4.1 COVID-19 and health messaging in the community 

Under-resourced communities in Cape Town can access health information in public service buildings, schools, healthcare facilities and public space. According to interviewed study participants, information is mainly presented through posters with policies, COVID-19 information, disease prevention and hygiene protocols. The community survey results also indicated that 50% of the sample group visit public spaces multiple times a day (Table 1) so are likely to be exposed to the public information. It should be noted that lockdown regulations limit movement and for fear of exposure, people may not be spending enough time in public spaces to properly engage with the information provided.

 

However, despite the availability of information, Table 1 notes that 40% of the sample group indicated that they would like to know more about prevention, COVID-19 and how it works, treatment and vaccination and only 30% felt adequately informed about vaccination. PHI002 identified that even though the information is available, it’s often not to the level of understanding of the communities since there is still limited access to education resulting in a lack of literacy and comprehension of provided information and while the work the NGOs do is effective, there isn’t enough resources to reach everyone in a community. PHI001 responded to the lack of education having further impacts to “health seeking behavior” and that literacy does affect engagement with health information and the application of knowledge for preventable diseases that are common in under-resourced communities. This is supported by Egbert & Nanna (2009), who said that the factors that classify a community being under-resourced, all contribute to low literacy levels and affect the application of preventative health measures.

 

While the use of visuals and graphics attempt to be more inclusive, constraints often lead to too much information being placed in one space leading to an overwhelming visual that is intimidating to a reader with a low literacy level (PHI002). A further consequence of inadequate education are language barriers. In South Africa, there are 11 official languages, and even though primary public messaging is predominantly in English, knowledge retention is found to be higher when it is provided in a mother tongue and is understandable to the reader (Hamaguchi et al. 2020: 2). Participant PHI002 pointed out that community members struggle to grasp concepts that they need to engage with independently and often require further explanation to understand what is being said. However, the reliability of word-of-mouth information is questionable since the comprehension of information is subjective and can add to the spread of misinformation if the explanation isn’t gained from a reliable source.

 

These communities make up most of the informal work force in South Africa and as a result of the ban on non-essential movement, many were left unemployed during the strictest lockdown periods. 70% of the community sample group had their income affected by lockdown while 30% were already unemployed before as seen in Table 2. Communities felt forced to break rules in order to find alternate sources of income for basic necessities such as food since the government provisions were disorganized and inadequate (Schmidt et al. 2020). Trust in leadership was minimal and resulted in widespread disbelief in the communication and protocols. This mistrust plays a large role in regulations not being adhered to as the government is then blamed for their loss of income and difficulties experienced (Abraham. 2011).

 

With limitations on the availability of understandable information and trust in sources, Participant PHI002 noted that communities are being influenced by old-wives-tales and allowing inherent biases and belief systems to govern their behaviour, even amongst the educated.

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4.2 Social media and technology for health messaging 

During an ongoing pandemic and continuous research and methodology being tested, it is important for medical and scientific communities to remain transparent and open with their findings as they develop. Developing print material and the lead times required for these can often render information outdated shortly after distribution. PHI002 also pointed out that due to budget constraints, if a poster or leaflet is damaged, it is often not replaced.

 

Logistics around the limitations of movement in public spaces and social distancing, have placed a larger reliance on the use of technology and social media for news and health messaging updates. Social media campaigns have been developed with the notion in mind that material can be photographed, shared and distributed (PHI001).

 

Social media platforms have been adopted as a faster, affordable and accessible method of keeping up with current affairs and, most recently, pandemic-related developments (Otten.2015: 1902). There was some success early in the pandemic, when a team created a simple infographic with all the basic necessary precautions available at the time, and shared it on social media. The infographic was shared and its efficacy noticed by other medical practitioners around the world and adopted and translated for their own countries and languages (Hamaguchi et al. 2020: 2). 70% of the sample group use smartphones to access updates on Facebook, as shown in Table 2. Using the internet and social media to learn about health conditions can be beneficial in reducing pressure on health services since patients are able to share experiences, participate and take steps to prevent illness (Househ et al. 2014).

 

While social media can reach a large number of people quickly, it has also been used to share false, unreliable news according to interviewed participants. Abraham (2011) supports this in saying that due to the open-source nature of the internet, anyone can create content without verification. The combination of the availability of fake news and literacy issues, means that not many people are able to search for more reliable sources and verify information. CI002 said that there isn’t a clear directive on where to find more reliable information, resulting in confusion and misinformation. PHI002 added that even though some of these messages are obviously fake, it still instills doubt in other information, reducing the belief in accurate sources. According to CI002, it has become increasingly difficult to filter through information.

 

In an attempt to create more reliable information, social media platforms have been adopted by some medical professionals to connect with the public, their patients and other practitioners. However, this is still frowned upon within the scientific community as blog posts and articles often skip the peer-review and publication process adding to the mass of information available on the internet (Panahi et al, 2014). 

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4.3  Data visualization and communication in health messaging

Reliable primary health data generated by the medical community is fact-based and imagery is often used as a minor addition to large bodies of text. To a person not scientifically inclined or with a high literacy level, this can be intimidating (Beene et al. 2020). PHI002 indicated that the health messaging currently available within communities is often compacted to include a lot of information resulting in a full infographic or poster that is time consuming and difficult to read.

