all faith that I would be able to complete my visit in a timely fashion, so I left.” - Youth During an unpredictable process, we found that the number system often added to patient uncertainty.
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So we asked - How might we demystify the testing journey? Testing process maps are simplified versions of the larger clinic process flow that will be part of the registration packet. The use of welcoming language and visual cues eases the patient into the testing journey and addresses the issue of comprehension for varying literacy levels. New number system consolidates the testing process and the number cards that the patient picks up. We propose flipping the letters for testing and number for results, and pairing them randomly, because a random assortment of letters does not imply a specific order. Testing process in the space allows us to activate the clinic spaces to respond to different phases in the testing journey. Icons and visual cues act as consistent visual reminders and are easy ways to absorb information to help those with low literacy. Automated text updates help patients to check in with a phone number and then be notified through text when their appointment is going to begin, as well as messages that explain what to expect during each stage.
Top: Current number and registration form system. Bottom: Redesigned number and registration form system.
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Conclusion
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Class Reflections Matthew Barr “I believe our biggest challenge remained navigating the bureaucracy and politics that come with collaborating alongside large institutions. My most valuable takeaway was learning how to use design research as a way to defend the action steps that are best for users, and not for entrenched systems at play.”
Jayne Chartrand “The best part of this Practice-Based Studio was working with our partners at the Youth Advisory Council and at Wide Angle Youth Media. Their enthusiasm during brainstorming and feedback motivated us to do work we were proud of.”
Valeria Fuentes “This project introduced me to Social Design as I look forward to entering MICA’s Social Design master’s program next year. My favorite part was working on the journey maps with the Youth Advisory Council (YAC) members because I enjoy working with youth.”
Maria Garcia “This project taught me a lot, especially in how to effectively collaborate with various partners. For this project, it was important to find a balance between the insights from the providers and the research team with the what we were hearing from the youth voices. Part of our role in the design team was to find that balance. It was a challenge at times, but it was also the fun part of being in the role of the designer.”
Devika Menon “While moving to the US was a journey in itself, this project has been one too. My key learnings came from immersing myself in the world of STIs, understanding Baltimore’s structural functions, and engaging with youth. Plus it’s rewarding to see some of our ideas being implemented in the real world.”
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Patricia Natalie “Working with both the youth and health professionals in the field gave me the most valuable insights and experience. I was able to see the complexity of this issue from both perspectives of our audiences, which was very crucial in identifying where we, as design-thinkers, could intervene to make a real and tangible social impact.”
Molly Reddy “Working in close collaboration with the Youth Advisory Council during this project was great. To have their feedback, and learn quickly when something wasn’t going to work for young people, or it needed to be adjusted, was invaluable to the process. Iterate, iterate, iterate!”
Rachel Serra “Seeing this project develop from the beginning research phase to the implementation phase was really incredible. It was great to work with Baltimore youth on this project; their voices were the driving force for our work and kept us engaged and inspired.”
Irina Wong “This project opened my eyes to the powers (and, yes, the joy!) of participatory research and user-centered design. I appreciated the insights we heard from the youth, providers, and public-health employees—each brought such a valuable and diverse perspective which helped shape our project.”
Cynthia Zhu “My favorite part of this class was when we presented our ideas and designs to BCHD, and I felt really encouraged when everyone gave positive feedback. It felt like all our efforts were strongly supported by the people we shared them with.”
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About the Grant CARS is a grant from the Center for Disease Control and Prevention (CDC) funded to the Baltimore City Health Department (BCHD), with sub-contracts to the Johns Hopkins School of Medicine’s Center for Child and Community Health Research (CCHR) and the Maryland Institute College of Art (MICA). The goal of this program is to mobilize a community coalition to reduce the rates of chlamydia and gonorrhea among adolescents and young adults in Baltimore City. Specifically, strategies for structural change that will lead to long-term, sustainable reductions in chlamydia and gonorrhea risk and increases in chlamydia and gonorrhea testing are sought. This work was funded through the CDC grant “Community Approaches to Reducing STIs” (U22 PS004541-01).
