Making Resilience Resonate

This guidebook is for independent researchers, NGOs, government officials, or private organizations that are interested in adapting the Resilience Message Program for improving the resilience and wellbeing of healthcare workers. The foundation of this guidebook is a set of 82 evidence-based, free, and adaptable messages created by the Johnson & Johnson Center For Health Worker Innovation (J&J CHWI) as part of the Resilience Collaborative, “a global learning community that aims to advance learning and drive adoption of evidence-based strategies for health worker resilience, particularly in low-resource settings.”

In order for the Resilience Message Program, or any other content-based program, to be successful, we believe that the content must be communicated in a way that is usable, accessible, and engaging for the target audience. In this case, the target audience are health workers, primarily from low- and middle-income countries. Therefore, this guidebook provides a roadmap for adapting and localizing messages that will resonate with health workers from diverse geographical and linguistic settings. Readers will be taken through a process of adapting messages to a local context, translating messages from English into a target language, and testing messages with health workers.

The messages are considered to be 80% ready to use, with the remaining 20% requiring adaptation and translation of the content to make it suitable for a local context.

Please note that the purpose of this guidebook is limited to the adaptation of the Resilience Message Program for a particular audience of health workers. If you are interested in learning more about the creation of the message program or considerations for its implementation, we recommend reviewing the J&J CHWI publication “Building Health Worker Resilience: A Toolkit To Protect Against Burnout On The Front Lines.”

This guidebook provides a roadmap for adapting and localizing the Resilience Message Program, a set of 82 evidence-based, free, and adaptable messages created by the Johnson & Johnson Center For Health Worker Innovation (J&J CHWI) as part of the Resilience Collaborative. When implementing the Resilience Message Program, it is important to adapt and contextualize the message content to make it relevant to the intended audience and their unique needs, socio-economic context, and cultural expectations. You can think of content adaptation as an important prerequisite to developing a resilience-building program that meets the needs of health worker audiences.

While approximately 80% of the Resilience Message Program will remain the same, implementers should anticipate that approximately 20% of the content will need to be modified for a number of reasons, including that

• Direct translation from English to the target language might not be possible
• Certain concepts or phrases may need to be updated to ensure cultural relevance and appropriateness.
• Different parts of the messages may have to be highlighted based on the experience of the selected audiences.
• Messages will have to be adapted as per the social and legal conventions of the implementation setting.

In this guidebook, the process of adaptation will be guided by human-centered design principles. In other words, you can imagine health workers as standing at the center of a resilience-building intervention, with any changes to the content increasing how well messages resonate with the audience’s thinking, behavior patterns, and experiences. In order to make these changes, insights from health workers will be gathered through the process of iterative user testing.

In each chapter, you will see real-world examples of how the Resilience Message Program was adapted for a variety of contexts. These examples come from the shared experiences of a working group that collaboratively adapted the Resilience Message Program for health worker audiences in Brazil, India, Mexico, Nigeria, Rwanda, and Uganda. While your content adaptation journey will be unique, these examples are intended to help you think through the questions that we discussed in our working group sessions.

In this chapter, you will gain an understanding of

• How to select a persona for the messages. In other words, who will the audience think that the messages are coming from
• How to select a voice and tone for the messages. In other words, how will the audience feel based on the way the messages are communicated?

Answering these questions might require multiple conversations with your team, implementing partners, and health workers. While this could mean scheduling meetings, traveling to health centers, and investing time up front, we believe that getting this part right is foundational for the work you’ll do later on in the process. Once you’ve arrived at these answers, write them down and keep returning to them as you make progress on the subsequent steps. This is a good way to validate that all of the messages have a consistent voice and tone throughout the process.

In all forms of communications, the tone of voice, or the manner in which words are spoken, helps us communicate the sentiment behind a message. This ultimately influences the way an audience perceives what has been said. For example, the same piece of constructive feedback can serve to motivate or upset someone depending on how the feedback is communicated. In the Resilience Message Program, the way messages are conveyed will impact the way health workers feel about the content. One way to develop an appropriate tone and voice for the message program is to associate these qualities with a particular persona that resonates with your audience.

Personas are prototypal users whose characteristics represent the needs, lifestyle and perspective of a larger group. In other words, a persona in the human-centered design process is an imperfect but representative characterization of a larger group of people. For example, you can imagine that a “doctor” persona might communicate with formal, serious, respectful, and matter-of-fact language. On the other hand, a “close friend” persona might use a funny, casual, enthusiastic, and irreverent tone of voice. While these characteristics don’t represent every doctor or close friend, they can be roughly representative of an audience’s perception about these personas.