 

Different types of messaging have different requirements, short-term messages that require immediate reactions from the public like mask wearing, hand washing and social distancing while long-term messaging aims to encourage environmental hygiene, physical behaviour changes and informed vaccination decisions (Abraham. 2011).

 

Public focus has been on keeping updated with the latest statistical news related to infection rates, hospitalization, death and sometimes recoveries. In the community survey sample group, 60% of participants selected the death rate as being the most important information to them when seeking updates as seen in Figure 1. However, this is mainly portrayed by numbers and the contextualization of the statistics is often lacking resulting in unintentional emotive responses in viewers according to CI002. Only 30% of the sample group use a news channel as a source of information, PHI002 suggested that the news has become negative and can be emotionally distressing to engage with considering the current circumstances. Health messaging affects an individual's view of mortality and should be carefully considered when being communicated as unwanted emotional stress affects the ability to understand and apply information (Estrada et al. 2015: 142). 

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During the first wave of infections, a #FlattenTheCurve campaign was developed to encourage people to adhere to the hygiene and safety protocols to reduce the number of infections. The use of a simple line graph curve and a clear call to action encouraged a change in human behaviour and the visual display of the result acted as a positive reinforcement (Mbunge. 2020: 1813). Andrews (2019) analysed the “roses” designed by Florence Nightingale to visualize the preventable mortality rate of soldiers in the 1850s who then presented it to a group of army officials. Only after seeing the mortality rate in a visual diagram were they convinced to implement changes in preventative health measures. This further supports the idea that the use of data visualisation techniques can enhance understanding and create context for data-driven information.

 

All interviewed participants spoke about the use of visuals and graphics being essential in engaging a wider audience and creating more accessible information since it can cross language barriers and literacy limitations. CI003 related a story about a book being used in different countries that only consisted of images as a means of communicating with native citizens through imagery, the participant went on to say: “Pictures are universal.”

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4.4 Inclusivity in the design process 

When creating visualisations and graphics for wide audiences, CI001 and CI003 said that they make use of basic shapes, colour and language in order to be as understandable to as many audiences as possible. However, PHI002 noted that the material reaching communities have become “generic” and in this way, unintentionally becomes unrelatable to the viewer.

 

According to Estrada & Davis (2015), successful inclusivity is considered to be a concept that investigates and appeals to what is fundamentally important to all humans and incorporates shared experiences. The Microsoft toolkit (Shum et al. 2016) for inclusive design outlines the concept of “Designing for one, extend to many” that explores permanent, temporary and situational exclusion. This refers to designing for people with permanent disabilities, but these design considerations include being able to cater to those who are temporarily impaired to those that could face challenges in particular situations. 

 

CI001 stated that over time, the inclusion of racial representation increased in order to make brands and products appeal to a wider audience. Representation in messaging is important as it creates an emotional connection with the viewer and it’s the emotional connection that is more likely to encourage changed behaviour (Panahi et al. 2014). To create an effective connection, CI002 stated that it is important to understand the context of the user and consider how they will be interacting with the material, where it will be and the potential mindset of the intended audience.

 

PHI001 said that when a new campaign is being aimed at a community, it is first tried and tested to better understand challenges and potential success or failure in the uptake of information. CI001 also commented that it’s an important part of the design process to engage with peers and the intended demographic to gain perspective and objective feedback. Hamaguchi (et al. 2020:3) conducted peer reviews and collaborated across specialties to have the most inclusive outcome of their COVID-19 infographic. Interviewed participants mentioned the importance of communication through the creative process to gain as much clarity as possible regarding the intended message for the correct audience, using the most ideal medium. PHI001 pointed out that in the initial phases of COVID-19 messaging, there were cases of the right message being sent to the wrong audience, but through constructive feedback and revision, have managed to adjust the necessary messaging to the appropriate audiences.

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4.5 Creative tools for effective engagement

All interviewed participants emphasized the importance of using visual graphics to communicate health and statistical information with success. Xiaojuan Ma conducted a study to understand the impact of visual aids and graphics in medical messaging by surveying a group of patients about treatments for common illnesses using purely text based information and then again with the use of simply designed graphics. It was found that people can retain and piece together narratives faster and more efficiently with the use of simple line art or illustrations without excessive amounts of text (Ma, 2016: 153).

 

This concept is further supported by CI001 who said that their primary goal in creating infographics is to “simplify the complex” as well as CI003 who uses a “less is more” approach when designing. 

From the primary research data and literature, the main factors that contribute to a health message being inclusive and well received are:

• Simplified graphics that represent the intended audience in some way
  (Ma. 2015: 153)

• Simple, direct wording and language that allows information to be translated easily and across platforms (Beene. 2020)

• Adhering to hierarchy in layout of information with consideration of white space and visual perception (Estrada & Davis. 2015: 145)

• Use of appropriate colour to create tone, ease of viewing and emotively considerate (Beene. 2020)

• Collaboration across specialties and peer reviewing for inclusive and reliable outcomes (Hamaguchi et al. 2020: 3)

• Platforms for experience-based feedback that allow for growth and improvement (Hamaguchi et al. 2020: 3)

 

PHI002 stated: “The country is not made up of one type of person, you have to talk to each group individually in ways they understand” to highlight the importance of incorporating inclusivity in the design process.