3 IS KEY: a visual communication campaign
Allegheny County has typically met or exceeded national averages for childhood vaccination rates, but is far behind targets for HPV vaccines. HPV is one of the most pervasive sexually transmitted infections and can cause cancers in both men and women. The HPV vaccine is safe and effective, but is often viewed as controversial because of the sexually transmitted nature of the infection and skepticism around the vaccine's safety. Furthermore, unlike the two other preteen vaccines, Tdap and Meningitis, that are administered at the same time and are mandatory, the HPV vaccine is an optional vaccination. After a failed and volatile effort to increase HPV vaccination rates in the county, the ACHD engaged the School of Design to explore new approaches for addressing the problem.
- Design prompt: Design a visual communication system for the Allegheny County Health Department (ACHD) intended to increase adoption of the HPV vaccination in Allegheny County.
- Team: Collaborative design project with Chris Donadio
- Personal contribution: Academic research, user research, experience prototyping, co-visual design, content creation
- Tools & Techniques used: Adobe Illustrator & InDesign, in person interviews, card sorting, paper/cardboard/tin foil low-fidelity prototypes, personas
- Produced for: MA Visual Communication Fundamentals Studio, Carnegie Mellon School of Design
- Client: Allegheny County Health Department (ACHD)
- Project length: 5 weeks, Nov - Dec 2016
Grounded in the fact that a doctor’s recommendation of the HPV vaccine has the strongest influence on parent’s decision to vaccinate, the 3 IS KEY toolset is designed to help doctors frame and strongly recommend all three preteen vaccinations together. The system is intended to be rolled out by the health department to pediatricians and family practices across Allegheny County and designed on the foundation of five core design principles:
- In your space- Elements flow easily into existing routines and spaces, because we heard that even the best designed quality improvement projects never get off the ground because they fail to integrate into existing process and workflows
- Subtly in your face- The system takes advantage of situated triggers and uses simple and low-fidelity methods to prompt action, because doctors have a lot on their plate and need to be reminded often to stay on task
- Low maintenance- Each element requires minimal effort to maintain, because we heard from doctors how difficult it can be to make changes to processes or add more paperwork
- Low cost- Acknowledging the budget constraints of the ACHD, each element has a low implementation cost and the system is modular so that solution could be deployed as a full toolset or as individual components depending on available resources
- Generates pride- Give doctors, parents, and preteens the opportunity to amplify the message outside of the doctor’s office, because we want to empower the silent majority of support for the HPV vaccination
The content of the 3 IS KEY system leverages best practices in preteen vaccine recommendations, sourced from academic research and physician interviews:
- Bundling all 3 preteen vaccines together, with HPV sandwiched in the middle
- Messaging that is direct, brief, and assertive
- Emphasis on starting the vaccine regime right away and on the same day
Designed to be worn on a doctor's ID lanyard or badge clip, a ubiquitous element of every doctor’s uniform, the front of the doctor's badge serves as a gentle outward reminder of the campaign to the doctor and potentially the patient, while the back is a "cheat seat" on messaging for the doctors. Doctors can, for example, take a quick peak in the hallway just before they walk into an appointment to see sample language for framing the vaccine to parents and preteens, ensuring that they stay on message and consistent.
For the posters, we considered what content was appropriate for the backstage environment in a doctor's office and the front stage in an exam room or hallways, where patients and doctors would be present.
For the backstage doctor's lounge, the content of the campaign is focused on tracking progress towards a clinic’s preteen vaccination goal. Recognizing that doctor’s offices are resistant to additional paperwork, we designed a goal tracking system that was low-tech and required minimal effort to maintain. The objective of the poster is to fill in the key on the right side with stickers, with each sticker representing a patient(s) that receives all 3 preteen vaccines. Recognizing that the ACHD will roll this system out to a diverse range of clinics, each with unique vaccination goals, the poster is laminated so that it can be easily customized with a dry erase marker.
The front stage exam room poster is designed to prime parents and preteens for the message they will hear from their doctor during the appointment. The poster is intentionally brief, simple and clear, just like the content and framing throughout the toolkit. Exam room posters are a common artifact within doctor's offices, and though skeptical at first, interviews with doctors and parents confirmed that these visual cues can actually be effective prompts for conversation.
The patient brochure is one of the most critical elements of the solution and serves multiple objectives:
- It acts as prompt to remind the doctor to recommend the vaccines
- It provides brief, clear, and easy to understand information about the three preteen vaccines to parents and preteens
- It drives vaccine initiation on the same day and scheduling of the follow-up visit
- It delivers stickers to the parent and preteen
Distinct from traditional tri-fold brochures often found in doctor’s offices, the 3 IS KEY brochure is designed to fit into a doctor's workspace, in such places as an exam room workstation/computer station. That way, when the doctor checks in and out of every appointment, they will see the brochure at their fingertips and be reminded to recommend the vaccines to patients.
Like all elements of the system, the content of the brochure is brief, concise and clear so that the information is accessible to both parents and preteens.
Inspired by “I voted” stickers and research that indicates that stickers can actually increase voter turnout, we created stickers to enable parents and preteens to publicly demonstrate their pride and sense of accomplishment for completing the vaccines. The stickers can also serve as a conversation starter between preteen or parents after the visit, hopefully having a ripple effect and encouraging more parents and preteens to get the vaccines.