Let’s look at an example:

When applied to the Resilience Message Program, applying a characteristic persona and voice and tone to the content allows you to influence how health workers will perceive the messages. By understanding the relationship that your health worker audience has with this persona, you can make decisions about how to present information throughout the message program.

We recommend defining your persona and their voice and tone up front to ensure consistency while adapting the message program. Especially if multiple people will be working in parallel on content adaptations, agreeing on a common persona and voice and tone at the beginning enables you to maintain consistency in your writing styles.

There are several ways to define the voice and tone of a persona. For the purpose of this guidebook, we recommend defining the following dimensions of your persona’s voice and tone:

• Funny or Serious: Will you use humor to convey the messages or will they be communicated in a serious manner
• Formal or Casual: Will the messages be conveyed using formal or informal language
• Respectful or irreverent: Will the messages be communicated in a serious and respectful manner or will they lack seriousness? A respectful tone is important as it enhances the quality of communication and will establish genuinity
• Enthusiastic or matter-of-fact: Will the messages be conveyed with enthusiasm and emotion or will they be stated as facts?

Based on the dimensions of voice and tone outlined above, let’s take a look at three personas that are relatively common at the field level in India: government officials, supervisors, and co-workers. The example below shows how each persona’s tone of voice has been defined:

In addition to having its own voice and tone, each persona also has a different relationship with health workers in India. While government officials wield significant power and authority in local health settings, experienced co-workers are less distant from the health worker in both their hierarchy and physical setting. As a result of these differences, a message coming from one persona or the other will leave health workers with a different perception of the messages being conveyed.

Now that you know what a persona is and how to define its voice and tone, how do you select a persona for your audience? We suggest starting by making an exhaustive list of options and then narrowing it down with some questions. If you work closely with health workers, you may already know what your options are. If you’re further removed from health workers, research can help you understand the context in which health workers operate, including the multiple roles they play in their homes and communities, their daily challenges, and the people who influence their patterns of behavior.

Once you have your list of possible personas, here are some questions to ask yourself:

After reflection, you might narrow your list down to a handful of personas, each with a unique voice and tone. That’s okay. Keep this list handy. We’ll talk about how to test various personas with health workers in Chapter 4. But for now, let’s take a look at how to ensure the messages are relevant to health workers by ensuring they are adapted to the local context.

In this chapter, you will gain an understanding of

• Unraveling Complex Concepts: In other words, how can I identify and adapt terminologies from the Resilience Message Program that are new and/or not commonly used by my audience
• Incorporating Relevant Examples: In other words, how can I improve the messages with examples that are relevant to the context of my audience
• Translating the Resilience Message Program: In other words, how can I accurately translate the messages into a target language?

‘Complex’ concepts are those that could jeopardize the relevance or understanding of the messages due to a lack of adaptation to a local context. While the Resilience Message Program provides you with a pre-decided set of messages, it is almost guaranteed that there are terms, concepts, or references made in the messages that won’t be relevant to your audience. Identifying and adapting these concepts is key to a successful implementation of the Resilience Message Program.

We define complex concepts as topics that are:

• Culturally sensitive: It is important to note that some of the terminologies and concepts mentioned in the Resilience Message Program should be described with care and may require different communication approaches. For example, messages that encourage health workers to seek support for mental health challenges may need to be adapted based on mental health literacy levels and support structures available to a target audience. It is critical for implementers to be aware of cultural nuances and adapt the messages accordingly.
• New and/or not commonly used: Since the concept itself isn’t understood, these concepts are better explained using examples from someone’s daily life. For example, members of the working group found that the word “resilience” is not well understood among health workers.
• Difficult to translate directly: Not all English words can be directly translated to another language. These concepts may need to be communicated using alternative words or explanations. For example, the word “stress” cannot be directly translated from English to Hindi; an approximate translation for the word “tension” was used instead.

Using the points above as a guide, we recommend reading through the Resilience Message Program and highlighting any messages, phrases, or words that contain complex concepts. Your institutional and practical knowledge of health workers will be a critical asset in identifying and addressing these tricky concepts. If time permits, you may even decide to engage health workers directly to help you with this activity. It is important to identify these concepts during user testing, make sufficient adaptations to the content, and get validation on your adaptation of the concepts to ensure that they resonate with your audience.

