Figure 1
Map of Unguja Island in Zanzibar, showing the locations of the four hospital sites and drone photos of each hospital
Source: First author.
Figure 2
Outline of the co-creation process aligned with the four stages outlined in the PRODUCES+ guideline
Notes: A = Additional co-creators that could provide valuable insights into the intervention design are identified during the conducting stage and recruited where possible. B = Process feedback from co-creators informs improvements to further activities. C = Summaries of the outcomes of each workshop are created and shared with co-creators. The solid lines indicate the linear progression of intervention development and assessment through co-creation; the different colours denote the separate invention group development. The dashed line indicates how different activities inform and improve the co-creation process.
Table 1
Summary of participants’ interest and influence in study topic
| PARTICIPANT CATEGORY | PARTICIPANT POSITION | PARTICIPANT’S INTEREST AND INFLUENCE IN STUDY TOPIC |
|---|---|---|
| Hospital staff | Medical officer in charge | Decision-making on hospital changes; shares experience with mosquito issues |
| Hospital secretary | Decision-making on hospital changes; shares experience with mosquito issues | |
| Hospital supervisor | Advises and supervises co-created interventions; shares experience with mosquito issues | |
| Matron (nurse officer in charge) | Advises on suitable interventions (especially in wards), supervises implementation, shares experience with mosquito issues | |
| Medical doctor | Advises on interventions and shares experience with mosquito issues | |
| Nurse | Advises on interventions and shares experience with mosquito issues | |
| Orderly/cleaner | Shares experience on mosquito issues, focuses on waste management and larval source reduction | |
| Cleaner supervisor | Identifies challenges in waste management, supervises and advises on larval source reduction interventions | |
| Garden worker | Shares experience with larval habitats and advises on larval source reduction interventions | |
| Security guard | Shares experience with mosquito issues, identifies stagnant water, manages outdoor mosquito traps | |
| Environmental health officer | Shares expertise in waste management and larval source reduction | |
| Receptionist | Advises on improvements for waiting areas and patient flow control | |
| Hospital technicians/maintenance | Responsible for hospital maintenance, including water systems | |
| Patients | Patients | Shares personal experience with mosquito issues, provides feedback on interventions in wards |
| External specialist | Entomologist/vector control | Contributes specialist knowledge and experience on mosquito control for the region |
| Healthcare Engineering Unit architect and biomedical engineers | Decision-making on hospital infrastructure improvements; holds knowledge of existing structures | |
| Ecologist (researchers) | Shares expertise on local biology, nature-based solutions, and landscape maintenance strategies | |
| Co-creator facilitators (MBD-Free) | Architect (researcher) | Facilitates workshops, guides discussions and activities, responds to participant input and questions |
| Entomologist (researcher) | Facilitates workshops, guides discussions and activities, responds to participant input and questions | |
| Observer | Observe the workshops for evaluation |
Figure 3
Examples of needs related risk factors identified through the needs assessment.
Note: A = Ward windows left open. B = Tears or openings in mosquito screening on windows. C = Heavily used waiting area (faces have been blurred for anonymity). D = Makeshift prayer area found under the stairs. E = Discarded plastic container that has become a larval breeding site. F = Damaged inspection hatch allowing access for mosquito entry.
Table 2
Activities conducted in co-creation workshops, including activity name, description and co-creation methods.
| # | ACTIVITY NAME | DESCRIPTION |
|---|---|---|
| Introduction workshop | ||
| W1.1 | Guiding principles | Participants collaboratively developed a ‘codex’ of guiding principles to create a safe, inclusive, and co-creational environment. These principles were designed to flatten hierarchies and ensure everyone felt comfortable contributing (co-creation method: Codex – Lotte Darsø) |
| W1.2 | Knowledge, expertise and experience map | Participants mapped their individual knowledge, expertise, and experiences to highlight strengths within the group and areas where their contributions could advance the project goals (co-creation methods: skill share, who is around the table, knowledge and expertise map – based on Susanne Justesen’s Knowledge Domains 2015) |
| W1.3 | Who is missing? | Participants brainstormed missing individuals or roles that could contribute to the project. Answers were recorded on sticky notes and organised on a board to visualise missing stakeholders or expertise (co-creation method: brainstorming) |
| Intervention ideation workshop | ||
| W2.1 | Where are you bitten? | Participants silently reviewed areas where staff and patients have encountered mosquitoes based on interview data. They marked areas they agreed with and added new locations on a blank page or drone photo of the hospital (co-creation method: brainstorming) |
| W2.3 | Why might windows be screened and doors left open? | Participants discussed and noted reasons and specific hospital practices that might result in windows and doors being left open in ward areas that allow for mosquito entry (co-creation method: brainstorming) |
| W2.4 | Ward intervention world café | Each group was given intervention cards describing modifications to the ward building that could improve patient comfort and/or reduce the likelihood of windows and doors being left open. Participants noted benefits, challenges and other ideas on how these interventions could be adapted to the hospital environment. Then groups swapped interventions and added their perspectives to the templates. The templates were pinned them to the wall for collective assessment (co-creation method: world café) |
