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In 2017, 650,000 Rohingya refugees fled to Bangladesh in an attempt to escape widespread violence and persecution by the Myanmar army. Most walked for days, even weeks, before finding shelter in the sprawling refugee settlements in the Cox’s Bazaar region of Bangladesh.
Many refugees lost family members to the violence, saw their homes destroyed, and lost all of their belongings. Living in humanitarian settings has a devastating effect on families, but women are particularly vulnerable; they face significant hardships trying to prevent unwanted pregnancy due to changing family structures, sexual violence, and disrupted health services—including sexual and reproductive health care.
In response to the need for sexual and reproductive health services, the Government of Bangladesh partnered with national and international non-governmental organizations, including Ipas (a U.S.- based reproductive health and rights organization) to meet the needs of Rohingya women. Clinics were established, and paramedics, midwives, and doctors were trained to provide reproductive health services. As more clinics were established and trainings added, the attention turned to how to expand reproductive health services, including health information for Rohingya women.
Clinicians, public health experts, advocates, and researchers from Ipas teamed up with technical experts from IDEO.org, a human-centered design (HCD) organization, to explore knowledge, attitudes, and beliefs about contraception and reproductive health in Bangladesh—particularly among Rohingya women and men and health workers in the refugee camps. Using HCD we explored the methods and preferences for communication on reproductive health for Rohingya women and men.
HCD is a creative approach to problem-solving that starts with the user and ends with solutions that fit their needs. As IDEO.org puts it, using an HCD approach not only builds empathy for the people you are designing for; it also generates numerous ideas, allowing for a variety of concepts (known as prototypes) to be shared, discussed, and altered until an innovative solution is found. We learned that HCD allowed us the flexibility to change direction and accept failure as part of the process, and how challenging conventional beliefs can lead to innovation.
Our work with IDEO.org started with a bid to win a challenge that called for ideas on how to highlight sexual and reproductive health issues in humanitarian settings. Out of the 250 applicants for the challenge, our idea for a mobile app was one of the winners. Our idea assumed that we needed a technology solution, in line with so many of the changes in our world. People loved the concept and all we needed were mobile phones or tablets to carry these contextualized messages. We worked under the assumption the app would be used to share information directly with women or community health workers. And there was an added advantage: the mobile app was already in development in Spanish and English, in a partnership between Ipas and the Hesperian Health Guides–the organization that brought public health to the people with the book Where There is no Doctor.
The concept was strong, the partnership reputable, and we expected implementing our idea would be easy—until it wasn’t.
During our HCD prototyping phase in Cox’s Bazaar, we developed exercises, interviews, and activities to explore the views of our potential users. These questions led to more questions and to the identification of problems that Rohingya women encounter. This led to kernels of solutions that, when simply drawn on cards and explained in plain language, resulted in ranking, voting and the discarding of bad ideas.
During this process we spoke with over 150 people—men and women, young and old, married and unmarried, health care workers and religious leaders. It was during this prototyping phase that it became clear Rohingya women did not need a technology-based solution.
There were multiple problems with our plan. The Rohingya language differs in dialect from region to region and most refugees cannot read and write the language, nor can health workers, who are mostly Bangladeshi. Cell phones were hard to find in the refugee camps, and restrictions imposed by the Bangladesh government forbade refugees to purchase sim cards. Among refugee households that managed to have cell phones, the phones were likely to be used by men, and refugees often had to work out creative ways to read the messages in Bengali or English. Using tablets to improve the information shared by both Bangladeshi and Rohingya community health workers offered a better option. However, when we explored this further we became concerned with the costs, sustainability, and limited reach of the technology. Since most conversations on reproductive health are still one-to-one, information from the app would not give us the impact we hoped for.
Finally, the fundamental flaw in our plan was that women were unlikely to choose and use a method without the support of their husbands. In speaking to Rohingya couples, we found the main obstacle facing women from accessing reproductive health services was that men were being left out of the conversations.
Simply put, since information on sexual and reproductive health was only targeted at women, men did not have the same understanding of health issues as their wives
What we initially saw as “conservatism” turned out to be something entirely different: first, men needed information on sexual and reproductive services and, second, they wanted to be involved in making health decisions with their wives. The mobile app was scrapped, and the decision was made to devise something different that could help us share information with men and encourage conversations among husbands and wives on reproductive health matters.
The first step was to learn more about how Rohingya refugees received health care information. Despite limited access to phones, television and radio, we found that most refugees in these camps had greater exposure to health care information and services than in Myanmar. We also found differences in how women and men received their information: While men received health and other information primarily from community and religious leaders, women were more likely to receive educational home visits from community health workers. And although preferences were to maintain the gendered separation of these discussions, most women said they discussed fertility issues privately with their husbands and respected his opinion regarding spacing or limiting births.
Our hope was that we might be able to influence both the tone and the content of these conversations between husbands and wives with a carefully crafted intervention. After several rounds of prototyping, the intervention most suited for the Rohingya men and women was a game called Kele-Kele Shiki—"learning through playing.” While the game may seem simple, the social norms it addresses are deeply entrenched.
By including men in these conversations, we hope to encourage behaviors and norms that will empower women to access the health services they want.
The many pieces of this intervention respect the Rohingya desire to maintain separate spheres for learning about and discussing reproductive health. Community leaders (Majhis) and Islamic religious leaders (Imams) play an important role: As they facilitate game play, their positions as trusted sources of learning helped ensure that the players, particularly the men in the community, accepted the accurate information contained in the game.
The game Kele-Kele Shiki works something like this:
- Husbands learn about the benefits of family planning at a Majhi meeting with the male version of the Kele-Kele Shiki Game. In their experiences with Kele-Kele Shiki, men discuss issues they have probably never discussed openly before and see that contraception and fertility control can be aligned with their religious beliefs.
- Their wives gain a deeper understanding of family planning with the female version of the Kele-Kele Shiki Game, supported by the Counseling Flipbook. In these steps, we challenge the widely held belief that family planning and fertility issues are the sole domain of women (women’s topics).
- The husband brings home the Decision Guide to facilitate the couple’s conversation about family planning. Again, this step challenges norms that discourage talking about sexuality and contraception, even within families.
- A community health worker counsels the wife or the couple on the best family planning method for them by using the Counseling Flipbook. Community health workers emphasize the message that contraception can help families prepare for the future and meet their personal and shared goals.
- Wives come to the clinic to receive health services. Husbands are given a Decision Guide to spread the word to other men and amplify the impact of the intervention.
We understand that Kele-Kele Shiki is not the only way we can reach women and men in these camps with health information, but we do know that using HCD helped us develop an innovative and light-hearted way of sharing important reproductive health information. Although the idea of a mobile app was cast aside, through prototyping and reassessing the intervention strategy, we found that working with women, men, and community health workers helped build a product that improves knowledge and is a culturally acceptable way to get new information to Rohingya refugees. Our work will continue, and we are discussing developing different variations of Kele-Kele Shiki that could be used with other target audiences. Whatever they are, whatever they look like, men won’t be left out of our equation again.