Once tricky concepts have been identified, they should be adapted into language that can be easily understood by your audience. In the case of concepts that are new to health workers or can’t be directly translated, you might need to find proxy words or concepts that can help you describe a concept. It’s important to look for adaptations that resonate with colloquial speech among your audience.

Another way to explain complex concepts is by outlining the “why,” “what,” and “how” of a message. The steps below show you how to do this:

• Why: Explain how a specific concept has relevance to a health worker’s life. For example, if a message recommends taking micro-breaks, you might explain that taking these breaks will allow a health worker to recuperate between visits with patients.
• What: Add examples from daily lives that are familiar to your audience. For example, a message might acknowledge that health workers experience stress at the workplace. You can include an example of heavy patient caseloads or limited resources at a hospital to illustrate stressors that are relevant to your audience.
• How: Break down the concept into actionable steps. Especially for new concepts, providing a step-by-step process for health workers to follow can make it easier to practice a new behavior. For example, if a message talks about mindfulness, you might add a series of steps describing how to practice mindfulness while walking.

In this chapter, you will gain an understanding of:

• Selecting a target language: In other words, in what language will health workers interact with the Resilience Message Program?
• Establishing a translation team: In other words, who will serve as a translator and reviewer to collaborate on the translation process?

Once the content has been adapted based on the learnings in chapter 1 and 2, you can start the process of translating the content into the target language. When selecting a target language, ensure that the language is well understood by the target audience in writing; sometimes health workers will be more comfortable speaking in a language than they are reading. It’s difficult to go backwards once you’ve selected a target language, so be sure that you’ve selected the right one at the beginning of the process.

It might sound obvious, but it’s important to acknowledge that translating the Resilience Message Program is a large undertaking. As you saw in the previous chapters, a lot of work goes into selecting the right persona and voice and tone for your messages and adapting complex concepts to be understandable. In order to preserve the changes you made to the message program, translators should be aware of the importance of nuance in the messages. The same feeling you hope to elicit from messages in English should be conveyed in the target language as well.

When establishing a translation team, we recommend identifying one translator and one reviewer. Both individuals should be fluent in both languages (English and the target language) and should ideally have knowledge of your audience. For example, our team in India worked with a translator who has fluency in both English and Hindi and has years of experience conducting field work with community health workers. This translator was well positioned to translate the Resilience Message Program because they knew how to frame the messages in a way that would be understood and were able to leave the intended voice and tone of the messages intact.

Once you’ve identified a translator and reviewer, we recommend starting the process with the following steps:

• The Translator begins by translating the first 10 messages of the Resilience Message Program. While translating and reviewing the messages, the Translator should consistently back-translate (in other words, translate from the target language to English) to ensure that the intended meaning of the message was retained in the target language.
• Once the initial 10 translations are done, they are shared with the Reviewer who reviews the translations and takes a note of any recommended changes.
• Finally, the Reviewer shares their feedback with the Translator during a meeting. As an outcome of the meeting, the Translator and Reviewer should finalize a translation for the initial 10 messages. This helps to establish a working relationship between the team and allows any issues with translation to be addressed before getting further into the process.

In this chapter, you will gain an understanding of:

• User Testing: What is user testing? Why is user testing important?
• Planning for User Testing: How can you select an appropriate user test? How can you create a user testing plan?

In this chapter, we discuss how to validate that your adaptation of the Resilience Message Program is usable and acceptable for your audience. We recommend that implementers follow an iterative user testing approach that is based on the principles of human-centered design. In other words, we recommend that you conduct multiple (iterative) rounds of testing with health workers (your users) and that your tests be conducted directly with your audience (human-centered design).

In the context of the Resilience Message Program, iterative user testing is important because it allows you to make incremental, user-responsive changes to the content based on insights and feedback from health workers. User testing provides an opportunity to assess how real users will react to the resilience messages when they are disseminated.

Before starting user testing, implementers should have a clear understanding of their audience, resources available (time and money), and the learning objectives of the user test. Below are some of the guiding considerations while planning user testing:

Selecting users for testing: In an ideal scenario, user testing allows implementers to anticipate challenges, questions, and feedback from their audience before a product is rolled out, therefore making the implementation process smoother. In order to realize the full potential of user testing, it’s important to select users that are representative of the larger audience for whom the program is intended. The representative users should roughly reflect the range of demographics, socio-economic background, knowledge, capability, and beliefs of the larger audience. For example, you may select some users from rural areas and others from urban settings. You should also ensure that you are able to secure any necessary permissions to interact with users before the test.

