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Health workers have traditionally delivered health promotion and education to rural communities in the Global South in paper leaflet formats or orally. With the rise of digital technologies, health promotion and education can be provided in innovative and more effective formats, which are believed to have a higher impact on disease prevention and treatment.
The aim of this tutorial is to illustrate how a multi- and interdisciplinary approach can be applied in the design process of digital health messages for use in the Global South.
The multi- and interdisciplinary team of the Non-discriminating access for Digital Inclusion (DigI) project digitalized and customized available government-approved paper-based health promotion messages into a screen-suitable format. The team worked closely together and used its diverse expertise to develop digital health messages with disease-specific content in Tanzania’s national language (Swahili) as well as English. The development process included the following phases: a local needs assessment; identification of government-approved health promotion materials in a nondigital format; identification of key health messages; creation of a practical and engaging story, easy to understand for the general public; drafting of a storyboard for an animated video with review, feedback, and revisions; forward and backward translation; audio recording of the story in both languages; finalization and presentation of the animations; development of relevant questions related to the health messages in each domain; and development of web and mobile apps to access the digital health messages.
Between 2017 and 2019, we developed key health messages, quizzes, and animated health videos to address HIV/AIDS, tuberculosis, Taenia solium cysticercosis and taeniasis, and anthrax, all of which are of public health importance in Tanzania. Feedback from local stakeholders and test users was included in various phases of the process. The 4 videos and other content are available in local information spots on a digital health platform (DigI platform), established by the DigI project, in both Tanzanian Swahili and English.
Our methodological multi- and interdisciplinary approach ensures that the digital health messages for the public are clear, high quality, and align with the government’s objectives for health promotion. It also demonstrates the diversity of scientific disciplines required when collaborating on a digital health project. We recommend this approach to be applied to the development of other digital health messages for a wide range of diseases.
RR2-10.2196/25128
The World Health Organization (WHO) emphasizes the use of digital technologies to enable people to access information, goods, and services to improve their lives [
It is well known that health promotion and participation in health promotion activities will be revolutionized by digital innovations and that health literacy increases when people begin using digital tools to access information and make informed decisions related to their own health [
Designing digital health messages for a Global South audience can be challenging considering the abovementioned shortfalls in literacy, digital literacy, access to internet, and access to devices. Power structures, poverty, gender inequality, and health inequities at large, including poor infrastructure, complicate the situation for several groups, including those marginalized. However, the future of health education and health promotion participation in sub-Saharan Africa may very well be digital [
In Tanzania, community health workers and health facilities, in addition to nongovernmental organizations, have traditionally provided health promotion and education orally or in printed format (leaflets, billboards, banners, posters, etc) to neighborhoods and communities [
The Non-discriminating access for Digital Inclusion (DigI) project, in which the development of health messages described in this paper is part, represents a classical multi- and interdisciplinary project funded as an innovation project, with the aim of connecting rural villages to digital information. The DigI project’s multi- and interdisciplinary team, comprising 11 partners from 8 countries, includes scientists in the disciplines of humanities, social sciences, formal sciences, and applied sciences. These main disciplines include a variety of subdisciplines: medicine and health, epidemiology, public health, veterinary medicine, electronic engineering, visual and creative arts with graphic and interaction design, human-computer interaction, communication, education or educational technology, information science, internet science, and ethics. Elements from anthropology, human geography, health psychology, and sociology of health and illness have been applied in the various steps of planning and implementation of this project. Through our collaboration of Tanzanian, German, Norwegian, Rwandan, and American partners, our objective is to develop digital health messages by converting printed materials into digital formats such as animated videos (animations), quizzes, graphics, and texts. The majority of the DigI partners either belonged to the information technology (IT) and design task force, or the health task force. The Tanzanian and German project partners with backgrounds in health and medicine provided expertise on HIV/AIDS, TB, TSCT, and anthrax. The team was able to draw on their many years of experience working with each disease in the target areas. The selected diseases in the DigI project are endemic in the chosen geographical areas and thus are important diseases in the Tanzanian public health context. All these diseases are of high priority and require preventive strategies including information dissemination to communities and populations.
A digital health education platform, the DigI platform [
In this tutorial, we want to share our contextualization of digital health message creation for a broader audience to illustrate how it is beneficial to take advantage of the various backgrounds in a multinational and multi- and interdisciplinary digital health project. Each step of the process is illustrated with a general takeaway message and lessons learned from our project.