Collaborators: Baltimore City Health Department The Baltimore City Health Department considers sexually transmitted infections and diseases to be an important health issue within their organization. The HIV / STI Prevention Program focuses on efforts and activities that prevent the spread of sexually transmitted infection across Baltimore City. The program operates two categorical STI Clinics. These clinics provide testing, diagnosis, and treatment for most commonly occurring STIs. The clinics also provide family planning services, Ryan White primary care services for HIV positive clients, and hepatitis B immunization through the Vaccine for Children’s program. The programs provide services for more than 30,000 patient visits per year. In addition, the program operates an outreach testing program that provides testing for syphilis and HIV in areas of high morbidity throughout Baltimore City. The outreach staff work out of mobile vans in areas where disease transmission is likely to be relatively high or to have recently occurred. The program also provides health education services to schools and community groups upon request. Health educators are available to provide presentations on STIs and HIV. Several program staff are faculty of the STI/HIV Prevention Training Center, which provides STI education to hundreds of health care providers each year.
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Johns Hopkins Center for Child and Community Health Research The Center for Child and Community Health Research (CCHR) is dedicated to improving the lives and the communities of disadvantaged children, adolescents, and young adults by engaging in innovative, translational public health research according to the highest scientific and ethical standards. Through CCHR’s Biostatistics, Epidemiology And Data Management (BEAD) Core, core faculty and staff are also committed to providing research support services that promote the careers of faculty and strengthen and expand research at the Johns Hopkins University.
MICA Center for Social Design Social Design is a creative practice dedicated to understanding social problems and supporting positive social change. The Center for Social Design utilizes a human-centered and collaborative process to understand and define social problems, identify opportunities and generate ideas, and make tools that support positive change. Practice-based Studios at the Center for Social Design bring students from a variety of disciplines together with outside partners from government, nonprofit, and business sectors to identify opportunities, generate ideas, and make tools for positive social change for social issues ranging from healthcare to food access.
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Partners Thank you to all of our community partners who helped us along the way. We could not have done this project without you!
C. Patrick Chaulk, MD, MPH Assistant Commissioner of the Bureau of HIV/ STI Services, Baltimore City Health Department Vira David-Rivera Program Manager, Teen Pregnancy Prevention Initiative, Baltimore City Health Department Suzanne Grieb, Ph.D., MSPH Research Associate, Johns Hopkins Center for Child and Community Health Research Charlotte Hager Family Planning Program Manager, Maternal and Child Health, Baltimore City Health Department Jacky Jennings, Ph.D., MPH Director, Johns Hopkins Center for Child and Community Health Research Dr. Luke Johnsen, DO Medical Director, STI Clinics, Baltimore City Health Department
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Sophie Meade Community STI Program Coordinator, Johns Hopkins Center for Child and Community Health Research Glenn Olthoff HIV/STI Prevention Program Manager, Baltimore City Health Department Dr. Kathleen Page, MD Director of STI/HIV/TB Clinical Services, Baltimore City Health Department
Credits Lead Faculty: Becky Slogeris Associate Director, MICA Center for Social Design
Youth Consultant: Brittany Griffin Research Assistant and YAC Facilitator, Johns Hopkins Center for Child and Community Health Research
Public Health Consultant: Sheldon Allen Health Communication and Behavior Change Specialist
Peer Health Educator: Brittany Bryan Health Educator, Baltimore City Health Department
Class Guests: Vanessa Geffrard Sexual Health Educator, Trainer, and Founder of Vagesteem Andy Masters Youth Health and Wellness Coordinator, Baltimore City Health Department Tina Suliman Communications Associate, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health
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Appendix
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Stay Sexy, Stay Healthy Campaign Materials The following pages detail all of the different materials and pieces created during the project as part of the “Stay Sexy, Stay Healthy” messaging campaign, directed towards youth.
Social Media Posts
STAY SEXY STAY HEALTHY GET CHECKED
What does sexual health mean to you?
“Knowing about the outcomes of your decision, keeping up with your physical sexual health and being aware of your sexual agency.