Resource availability: User testing is a resource-intensive process. Thus, it is important to assess your available resources (both human and financial) before planning the testing. For example, do you have adequate human resources to conduct the user testing? What would be the financial implications of conducting the user testing? Would you be able to provide any monetary or non-monetary compensation to the participants?

Setting the learning objectives: Before embarking on user testing, it’s critical to align on the learning objectives of your user testing. This involves brainstorming on the outcomes you are trying to achieve as part of the user testing. For example, your user testing might be used to assess users’ reactions to the content shared, to gather feedback on the translation of the messages, or to assess whether users are able to understand the complex concepts you identified earlier.

Once your learning objectives are set, the next step is to decide which type of user test will be conducted. Below are a list of considerations you can use to select the type of user testing you conduct:

• Will your testing occur in person or remotely
• Will the test be moderated or unmoderated
• What type of data (e.g. qualitative or quantitative) will be collected?

As an expansion of the questions mentioned above, the table below provides an overview of user testing approaches that you can choose from, grouped by consideration:

Let’s pretend that you reviewed the user testing approaches in the previous section and decided that you want to conduct in-person, moderated interviews with a small group of 15 health workers. The learning objective of the user testing is to assess whether the complex concepts of resilience and mindfulness have been adequately addressed in your adaptation of the messages. In this case, you may opt for an explorative assessment method that allows you to understand how health workers perceived the messages.

Once you select a user testing approach, it’s important to design a user testing plan that establishes a common set of protocols and guidelines for the test. This ensures a standardized experience for your participants and allows room for flexibility to adapt the plan on-the-go. We recommend that a user testing plan includes the following components:

• The target audience (e.g. the number of health workers who will participate in the testing), the location of the test, and the data points that will be collected as part of the test. In the context of the Resilience Message Program, you may also want to specify which messages will be tested as part of the scope of work.

• Calculate the human and financial resources required for the user testing activity. If you select a moderated testing approach, it is also critical to consider if the moderators will require any prior to conduct the user tests.

• Once the scope of work and resources are finalized, implementers should focus on planning logistics for conducting the user testing. This can include
  • Securing relevant permissions to conduct the field visit.
  • Identifying the participants who will be a part of the usability testing based on the guiding questions shared earlier in this section.
  • Reserving a conference room or other space where the test can take place, ideally near to the user’s place of work to reduce the time they spend on the test
  • Setting up monetary or non-monetary compensation for participating in the test
  • Creating a test schedule that the moderators should follow as part of the testing plan. A sample is outlined in this section of the appendix.

• It is important to determine the length of time required for conducting user testing. As a best practice, the duration of the test should be long enough for participants to warm up to their interaction with the moderators but short enough that the test doesn’t significantly disrupt the participant’s regular schedule.

• Prior to conducting the test, implementers should finalize the data points that they wish to collect as part of the process. A survey or interview script should be developed to ensure that the desired data is collected as part of the test.

• As part of the test plan, organizations will need to spend some time creating collateral for conducting the test. This can include consent forms and data collection tools that will be used to record responses to the test (such as the sample listed in the appendix).

As we mentioned in the beginning of this chapter, we recommend an iterative approach to user testing. In other words, you should aim to repeat the process above multiple times throughout the content adaptation process. In each iteration of user testing you can choose to ask different questions and interact with different users; however, the more interactions you have overall, the more confident you will be in the impact of the Resilience Message Program once it is fully adapted.

This guidebook is an outcome of the working group “Improving Resilience of Health Workers“ that was facilitated by Dimagi from March to May 2022. Over the course of three months, six organizations engaged in a collaborative process of adapting, translating, and testing the Resilience Message Program for health workers using human centered design techniques. In this section, we share some of the insights shared by participating organizations as after their user testing processes.

Overall, the interest in the Resilience Message Program was high. The degree of burnout and exhaustion among community healthcare workers is significant and this problem is more prevalent in low-resource settings. As part of the Working Group, organizations shared the specific challenges that the health workers face. The public healthcare systems are rapidly evolving in an effort to deliver better quality services and improve accessibility to quality healthcare, as a result of which the role played by health workers is expanding. Unfortunately, due to these changes the health workers are facing added pressures, they experience high degrees of burnout, stress, emotional, physical exhaustion and bereavement overload. During the user testing, the need for implementing a resilience intervention amongst health workers became more evident. Health workers were eager to know more about the program and how these messages can support them to manage their stress & burnout levels.