In this paper, the terms health promotion, health education, health communication, health information, health literacy, health message, and digital literacy are used. Here, health education and health promotion are 2 terms that are sometimes used interchangeably [
On the basis of the information in the print materials, the digitization process began by creating a narrative story capturing the key health messages, with elements of storytelling to maintain the
The exact approach to content creation was established based on the internal discussions. We aimed to meet clients’ needs, values, language, and culture and emphasized the rural Tanzanian context throughout the development process.
In the following 10 sections, each phase of our methodological approach is described in detail, with general advice and takeaway messages for each section.
Health message digitization process.
A human-centered design process [
Our general advice based on our experience is to spend substantial time exploring the local needs and involving local stakeholders as partners to form the process and shape the end product from the very beginning.
Health strategies and guidelines may vary from one country to another, and it is important to pay attention to the efforts that have already been laid down by policy makers, health workers, and researchers at a national level when mapping the local environment. Our video animations represent up-to-date, high-quality, and clear health messages that are based on approved health information materials, as a point of departure for digitization. The messages are taken from leaflets, posters, brochures, banners, guidelines, and strategies, all carefully reviewed for key health messages aimed at a public health audience (
From this step, we recommend exercising caution and respect toward the national health authorities. National strategies and guidelines may contain important health messages to be conveyed, especially to target populations, because of context-specific reasons, and may differ from international and global guidelines.
Examples of the education material used as a point of departure for digitization (Taenia solium cysticercosis and taeniasis on the left and tuberculosis on the right). Sources: Cysticercosis Working Group in Eastern and Southern Africa and Ministry of Health, Community Development, Gender, Elderly and Children, respectively.
Establish the most important key messages that you want to convey, depending on the health topic and target population. In our project, we dealt with infectious diseases for a rural population in Tanzania, thus dividing our key health messages into the following domains: (1) prevalence of the disease, (2) cause or transmission of the disease, (3) signs or symptoms of the disease, (4) treatment of the disease, and (5) prevention of the disease.
Once the domains were identified, we extracted key health messages from the materials described in the previous section. In the course thereof, short paragraphs, emphasizing the most important messages for each domain, were created. This is transferable to all health topics: to keep it short and simple.
The first domain intends to raise local awareness and includes health messages regarding the disease and its prevalence in the area. The second domain contains information on how diseases spread and infect others. The third domain describes the signs and symptoms of the disease, to help with early detection and management of the disease. Health messages encourage and motivate clients to seek medical advice if symptoms appear. The fourth domain is related to the treatment of diseases. The last and perhaps most important domain includes information on how people can protect themselves and their families and how the disease can be prevented from spreading between individuals and within communities.
This work established the basis for the written key health messages on the platform and in the animated health videos and moreover identified the most important information that the DigI team health task force wanted to provide to clients. The key health messages typically consisted of 50-150 words and were available on the platform. An example of a key health message (from the domain of symptoms in the TB section) is as follows:
Most TB patients show the following signs and symptoms: cough for more than 2 weeks, fever for more than 2 weeks, weight loss, night sweats and lymph node enlargement. People with these signs and symptoms should immediately visit a health facility for proper TB diagnosis and treatment.
Our general advice based on our experience is to rather focus on few key messages at the time and keep the messages short and simple so as to not overload the audience with information.
Throughout time, people have learned from stories. Stories can be a powerful way to pass on knowledge and specific messages to other people [
The stories are presented by a narrator and include references to family members as well as the community affected by the diseases (see TSCT example in
Our general advice based on our experience from the story creation is to include a variety of stakeholders to revise the scripts. Specialists and locals can contribute equally, but with different perspectives. Specialists want to ensure that the health content is being presented in an adequate way and that no key messages are left out, whereas locals can point out words and phrases that are difficult to understand. It can be useful to ask questions such as “Are all key messages promoted clearly? Is the language understandable and the story credible?”
Excerpt from “The Story of Tapeworms”.
After the script is approved, a storyboard needs to be created if the aim is to create a film or animation. A storyboard is a drawing with text below, illustrating scenes such as farming scenes that may be a common experience for rural clients (
Our general advice based on our experience is to establish the storyboards as soon as the script is approved. The storyboards make the animation visualization more realistic and can be effective in identifying scenes of importance for key message uptake. It is beneficial to include target users in this stage to point out recognizability and authenticity, or lack thereof, in different scenes.
Extracts from the storyboard used in the creation of “The Story of Tuberculosis.” TB: tuberculosis.