Getting a sexual health check is free, simple, and confidential!
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”
– DeAndrea, 16 Dundalk
STAYSTAY SEXYSEXY HEALTHY STAYSTAY HEALTHY CHECKED GET GET CHECKED
STAYSTAY SEXYSEXY HEALTHY STAYSTAY HEALTHY CHECKED GET GET CHECKED
Beforegetting gettingburnt burnt Before upthis thissummer, summer,get geta a up sexualhealth healthcheck. check. sexual
Beforecuffing cuffingupup Before thiswinter, winter,get geta a this sexualhealth healthcheck. check. sexual
Free, simple, and confidential Free, simple, and confidential
Free, simple, and confidential Free, simple, and confidential
Sexual health checks protect Sexual health checks protect thethe sexual health of you your partners against STIs sexual health of you andand your partners against STIs #swimsuitseason chlamydia gonorrhea. #swimsuitseason likelike chlamydia andand gonorrhea.
Sexual health checks protect Sexual health checks protect thethe sexual health of you your partners against STIs sexual health of you andand your partners against STIs #cuffingseason chlamydia gonorrhea. #cuffingseason likelike chlamydia andand gonorrhea.
Social Media: Facebook
For more info on STI testing and taking charge of your sexual health, visit #staysexystayhealthy
What does sexual health mean to you?
“Knowing about the outcomes of your decision, keeping up with your physical sexual health and being aware of your sexual agency.
”
– DeAndrea, 16 Dundalk
Stay Sexy, Stay Healthy, Get Checked 75
Postcards
Where Can I Get My Sexual Health Check? Eastern Sexual Health Clinic 620 North Caroline St. Baltimore, MD 21205
What does sexual health mean to you?
Tel: 410.396.9410
“Knowing about the outcomes
Mon & Tues: 8:30AM–5:00PM Thurs: 8:30–1:00PM Wed & Fri: Closed
CityLink
LM
LocalLink
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of your decision, keeping up with your physical sexual health and being aware of your sexual agency.
”
– DeAndrea, 16 Dundalk
Druid Sexual Health Clinic + Healthy Teens Young Adults (HTYA) 1515 W. North Ave Baltimore, MD 21217
CityLink
GD
LocalLink
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Druid Clinic Tel: 410.396.0176
HTYA Tel: 410.396.0185
Mon: Closed Tues: Closed Wed: 8:30AM–5:00PM Thurs: Closed Fri: 8:30AM–5:00PM
Mon: 9:30AM–5:30PM Tues: 11:00AM–7:00PM Wed: 10:00AM–6:00PM Thurs: 11:00AM–7:00PM Fri: 9:00AM–5:00PM
STAY SEXY, STAY HEALTHY, GET CHECKED
#staysexystayhealthy
Getting a sexual health check at these clinics is free, simple, and confidential! For more info visit: www.knowwhatuwant.org
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Testing Journey Map
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Seasonal Campaign Materials
Before getting burnt this summer, get a sexual health check. Sexual health checks are free, simple, and confidential. Protect the sexual health of you and your partners against sexually transmitted infections (STIs).
STAY SEXY STAY HEALTHY GET CHECKED
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For more information visit: www.uchoosebaltimore.org
#swimsuitseason #staysexystayhealthy
Before cuffing up this winter get a sexual health check. Sexual health checks are free, simple, and confidential. Protect the sexual health of you and your partners against sexually transmitted infections (STIs).
STAY SEXY STAY HEALTHY GET CHECKED
For more information visit: www.uchoosebaltimore.org
#cuffingseason #staysexystayhealthy
Roses are red, violets are blue, sexual health checks are healthy for you! Sexual health checks are free, simple, and confidential. Protect the sexual health of you and your partners against sexually transmitted infections (STIs).
STAY SEXY STAY HEALTHY GET CHECKED
For more information visit: www.uchoosebaltimore.org
#rosesarered #staysexystayhealthy
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Stickers
STAY SEXY STAY HEALTHY GET CHECKED
Stickers to encourage testing.