• Selecting the right test: In-person moderated testing was preferred by participating organizations as it allowed them to gather more information and ask follow up questions. However, some organizations opted for remote testing using digital tools like whatsapp in order to reach health workers located in remote areas who would have had to travel long distances to assemble at a common location.
• Choose a convenient location: It is important for organizations conducting user testing to be cognizant of the schedule of the health workers and to plan user testing around that. For example, one partner recommended that user testing should take place in a location near the health worker’s place of work instead of asking them to travel to a different location
• Logistics planning: As part of the testing process, it is critical that implementers plan the logistics around the testing well in advance. This includes finalizing the location for the testing, securing permissions for the visit, preparing required collateral, and training the team who will be moderating the usability test. This makes it easier to respond to unexpected challenges that inevitably occur during the testing period. For example, one partner intended to conduct user testing with a small group of health workers but ended up having to include an entire hospital!
• Incentivizing the program: Given the workload and the schedule of the health workers, it is recommended that the organization compensate participants for their time and contribution. The incentives can be monetary or non-monetary depending on the organization.
• Legal review of the messages: Before sharing the messages with health workers, participants shared that it would be important to get clearance from the legal team to ensure that there are no legal implications of the content being shared. For example, one participant shared that there could be ramifications if the Resilience Message Program was portrayed as coming from a government official persona.
• Testing the content internally: It is important to conduct an internal testing prior to the actual user testing to gather insights on the testing plan, clarity of instructions, flow of the session and tools for data collection. For example, one organization found that their testing plan required much more time than they initially thought. They were able to adjust their plan to ensure that health workers weren’t overburdened by the test.
• Orientation to the program: While conducting the usability test, it is important for the program teams implementing the Resilience Message Program with their health workers to spend adequate time setting context around the program and the intended impact it can have on health worker’s resilience and burnout levels. Organizations can go a step forward and conduct focus group sessions to talk about the importance of adopting behavior change techniques and the role the RMP messages will play in their personal journey. For the user testing, it is important to share information with the health workers about the purpose of the user testing and set expectations around how the usability test will be conducted so that the health workers know what they can expect as part of the testing. For example, one of the partners shared that as part of the orientation, the health workers were interested to learn what the program is about and who it is coming from. Therefore, it was important to share a brief on the learning objectives of the user testing.

The learnings from the Working Group showed us that the degree of burnout and exhaustion among frontline healthcare workers is significant and this problem is more prevalent in low-resource settings. The public health-care systems are rapidly evolving in an effort to deliver better quality services and improve accessibility to quality healthcare, as a result of which the role played by health workers is expanding. Over time, the stressors faced by the health workers at work can lead to high degree of burnout, mental & physical exhaustion that can negatively impact health workers as well their job outcomes. Thus, there is a need to improve health worker’s ability to cope and manage stress by building their resilience. To successfully implement any Resilience building intervention, it is imperative that the program resonates with the needs of the health workers.

At the heart of this guidebook is a belief that in order for the Resilience Message Program to have the intended impact, it must be adapted to reflect the lived experiences and challenges of health workers. We hope that by reflecting on the questions included in this guidebook, you’ve been able to uncover new insights about how to communicate resilience-building skills to your audience. Resilience is a critical and evolving topic in health systems. We encourage you to stay connected by joining The Resilience Collaborative.

• Name of the worker
• Age & role
• Number of years of work experience
• Location
• Date & time of the visit

1. Johnson & Johnson Resilience Collaborative
2. Kate Moran, 2016, The Four Dimensions of Tone of Voice
3. Kalpana Srivastava, Kaushik Chatterjee, and Pookala Shivaram Bhat, Mental health awareness: The Indian scenario
4. Opinion: Digital health solutions need to consider the health worker
5. Types of usability tests: https://www.hotjar.com/usability-testing/methods
6. https://www.devex.com/news/sponsored/opinion-digital-health-solutions-need-to-consider-the-health-worker-102333

This resource was developed by Dimagi with funding from the Johnson & Johnson Center For Health Worker Innovation (J&J CHWI)

This guidebook is an outcome of the working group “Improving Resilience of Health Workers“ that was facilitated by Dimagi from March to May 2022. Over the course of three months, six organizations, namely the- Institute for Healthcare Improvement (IHI), TIP Global Health, Africa Growth Youth Foundation (AYGF), Living Goods & Partners In Health (PIH) engaged in a collaborative process of adapting, translating, and testing the Resilience Message Program for health workers using human centered design techniques.

Dimagi would like to thank each of these organizations and individuals for their participation and engagement during the working group.

We would also like to thank the Johnson & Johnson Foundation for their support in making this Working group and Guidebook a reality.