Youth-friendly Sexual Health Testing, Baltimore

In Baltimore City, youth aged 15-24 represent 70% of new STDs reported to the Baltimore City Health Department (BCHD) in 2012, with breakdown being 60% for gonorrhea, 70% for chlamydia, 27% for syphilis and 25% for HIV. Thus, it is important to be attuned and responsive to youth needs and desires about sexual health and their testing experience while making sure more people get tested. This work was funded through the Centers for Disease Control and Prevention (CDC) grant “Community Advancements in the Reduction of Sexually Transmitted Diseases” (CARS). Through this grant, the BCHD, Johns Hopkins Center for Child and Community Health Research (CCCR), and the Center for Social Design at Maryland Institute College of Art (MICA) have been working collaboratively to design, implement, and test interventions to increase access to STI testing and normalize STI testing for Baltimore youth aged 15-24. Prior to this project, youth and young adults in Baltimore were a part of this effort through the Youth Advisory Council (YAC) as a part of the CARS grant. 

As part of the MICA team which comprised of 14 graduate students in the MA in Social Design program, over the course of the 2016-2017 academic year, in Fall 2016, we worked as a larger group to better understand the issue and the challenges that young people face leading us to develop early insights and prototypes. In Spring 2017, I was part of a smaller team that focused on the testing experience within a BCHD STD Clinic. In addition to conducting design research at the clinic and creating testing process flows, I was instrumental in developing prototypes and eventually creating designs of new material that are currently being implemented, tested and evaluated.

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Preliminary Research

As students, we each completed our own testing journeys, reviewed current literature, observed clinic spaces, interviewed, surveyed, and spent invaluable hours getting feedback from and workshopping ideas with Baltimore youth, clinicians, and health department staff.

Based on this research, we developed six design principles to to help make the STI testing process a more positive experience for youth:

1. Comforting because clinic and health spaces can be “cold” and “scary” to a young person.

2. Enjoyable because this is often the first time young patients are interacting with the clinic and first impressions matter!

3. Confidential because we learned youth and clinicians have different definitions of confidentiality. Clinicians follow HIPAA protocols. Youth want to feel “invisible.”

4. Transparent because youth want to know what is about to happen to them at each step.

5. Timely because the longer youth have to wait, they’re less likely they are to complete testing.

6. Sex Positive because we want to move away from being punitive and towards being supportive. 

Our most important takeaway from all of this research was - What’s good for Baltimore youth is good for everyone. 


Early Insights and Prototypes

After making themes, we created insights as a way to understand the clusters of information. Insights are a way to explain the clusters of information, detail a surprising tension from the observations, or make sense of the feelings we captured about the overall problem. Below are some of our insights:

  • Youth value privacy and anonymity - values which are currently lacking in the testing experience. Moreover, youth’s definition of confidentiality is different from the HIPAA confidentiality protocols that providers follow.

  • Self esteem and emotional intimacy are foundational for healthy sexuality, but are traditionally left out of STI interventions. 

  • Even with positive doctor-patient interactions, wait times for service and results are strong influencers of fear and anxiety during the testing process.

  • Funding drives programming, which often limits effective collaboration, the dedication of time and resources to pressing community issues.

Brainstorming and feedback sessions with the following groups paved the way for our narrowed focus:

Baltimore City Health Department: About 10-12 professionals, including BCHD staff, Johns Hopkins team members, and two MICA professors

Wide Angle Youth Media: 15 high school aged students

Practice Based Studio group at MICA: 8 graduate students, 1 professor, 1 CARS member, 1 youth leader

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Testing Experience at Eastern Clinic

A lot of our insights from the Fall 2016 research had to do with the multiple moments of waiting in the testing process. Using what we had already gathered and learned, we developed a more focused how might we statement to guide our research in the Spring of 2017. We wanted to ask, “How might make STI testing friendly and transparent for Baltimore youth?”

The focus this time was a BCHD STD Clinic- Eastern Health Center at 620 N Caroline St, Baltimore. We worked towards understanding and breaking down the testing process at the clinic, conducted qualitative interviews with clinicians and staff. Through interviews and research we discovered one overarching insight that guided the work of the patient experience team, which was:

Unsuccessful registration can have a ripple effect on the entire patient and clinician experience.

This overarching insight led us to dive deeper and land on three primary interventions, which occur during the registration phase:

  1. Registration and Triage Forms
  2. Testing Process Map
  3. Staff Photo Wall
 
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1. Registration and Triage Forms

Eastern Clinic sees patients with a wide range of literacy, language, comfort, and ability levels, affecting the way they fill out forms, which affects the accuracy of their triage, and ultimately the service they receive. The scheduling system depends on the accurate allocation of patients. Due to frequent errors on forms, clinicians dedicate valuable time during a patient’s visit to fixing errors. Forms that are redesigned and easy to interpret will result in a more positive registration experience for youth, and also lead to more accurate and efficient triage of youth patients. 

“I filled out the forms, which felt like writing an essay. We just want something that doesn’t feel like a complicated homework assignment.” - Youth Patient
“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
 
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2. Testing Process Map

Youth patients are unable to easily gauge their progress during the wait time, a moment in the process where they feel the most anxiety. Because of this patients can drop out during the process. Process maps will increase transparency and predictability around the testing process and reduce the fear and anxiety many youth feel while seeking testing.

We recommended printing out testing maps with patient numbers to be given along with forms and also putting it up in the waiting spaces throughout the clinic.

 

“I want to know what to expect and what I’m in for, because some people go and they’re scared.”  - Youth Patient
“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.” - Provider
 
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3. Staff Photo Wall

For worried youth patients, ancillary staff members are the first impression and first resource for answers to questions. The photo wall will increase the level of familiarity and comfort between youth patients and the staff, leading to a more supportive and less anxiety provoking clinic visit. 

“I want a place that makes testing feel less scary” - Youth Patient
“The doctor felt like a stranger. I didn’t want to talk to her about these personal things.” - Patient
 

We created an Implementation Guide for implementing the low-fidelity prototypes that we suggested as quick-wins for the clinic. We also recommended creating additional unified branding and messaging across the clinic to provide clear and consistent messaging. Below are some mock-ups and new redesigns of clinic material that I designed.