Clinic Messaging
Get a SEXUAL HEALTH CHECK here!
Window cling for clinic door.
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STAY SEXY STAY HEALTHY GET CHECKED
Training Visuals
MASTER OF SEXUAL HEALTH in honor of your sexual health knowledge, we present:
with this certificate.
Signature
Date
#staysexystayhealthy
Training presentation template and certificate of training completion.
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Exterior Clinic Signage
Banner above clinic entrance, sandwich board pointing towards clinic, spinner board (could be held by a youth to direct other youth to the clinic.)
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Bus Shelter & Bus Interior Ads
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Testing Experience Materials The following pages detail all of the different materials and pieces created during the project for improving the physical clinic space.
Testing Process Graphics
the testing process the results process
get registered
receive appointment
meet with staff
collect samples
Vinyl testing process graphics in the waiting rooms at BCHD’s Eastern and Druid Clinics.
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finish visit
Number System for Testing and Appointments
1
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Number System for Results
A
86
Number system at BCHD’s Druid Clinics.
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Registration Form (English)
confidential registration form
Date:
Fill in your information so we can help you get registered (Please ask the front desk if you need help) Baltimore City Health Department Division of Clinical Services, Sexual Health Clinic Privacy Policy Notice:
BCHD STD Program respects your right to the privacy and confidentiality of the information that we maintain in your medical records. The information that you provide us is primarily maintained in a secure electric file. Your information can only be disclosed with your written permission or by subpoena signed by the court judge.
Primary Information Social Security Number:
Date of Birth: Name:
First
Middle
Last
Address:
Apt #:
City:
State:
Cell Phone:
Zip:
Home/Work:
Insurance:
Medicaid
Private Insurance
Medicare
No Insurance
Secondary Information Preferred Name: Sex:
Preferred Pronouns:
Male Female
Race:
Transgender M to F
F to M
American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White Other Race:
Ethnicity:
Hispanic
he/him
she/her
they/them
Other:
Primary Language:
English
Spanish
Other:
Marital Status:
Single
Married
Divorced
Widowed
Separated
Are any of your sex partners in the clinic with you today? No
Yes, Number assigned to them:
Have you ever attended a BCHD STD Clinic before, if yes which one? Non-Hispanic
Druid
Eastern
Year of last visit:
Emergency Contact Information Name:
First
Last
Phone:
Relationship:
Consent for Care: I request that I get examined, tested and treated for Sexually Transmitted Diseases (STDs). I understand that the testing routinely includes tests for gonorrhea, syphilis, trichomonas, HIV, and other STDs. I also understand that there are side-effects and risk involved with some forms of treatment, which will be explained to me by the clinician. Signature:
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Date:
Flip over ›
Triage Form (English)
how can we help you?
Tell us why you’re here so we can help you get registered (Check all that apply)
testing I HAVE symptoms Painful or burning urination Discharge (draining, drip) from penis, vagina or rectum Sore/bumps on penis, vagina, rectum or mouth Rash Vaginal itching or burning Pain in rectum, penis, testicles or vagina Abdominal pain (females only) I am pregnant or think I may be pregnant I have NO symptoms I don’t have symptoms, only need a routine STD check-up My partner has an STD and asked me to come get tested: HIV
Syphilis
Chlamydia
Hepatitis (B or C)
Gonorrhea
Trichomonas
I don’t know
results I am here for results I am here for results but have symptoms I was given a Blue/Yellow/Pink card or received a call from the clinic to come in I received a letter telling me one of my tests was positive
other I am here for blood test only -
HIV
Hepatitis
Syphilis
I am here for 2nd / 3rd Bicillin shot (syphillis treatment) I am here for a follow-up appointment I am over 21 and not had a Pap smear (cervical cancer test) in over 3 years Other Reason: ____________________________________________________ I understand if the information I enter is incorrect, I can be asked to re-register and may not be seen by a clinician today. Signature:
Date:
thank you!
