Our human-centred approach to protecting female sex workers claims a major design prize
They are devastating numbers. Kenya has the fourth-largest HIV epidemic in the world, with a prevalence rate of six per cent. That means approximately 1.6 million Kenyans are living with HIV infection.
And female sex workers are one of the most affected groups.
ThinkPlace Kenya has been awarded a prestigious design award from New-York based Core77 for a ground-breaking project – Sex Work is Real Work – that uses the principles of human-centred design to help drive uptake of available preventative medications by female sex workers.
It is work that will save lives.
The Kenyan Government recently introduced (Oral PrEP), a method that uses antiretroviral drugs to protect HIV-negative people from getting infected by the virus. The drug reduces the risk of HIV infection by taking one pill once a day.
But while Oral PrEP is a viable HIV prevention option, it cannot work if those most at risk are not aware of it, able to access information about it or persuaded of its benefits.
Our work – which was funded by the Bill and Melinda Gates Foundation - included a combination of both in-depth exploratory research and behavioural insights research. It was able to understand the motivators, decision-making pathways, and behavioural norms that are involved with decisions to access the drug.
This was a ground-breaking approach. So many public health communication strategies are grounded in using fear-based messaging to reduce harm.
We wanted to do something different, starting from a position of empathy and respect. ThinkPlace’s project uses a unique research strategy that works not only at the individual level (using aspirational messaging to encourage adoption and retention) but also at the peer group and community level (stimulating long-term social norm change).
Human-centered design involves seeking emotional understanding of the users for whom it is intended. With that in mind, we engaged female sex workers very early in the process, and even trained some of them to conduct research in an environment that was familiar to them and their peers.
ThinkPlace researchers gained qualitative insights by exploring the contexts in which female sex workers expose themselves to risk and make decisions.
We spent full days and nights shadowing female sex workers, both inside brothels and in the street at designated "hotspot" zones. This allowed us to naturally observe what a typical day looks like for them, including the flow of clients in-and-out and the decision-making processes the women took to determine how clients are assigned.
Among other things we uncovered blockers to successful uptake of PrEP, such as brothel owners being unwilling to display educational material for fear it would turn clients away.
The project involved a number of innovative methods. When we needed to understand healthworker bias around serving female sex workers we challenged a group of sex workers to create a model of the "ideal sex worker-friendly health centre" using Lego blocks.
Building on this fieldwork, behavioural economics supported a more data-driven approach to understanding the psychology behind human attitudes.
This research phase informed the creation of a quantitative tool used for segmenting the target population into clusters based on self-reported sexual behaviors, decision factors and objective-subjective risk levels.
That allowed us to identify personas within the quantitative data to draw population-level conclusions and help inform new strategies for intervention.
Having started by understanding the views, behaviours and needs of female sex workers we next began to design solutions. ThinkPlace ran several co-design sessions around the country, invited a diverse group to design with us, including people who represented the key personas identified earlier in the project as well as subject matter experts.
This process generated a wide range of concepts, allowing us to choose the most promising ones to build and test.
One successful initiative arising from this work was stickers featuring the slogan "Sex Work is Real Work", aiming to provoke inquiries for more information about PrEP. These stickers were pasted inside matatus (minibuses) that routinely passed hotspots or places where brothels are common in Nairobi.
They were intended to both legitimize the sex work profession and appeal directly to sex workers, in an unapologetic manner. This simple intervention was able to catch the attention of sex workers who take matatus to and from work.
The successful messaging was only possible because we understood how the subjects of this campaign wanted to be represented. Our research showed female sex workers wanted to see more depictions that painted themselves and their peers as successful in their work and their personal lives. They felt a desire to see their professionalism recognised and their position in the workforce and society legitimized.
In this way the message around PrEP was delivered more effectively. Being direct about PrEP as it relates to the empowered, professional sex work was critical in catching their attention.
The types of interventions we co-created and tested in collaboration with the intended users achieved significant individual, social and structural change. Our communication strategies focused on influencing the female sex worker as an individual, identifying and intervening in her decision-making process.