Working in 2 languages can be challenging and may complicate the process. Hence, qualified translators with experience in the field are needed to ensure that translation is consistent throughout the various versions of the script. In our project, the health messages and story scripts were created in English and then translated to Swahili for the target audience. The process was as follows: English health messages and story scripts were given to a person to translate them into Swahili. Thereafter, the Swahili versions were given to another person to translate them back into English. Further, the back translation was compared with the original English health messages and story scripts to ensure that the messages were the same. The Swahili messages were also read by the medical doctors who spoke Swahili to ensure that the messages had the same information as the English messages.
Our experience indicated that alterations of the script were done several times, also after translation; thus, it is important to ensure that the final script represents the same key messages in both languages.
When the script and translations are final, it is time to record the story. Although it is recommended to use a professional recording studio, the most important factor is to be able to present the audio file without background noise and with a clear and understandable narrator. In our project, we used professional narrators, and voiceover recordings were produced in both English and Swahili. Technically, recording itself was a straightforward process. It was emphasized that the narrators spoke slowly and clearly in an informal tone. The audio file was carefully revised by team members who were Swahili natives and near-natives in English. We recommend paying particular attention to the initial revision process of the audio file. There are cases where a written sentence conveys health messages more effectively than when reading aloud, and to save costs, it may be useful to read the script aloud to team members before recording it.
Once the voice recordings and animation scenes are ready, the animated video can be fully produced and shared with the team for revision and improvement. In our case, all team members carefully reviewed the English version of the draft video. After at least 2 rounds of revisions, the final animated videos were produced and then presented to an audience in rural Tanzania. The
Generally, this phase can be costly, but it is worthwhile to address small changes in the final product, which can be of importance for knowledge transfer.
To increase knowledge uptake, it may be useful to establish questions from digital health messages, such as animations, and present them to the audience in a quiz format, for example, after the audience has viewed the animation. We derived knowledge questions related to different diseases from the key health messages for each domain. These questions were constructed for research purposes to test people’s knowledge before and after being exposed to our digital health messages in a quantitative study. The same questions were published on the platform in a quiz format so that users could test their own learning. We ensured that the questions did not use medically advanced wording or information. In particular, the health task force assessed their quality as they related to the health content, and the social scientists made the questions easier to understand for the clients. An example of a quiz question is shown in
Our experience is that the questions created should not be too difficult, but should reflect the health messages, and work as reinforcers of the information provided in the animations.
Sample questions presented on the platform. TB: tuberculosis.
Access to information can be a bottleneck in disease prevention in the Global South. Animations and other digital formats for health education in the local language are only useful if they are accessible to the target audience. Hence, in the DigI project, it was equally important to develop an easy-to-use digital platform so that people in rural areas could access health messages. Key requirements for the success of the platform included that it would be easy to learn
As part of the human-centered design process [
The test participants were given a number of tasks to carry out, while a usability evaluator observed their performance to find any problems with the software under testing. Although posttest focus group interviews were conducted to gain insights into users’ impressions, a self-reporting web-based survey helped to collect users’ opinions on a Likert scale. The resulting web designs, shown in
Given that an increasing number of people have access to low-cost mobile devices, an Android mobile app, shown in
On the basis of our experience, we recommend digital health content developers to assess the access and context that users have to any digital information source. Digital health education projects are only useful if the target population is able to access health messages either supervised or unsupervised.
The platform user interface. The dashboard on the main health page is shown on the left. On the right, an example of the key health messages and quiz questions within the transmission domain of Anthrax is portrayed.
Health Messages mobile app "Linda Afya".
The resulting apps developed through the above-described process can be found via the internet [
In November 2019, seven InfoSpots were available and accessible with the platform, in Esilalei, Selela, Migoli, and Izazi. InfoSpots are still accessible and available for the local population. As of September 3, 2020, the mobile app had been installed by 425 users in 3 months since the launch of the latest version in June 2020. By February 1, 2021, the app store listing had been visited by 1531 people, out of which 1127 were users registered in Kenya. The app can be installed worldwide by searching the app called
Swahili Taenia solium cysticercosis and taeniasis health education on the platform.
In this paper, we have provided a tutorial for the various steps in the development process of digital health messages for a rural population in sub-Saharan Africa. The result of our project is a functional health education platform, and the feedback from the local stakeholders and test users was included to improve the platform’s usability and impact for the target users. In this section, we present a discussion of the chosen approach used in this project.
A multi- and interdisciplinary approach has become increasingly important in complex research and innovation projects [
A mixed methods study is currently ongoing within the DigI project to gather evidence for health information uptake and retention based on the above-described animations and access to the platform in 2 villages in rural Tanzania [
Regarding the technical aspects of the animation development process, there are various lessons learned that we want to share. We started with the identification of relevant key health messages and then created local stories around those messages, as described above. We had wishes and recommendations from the local community that increased the technical difficulty level but were crucial for the reception in the communities. The many inputs from local stakeholders were acted upon as the DigI team emphasized a co-design process.