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Registration Form (Spanish)
forma de registro confidencial
Complete su información para ayudarle a registrarse (Por favor, pregunte a la recepción si necesita ayuda)
Fecha:
Aviso de Privacidad del Departamento de Salud de la Ciudad de Baltimore División de Servicios Clínicos, Clínica de Salud Sexual: El programa de enfermedades de transmisión sexual de BCHD respeta su derecho a la privacidad y la confidencialidad de su información médica. La información que nos proporciones se mantiene principalmente en un archivo electrónico seguro. Su información sólo se puede compartir con su permiso por escrito o mediante un pedido firmado por un juez.
Información Primaria Número de Seguro Social:
Fecha de Nacimiento: Nombre:
(Deje en blanco si no lo tiene)
Primero
Apellido
Dirección:
Apt #:
Ciudad: Celular: Seguro:
Código Postal:
Estado: Número de la casa/trabajo: Seguro Privado
Medicaid
Medicare
Ningún Seguro
Información Secundaria Nombre Preferido: Sexo:
Varón Mujer
Raza:
Transgénero Varón a Mujer
Mujer a Varón
Indígena/Nativo de Alaska Asiático Afroamericano
Pronombre de Género Preferido:
él
ella
Otro:
Lenguaje Primario:
Inglés
Español
Otro:
Estado Civil:
Soltero/a
Casado/a
Divorciado/a
Viudo/a
Separado/a
¿Sus parejas sexuales están con usted en la clínica hoy?
De Hawaii o Islas Pacifícas
No
Blanco
¿Alguna vez ha visitado una clínica de ETS del Departamento de Salud? Si es así, cual?
Otra Raza: Etnicidad:
Hispano
Sí, número asignado a él/ella:
Druid
No Hispano
Eastern
Año de la última visita: ________
Información de Contacto de Emergencia Nombre:
Primero
Apellido
Número de Teléfono:
Relación:
Consentimiento para el Cuidado: Solicito que me examinen, me hagan pruebas y me traten para Enfermedades de Transmisión Sexual (ETS). Entiendo que los exámenes incluyen rutinariamente pruebas de gonorrea, sífilis, trichomonas, VIH y otras ETS. También entiendo que puede haber efectos secundarios y riesgos involucrados con algunas formas de tratamiento y mi proveedor de salud me las explicará. Firma:
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Fecha de Hoy:
Doblar la página ›
Triage Form (Spanish)
¿cómo le podemos ayudar?
Díganos por qué está aquí para que podamos ayudarle a registrarse (Marque todo lo que corresponda)
pruebas Tengo Síntomas Dolor al orinar Descarga (drenaje, goteo) del pene, la vagina o el recto Ulcera/herida en el pene, la vagina, el recto o la boca Erupción o sarpullido Picazón vaginal Dolor de panza (solo mujeres) Dolor en el recto, el pene, los testículos o la vagina Estoy embarazada o pienso que puedo estar embarazada No Tengo Síntomas No tengo síntomas, solo necesito un chequeo rutinario de enfermedades de transmisión sexual (ETS). Mi pareja tiene una ETS y me pidió que fuera a hacerme la prueba: VIH
Sífilis
Clamidia
Hepatitis (B or C)
Gonorrea
Trichomona
Yo no sé
resultados Estoy aquí por resultados Estoy aquí por mis resultados pero todavía tengo síntomas Me dieron una tarjeta azul/amarilla/ o rosa o recibí una llamada de la clínica pidiéndome que viniera Recibí una carta diciéndome que una de mis pruebas salió positiva
otra razón Estoy aquí solo por una prueba de sangre -
VIH
Hepatitis
Sífilis
Estoy aquí para mi 2do / 3ro vacuna de Bicillin (tratamiento de sífilis) Estoy aquí para un seguimiento Tengo más de 21 y no he tenido un Pap (prueba de cáncer cervical) en más de 3 años Otra razón: ____________________________________________________ Entiendo que si la información que ingreso es incorrecta, me tendré que volver a registrar y es posible que no pueda ser visto por un médico hoy. Firma:
Fecha de Hoy:
¡gracias!
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