Using Human-Centered Design to Develop, Launch, and Evaluate a National Digital Health Platform to Improve Reproductive Health for Rwandan Youth

"Using a human-centered design (HCD) approach throughout the design and adaptive implementation phase with youth and key stakeholders led to major pivots in the product, implementation, and evaluation design of a digital health product for Rwandan youth."
Human-centred design (HCD), a creative problem-solving process used to develop interventions that centre on the person or beneficiary, has emerged as a promising methodology to engage youth in the design and adaptation of solutions to better meet their needs. The HCD process provides a framework to design and iterate on interventions while taking into account desirability, feasibility, and viability. This article describes how the global design and research organisation YLabs used HCD in Rwanda to create CyberRwanda, a digital platform aiming to provide adolescents (aged 12-19 years) with evidence-based, unbiased, and youth-friendly family planning and reproductive health (FP/RH) information and care.
From 2016 to 2020, YLabs designed and piloted CyberRwanda using an HCD approach in partnership with 1,074 Rwandan youth, parents, teachers, and public and private healthcare providers. Those who took part did so in the context of Rwandan adolescents' limited access to high-quality FP/RH information and care, juxtaposed against the rapidly increasing access to digital devices and the internet for young people in sub-Saharan Africa. The below figure summarises the phases of the process:


The article describes the methods used to design CyberRwanda and the populations engaged throughout the phases of design research, prototyping of initial and refined concepts, product and content development, pilot, and adaptive implementation and evaluation. For example, during the problem recognition phase, HCD revealed participants' beliefs, behavioral preferences, and experiences as they relate to FP/RH specifically and their broader life experiences, motivations, and challenges. Prototypes were tested and assessed based on predefined criteria that included desirability for participants, cultural acceptability, and feasibility.
Throughout the HCD process, the YLabs team moved from youth-centred design to youth-driven, to a youth-led approach today. The team has considered the following as they partnered with youth:

• Training youth designers: YLabs trained young Rwandans were trained as youth researchers to conduct HCD sessions; most sessions, including user testing and development of all content, were led by youth. Trained youth designers were compensated in line with national salary benchmarks.
• Creating safe spaces: The design team incorporated principles of trauma-informed care and led icebreaker activities designed to address the inherent power differential between researchers and participants. Less-taboo topics were leveraged as "gateway" activities, and the team took steps to ensure that the session was valuable to youth. All young people were compensated for their time and participation.
• Ensuring comprehensive safeguarding protocols: All staff were background checked, trained on child protection and safeguarding, and followed robust child protection policies.
• Conducting comprehensive risk mitigation assessments: Due to sensitivities and stigma surrounding RH, risk analysis and mitigation planning were conducted before prototyping, and prototypes were tested with parents, teachers, and community leaders for acceptability and to help inform risk estimation before the pilot.
• Ensuring ethical use of participant images and data: All young people provided written consent or assent with adult consent for their participation in the HCD process. Images were only taken and/or used with written consent from the young person. No images of youths aged younger than 18 years were used in programme materials.

The HCD process resulted in a digital behaviour change intervention designed with 2 main users in mind: urban and peri-urban young people and pharmacy staff (nurses and head pharmacists). The direct-to-consumer platform (via an application, or app) enables adolescents to learn integrated, age-appropriate health, and skills-building information through edutainment behaviour change stories (3 seasons, as of this writing) and a frequently asked questions library, order health products online, and be linked to CyberRwanda's network of private and public healthcare providers who have been trained to provide adolescent-friendly care (and who will receive access the online CyberRwanda pharmacy portal, which enables them to add and update health products and pricing online, as well as tech support).
As of this writing, CyberRwanda is entering into a 2-year implementation and evaluation phase, in which the same HCD methodology used to design CyberRwanda will be applied as the team iterates the design of the web app and adds features and content. This process includes working with young people to develop all new narrative content and validating it before it is finalised, analysing data generated by Google Analytics to understand which pages and content young people respond to the most, conducting focus group discussions with youth and teachers on additional topics and features that are needed, and working with parents and other stakeholders to support usage of CyberRwanda in schools and at home. (CyberRwanda will be available to participating schools and youth centres, where the intervention is made available on online tablets. Youth may also access CyberRwanda on their personal devices and school computers, where available.)
To date, user testing revealed that despite rapid increases in technology ownership and use, for many Rwandan youth, especially those with lower incomes, using a smartphone or tablet is a new skill. In response, the team developed 2 instructional videos. Also, based on youth preferences for shorter content, the intervention pivoted to a less text-dependent webcomic format delivered in both Kinyarwanda and English to accommodate different levels of literacy and support visual learners. (See the full paper for additional iterations made.) Ultimately, CyberRwanda will be tested in a 2-year impact evaluation, consisting of a 3-arm randomised controlled trial (RCT) in schools, serial cross-sectional study in youth centres, qualitative studies, and a cost- effectiveness evaluation across 60 schools and 9 youth centres in 8 districts in Rwanda. This RCT will compare a facilitated model, building on this existing school club culture to foster group- and peer-driven learning, with a self-service model that supports more private, self-directed learning. These findings are expected to demonstrate which programmatic components lead to behaviour change and how best to implement digital interventions for youth.
Reflecting on the CyberRwanda experience to date, YLabs asserts that the HCD process "paved a supported pathway toward implementation and evaluation by ensuring that the ultimate intervention was desirable among many key stakeholders, feasible for nationwide implementation and scale." Some implications for future practice and research include:

• HCD offers foundational methods and mindsets to support continued iteration throughout implementation.
• Iterative and equity-centred approaches to design can allow for the inclusion of new technology users in digital initiatives. (Prioritising equity of access led in this case to the design of interventions for users with and without their own devices and with varying levels of digital literacy and experience using digital platforms.)
• Engaging youth throughout the design process requires special considerations, particularly when designing for taboo topics.
• It is critical to include a diverse population of young people and community stakeholders as both collaborators and leaders.
• With increasing interest and investment in digital health interventions, especially those supporting direct-to-consumer products, funders should support and encourage time for codesign, development, and prototyping with the intended audience in both the design and implementation phases.

In conclusion: "Using HCD as an end-to-end approach...provided a natural approach to center young peoples' needs, aspirations, and perspectives into the intervention design by having youth lead design research, prototyping, and data collection efforts with their peers. The process toward designing and implementing CyberRwanda has demonstrated the value of supporting youth-driven or youth-led HCD approaches that shift decision-making power to young people through funding, mentorship, and training."