| W2.5 | What if… imagining different waiting spaces | In groups, participants envisioned alternative layouts, activities, and designs for waiting spaces that would benefit hospital users and help alleviate overcrowding. Each group picked a favourite idea and presented it to the others (co-creation method: what-if brainstorming) |
| W2.6 | Alternative waiting queue options | Participants were shown three different queue systems to notify patients to return to reception if spread across different areas of the hospital. Groups brainstormed users, challenges, benefits, and voted for their preferred system (co-creation methods: prototype, brainstorming and dot voting) |
| W2.7 | Adapting known interventions to the hospital | Groups were given intervention cards that could be applied to the hospital environment. Participants noted benefits, challenges and other ideas on how these interventions could be adapted to the hospital environment. Then groups swapped interventions and added their perspectives to the templates. The templates were then pinned to the wall for collective assessment and voted on preferred interventions (co-creation methods: world café and dot voting/silent voting) |
| W2.8 | Closing circle | Participants and facilitators gathered in a circle, where each shared something they had learned during the workshop (co-creation method: closing circle) |
| Intervention development workshop – co-creation intervention group 1 (I-1) | ||
| W3.1 | Understanding hospital waste management | A map template indicated the journey of waste from creation through to disposal off site. Participants are split into groups, given a part of the template and asked to add in what are the challenges along the way that prevent proper disposal, what solutions can prevent this and who should be responsible for this (co-creation method: systems mapping) |
| W3.2 | Waste dumping questionnaire | An online form, created with Google Forms and sent to participants via the co-creation WhatsApp groups. This gathered feedback on dumping sites that were not covered in the understanding hospital waste management workshop (co-creation methods: questionnaire and silent voting) |
| W3.3 | Intervention waste bin and sign design questionnaire | An online form, created with Google Forms, was sent to participants via the co-creation WhatsApp groups, to gather feedback on sketch designs for waste bins and signs, identified as interventions in W.1 and W3.2. Participants could vote for their preferred design and provide qualitative feedback (co-creation methods: questionnaire and silent voting) |
| Intervention development workshop – co-creation intervention group 2 (I-2) | ||
| W4.1 | Architectural walkthrough and feedback | Co-creators were presented sketch proposals for different architectural changes in the wards and creation of new external waiting areas, based on feedback from the intervention development workshops, and visited the proposed areas via a group walkthrough. Templates were filled in groups to provide qualitative feedback. (co-creation methods: walkthrough and questionnaire) |
| Implementation workshop – co-creation intervention group 2 (I-2) | ||
| W5.1 | Planting day | Co-creators were invited to participate in planting shading plants around newly proposed waiting areas and give feedback on plant species, placement and maintenance strategies |
[i] Note: A detailed description of each activity can be found in the appendix (Supplemental data file 3: Workshop Descriptions).
Figure 4
Example of intervention cards developed for the intervention ideation workshop, based on interventions identified in a review of global health and entomology literature (Sloan Wood et al., in review)
Note: The front side of the card describes the intervention in layman language in Swahili and English. The back side shows photograph examples. Also see Supplemental data file 1: Intervention Cards.
Figure 5
Photos of different co-creation workshop activities.
Note: A = Co-creators were given T-shirts and diaries. B = Architectural models of ward spaces used to demonstrate mosquito entry points. C = Silent dot voting used to indicate intervention preference. D = Prototype queue app developed by authors and tested during the intervention workshop alongside other queue management systems. E = Each task had a custom co-creation template with questions to structure group activities. Co-creators wrote their feedback either directly onto the templates or on Post-it notes. F = Co-creators were presented with different sketch proposals for modifications to the hospital building and surroundings and gave feedback during a hospital walkthrough. G = Groups mapped out how waste is disposed of in the hospital, identifying challenges that prevent proper disposal, who is responsible and potential solutions. H = Co-creators took part in a planting day as part of the intervention implementation.
Source: First author.
Figure 6
Summary of interventions and how they developed through the co-creation process.
Notes: Left column shows the unmet needs relating to MBD transmissions that were identified as focus areas in the needs assessment. The middle column shows the initial intervention ideas established in the ideation workshop (W2). The right column describes the different interventions developed and implemented in the intervention development and implementation workshops (W3–5).
Figure 7
Photos of select interventions from intervention groups 1 and 2, described in Figure 6.
Note: I.1.1 = Insect-proofing septic tanks. I-1.2 = Replacing inspection hatches with more robust versions. I-1.4 = Example of painted sign encouraging use of outdoor bins. I-1.6 = Example of additional external waste bins with foot pedal. I-2.5 = Planting of climbing plants with supporting structure to shade wards. I-2.6 = Personalised fans installed at patient beds. I-2.7 = Extractor fan installed about door to wards to bring in cooler air from the corridor. I-2.8 = New exterior waiting spaces in existing shaded areas. I-2.9 = New shaded areas seating areas.
Figure 8
Discarded containers identified as larval breeding sites were repurposed into building materials and furniture used in the interventions.
Note: Left: Discarded bottles that are used to make terrazzo tables with draughts boards integrated into them. Right: Plastic containers used to make the structural members used in some of the seating areas.