Feedback from people in rural areas indicated that the proposed platform should provide information in three main categories: (1) village information, (2) health information, and (3) information on social life and activities. On the basis of this, the design team created templates and user interfaces. In the next stage of the co-design process, people were presented with the interfaces, and they gave positive feedback that the platform was easy to use. However, it seemed difficult to collect the necessary information for publication on the platform, particularly concerning the villages’ information and social information. The involved users had limited digital literacy for creating and updating information, for example, using the social media feeds provided by the platform. The research team realized the need to work with a selected group of individuals in each village to increase the usefulness and acceptance of the platform.
The inclusion of digital literacy training programs for the local population is a key factor in the successful implementation of digital health projects. Undoubtedly, the importance of digital literacy is evident when it comes to the use of digital health technologies by people with lower literacy levels, as these technologies could help overcome limitations and surely include new groups in the information society. The DigI team also set up the Key Performance Indicators framework for digital society development and, specifically, to provide a success indicator framework for this project. One of the most relevant success indicators is the level of digital literacy skills, and the health knowledge retention of the participants after the digital skills programs were obtained. Digital literacy goes hand in hand with digital inclusion and social empowerment; thus, it is important that Key Performance Indicators become an integral part of digital literacy initiatives and projects [
The drafted stories seemed only to meet the agreement of the full team after several rounds; therefore, the iterative process went on for a long time. In retrospect, the drafting of the storyboards should have been done at an earlier stage within the project, as this process would have provided the group with a good overview of the key health messages and scenes that we wanted to disseminate to the local population. It would have been much easier to imagine the final result if it had been possible to review the different scenes of the animation at an earlier stage.
The translation process of the first animation (TSCT) was performed too early. As the DigI team worked in English and the editing process went on over time, we had to update the Swahili version several times. When the final script was completed in English, the translators had to go through the Swahili version again to ensure that the 2 scripts convey the same story. Consequently, at the stage of the actual recording, the TSCT animation had to be recorded twice because the spoken version sounded different from how it was read. We also had to make adjustments to some wording to avoid misunderstandings. Rerecording was costly and time consuming and could have been avoided. In the following productions, we were more careful with the voiceover recording in the working language and the finalization of the script before translation.
The IT, social science, and health researchers in the DigI project undertook a participatory research approach and spent substantial time partnering with the local population to identify the preferences for digital health message design and knowledge gaps. The WHO has recommended a similar approach of using the existing Ministry of Health documentation and the engagement of different stakeholders [
A study that introduced a remote measurement technology platform reported that during the introduction of the remote measurement technology, a multi-stakeholder approach, including patients and research clinicians, provided knowledge about varying requirements for the design and development of the platform [
The digital health messages, video animations, quizzes, and web applications described in this paper were created through an integrated approach based on various scientific disciplines in addition to engagement of and input from village stakeholders and test users, thus taking advantage of the network and expertise of the DigI team members.
We believe that the methodological approach described in this paper, referring to the digitization of approved printed health education materials, should be promoted. The production process resulted in high-quality educational material that can be used in different forms and in different settings, such as stationary health messages on an internet platform or animated videos telling the story of four diseases in their local context in rural Tanzania. Potentially, health animations developed through the approach described in this paper could also be used in national knowledge portals, as the health messages they contain have been fully approved.
Screenshot of the platform.
Definition of terms.
HIV/AIDS health animated video (English).
Tuberculosis health animated video (English).
Taenia solium cysticercosis and taeniasis health animated video (English).
Anthrax health animated video (English).
HIV/AIDS health animated video (Swahili).
Tuberculosis health animated video (Swahili).
Taenia solium cysticercosis and taeniasis health animated video (Swahili).
Anthrax health animated video (Swahili).
Non-discriminating access for Digital Inclusion
information spot
information technology
tuberculosis
Taenia solium cysticercosis and taeniasis
World Health Organization
The DigI project was funded by The Norwegian Ministry of Foreign Affairs, The Norwegian Agency for Development Cooperation and Norwegian Research Council. The research assistants Ernest Nyoni, Sarah Swai, Bernadetha Tungu, Joan Kalugendo, Pudensiana Hilary, and Getrude Maganya gave constructive feedback during the Morogoro meeting. Merete Taksdal from LHL International provided feedback on TB content.
None declared.