Designing with end users as participants is not a ‘once and done’ task, but an ongoing opportunity with each design iteration.
How Solutions Meet Needs
Community-based Antenatal Care and Immunization Coordination is a five-year-old partnership between the non-profit tech company Medic Mobile, the Kenyan Ministry of Health, and the NGO Kilifi Kids. In this initiative, the design team at Medic Mobile involved nurses and community health workers (CHWs) in designing and testing an evolving toolkit of technologies and supported workflows.
Medic Mobile’s open source technology tools enable community health workers to register pregnant women and children with their cell phone and receive time-targeted messages related to their care. This can be done using a simple structured text message, or through a SIM card application installed on a thin parallel SIM card on the phone. The Medic Mobile web application receives these messages from community health workers and sends automatic text messages back to them over a gateway modem. Nurses can monitor the status of the pregnancies in their community on dashboards from this computer.
Medic Mobile also needed to reconfigure their analytics dashboards to highlight CHW activity. Information such as the number of pregnancy and immunization visits reported compared to number of pregnant women and children registered helps CHW supervisors provide additional support to the CHWs who need it most. CHW supervisors can see this information over time to identify trends in CHW performance and target refresher trainings on areas where the CHWs appear to be struggling.
Design with the User: Medic Mobile’s approach is guided by pragmatic as well as ethical or political concerns, as has been the case with many participatory design projects since the 1970s (Simonsen & Robertson 2013). The design approach actively engages health workers in imagining how these tools can be integrated into work practices that will lead to greater impact in maternal and child health. Two of the design methods employed in this process are user personas and system design cards. A persona is a character that tells the story of larger group of users. This helps cultivate empathy for users and helps better understand drivers of their behavior. System design cards are simple images that represent people, places, actions, and things and can be played in a highly participatory way to map the flow of people, information, and resources. This helps to document and understand the existing system as well as to imagine a more optimal future alongside users.
Outcomes and Lessons Learned
- Vital insights emerged in the second and third major design iterations, in preparation for and after each major point of scale. This experience illustrates the important principle that designing with end users as participants is not a ‘once and done’ task, but an ongoing opportunity with each design iteration.
- In practice it is often unclear whom to include in the list of ‘all user groups’ until after technologies are already in use. While CHW managers had participated in initial design sessions, they and other members of the design team did not foresee the role they would ultimately play in using the analytics dashboards.
- Technologies and new service workflows are both vital to complex digital health systems; changes in one often lead to changes in the other. Putting tools in the hands of health workers, making emergent work patterns visible, and understanding how they influence technology needs is often more feasible that predicting these dynamics up front.
- As a result of this project, Medic Mobile has invested additional time and resources in hiring and cultivating the expertise of regional/local designers who are more available for frequent design iterations. Their updated Training of Trainers manual also highlights that ongoing refresher training
is an important component of a sustainable project.
- Confusion among stakeholders regarding which surprises and difficulties were hindering the design process and which were in fact learning opportunities and
integral to an effective design process.
- After training, CHW supervisors (rather than nurses) took responsibility for the fact that CHWs were not submitting all of the forms expected of them. This observation proved vital to the unfolding design process.
- Medic Mobile’s initial dashboard design work revolved around the Nurse Mary user persona, but a non-clinical CHW supervisor persona ultimately proved more fruitful. This insight was a breakthrough in the design process.
- Key members of design team were not located in the same region as end users, which increased the expense and scheduling difficulty of more frequent design iterations. This barrier genuinely hindered the design process.
- Designing the service that the technology is intended to enable is as important as designing the technology.
- Technology changes the way that people work and interact. Allow your story to change, and look for ways to continue growing with and supporting partners beyond your initial concept. The best design insights sometimes come only after users have the technology in their hands.
- Look for opportunities to strengthen your intervention outside of the actual technology implemented. Take time to understand cultural practices, learning styles, and external influences that may affect success.
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