Research & Process
In order to ground ourselves in the world of HPV vaccinations and the healthcare space, we began our process with thorough desk research and engaged the ACHD to understand the challenges and opportunities from their perspective. We conducted an extensive review of academic research on HPV vaccination dynamics, parent and preteen experiences with the vaccine, approaches to framing the vaccine, and successful intervention techniques. We reviewed the existing efforts by the CDC, health departments across the country, and international initiatives in the UK and Australia. Additionally, we explored case studies outside of HPV context, such as the PrEP vaccine, flu vaccines, blood donation, and the psychology and social dynamics of “I voted stickers,” bumper stickers, and support-the-troops-style ribbons in search of strategies that could potentially be translated into the HPV scenario.
Given the dynamics of the 2016 Presidential Election and the fact that the ACHD received an explosive response from a small, but loud, anti-vaccination group in their latest efforts to engage the community, we were particularly inspired to explore the framing of the HPV vaccine in the general public. Noting that it is often easier to coalesce support in opposition to something, we were interested in finding ways to amplify the voices of people who supported the HPV vaccine. We started with asking the following questions:
- How might we help parents and preteens feel a sense of pride around getting the vaccine and to share that publicly?
- How might we create an identity for parents and preteens that are pro-vaccine?
- How might way shift the frame of debating the efficacy and safety of the vaccine to championing the benefits?
PARENTS & PRETEENS: To validate some of our initial hypotheses, we conducted in person interviews with parents of preteens that were both for and again vaccinations. We asked general questions around what causes parents felt strongly about and how they did (or did not) demonstrate that support publicly, and specific questions around health care decisions they were particularly proud of, vaccination attitudes, and dynamics with their pediatricians. We also conducted card sorting exercises to explore what parents valued most in preparing their children to enter their next phase of life as teenagers. The key insights we learned were:
- Trust: Parents have a lot of trust in their children’s physician. They feel their doctors know them and their family, and generally feel good about following their recommendations.
- Vaccines are tricky territory in the public domain: Parents were often proud of their choice to (or not to) vaccinate, but were often weary of discussing this with people they thought may disagree with their position. Since HPV is sexually transmitted, there was also particular hesitancy around children displaying an explicit reference to an HPV vaccination, for fear of the potential for blow-back from people with opposing viewpoints that may be in the child’s orbit.
- Normalization: Whether it was healthy eating habits, activities, or staying on top of vaccine schedules, parents wanted their children to see these decisions/values as the normal course of business. Calling too much attention to any one thing could make the action seem exceptional, when their goals were to normalize these behaviors.
PHYSICIANS: We conducted in person and phone interviews with a number of physicians to better understand their experience discussing and administering the vaccine with patients, their internal work flows, and incentive and metrics structures that exist that may influence their behavior and patient priorities. Through these conversations, a number of themes arose:
- Lack of training: We were shocked to hear from every doctor that we spoke with that they do not receive any training on how to frame challenging conversations with patients. Aside from hallway conversations with fellow physicians, there is a large gap in training for physicians in what is arguably the most critical part of their job, communicating with patients.
- Doctors are BUSY and human: Appointments are short, back to back, and there are multiple clinic-wide and patient-specific priorities to cover in every appointment. Don’t even get them started on the paperwork. Doctors easily forget things, unless they are reminded.
- It's all about workflow: Delivering health care is a complex orchestration between many individuals and process matters. Most health care providers disdain any changes to their process or paperwork, meaning that even some of the best intended quality improvement projects fail in implementation because they do not take into account existing workflows.
Given what we learned from parents and physicians, we shifted our approach from concentrating on the public framing of HPV to seeing the physician-patient interaction as a key point of leverage and began to explore:
- How might we improve doctor’s communication about the HPV vaccine?
- How might we make the HPV vaccine feel like the default and expected course of action for parents and preteens?
Based on our interviews, we created personas to facilitate a live prototyping session of conversations and information exchanges between doctors and patients. We experimented with getting doctors versus patients to prompt the HPV conversation and if it would be possible for doctors to remember to give the patients stickers at the end of the appointment.
During our experience prototyping session we realized that the handoff of the brochure from doctor was awkward, if it even happened at all. We had been struggling with how to make this handoff more seamless and ensure the doctor would remember to bring up the vaccines, when I had an unexpected doctor’s appointment.
During the appointment, I was handed a wallet-sized brochure and sexual assault spiel by BOTH the nurse and doctor. It was clear to me that sexual assault education was a key priority for this clinic, and I was immediately curious how this clinic had been so effective at getting the message out. The doctor explained that the clinic had actually been failing in their educational objectives until someone had created these smaller pamphlets that were right next to their workstation keyboard. Now, she saw the pamphlet every time she came in and out of patient’s room and was reminded to hand over the brochure and give their messaging.
This experience shifted our thinking again, and we began to explore how we could replicate the successful parts of my experience in the doctor’s office and search for other similar leverage points within a physician’s daily routine. This eventual focus on situated triggers within a physician’s workflow is what ultimately makes the 3 IS KEY toolset unique from other HPV communication campaigns, and was the inspiration point for the Doctor’s Badge, Patient Brochure, and Doctor Room Poster.
Due to time constraints we were not able to take this concept further in the context of this class project. However, if I were able to continue working on this project, I would like to explore how we could leverage digital assets to trigger conversations and amplify the message of the campaign. In particular:
- How might we enable more sharing of vaccine messaging best practices between physicians within and between clinics?
- As the content of the system uses normative methods of messaging, how might we extend that to use normative comparison between doctors or clinics to help motivate more vaccine conversations?
- Are their opportunities within electronic medical record systems to incorporate prompts with messaging recommendations, in addition to reminders for test results, vaccination schedules etc?
- Could this toolset concept be made flexible so that it could be utilized for multiple health care objectives? A digital ID-style badge? Integration into an iWatch or A/R headset?