Records for Life: Re-evaluation and Re-design of a Healthcard Framework

Image courtesy: Center for Knowledge Societies (CKS), Patna, Bihar.

RECORDS FOR LIFE

Re-evaluating and Re-designing a Health record

ORIGINALITY STATEMENT

I hereby declare that this submission is my own work and it contains no full or substantial copy of previously published material, or it does not contain substantial proportions of material which have been accepted for the award of any other degree or diploma of any other educational institution, except where due acknowledgment is made in this diploma project. Moreover I also declare that none of the concepts are borrowed or copied without due acknowledgment. I further declare that the intellectual content of this Diploma Project is the product of my own work, except to the extent that assistance from others in the projectâ&#x20AC;&#x2122;s design and conception or in style, presentation and linguistic expression is acknowledged. This diploma project (or part of it) was not and will not be submitted as assessed work in any other academic course. * The Design Research phase of this project was done by me as a part of the Center for Knowledge Societies (CKS) team. Anupriya Arvind Date:

I hereby grant the National Institute of Design the right to archive and to make available my diploma project/thesis/ dissertation in whole or in part in the Instituteâ&#x20AC;&#x2122;s Knowledge Management Centre in all forms of media, now or hereafter known, subject to the provisions of the Copyright Act. I have either used no substantial portions of copyright material in my document or I have obtained permission to use copyright material. Anupriya Arvind Date:

Copyright ÂŠ 2014 Post Graduate Diploma Programme in Design, Communication Design (Graphic Design), 2011-2014 National Institute of Design, Ahmedabad, India. All illustrations and photographs in this document are Copyright ÂŠ 2014 of the author, or respective people / organisations wherever mentioned. Please note that the colours used in the design deliverables throughout the document may not be the correct colour due to difference in printing process and pigments used for producing this document.

Written and designed by : Anupriya Arvind

anupriyarvind@gmail.com anupriya.a@nid.edu Processed at :

National Institute of Design (NID) Paldi, Ahmedabad - 380007 Gujarat, India www.nid.edu Digital offset printed in Ahmedabad September, 2014

Image courtesy: Center for Knowledge Societies (CKS), Patna, Bihar.

NON DISCLOSURE AGREEMENT (NDA) with

* The Design Research phase of this project was done by me as a part of the Center for Knowledge Societies (CKS) team.

Image courtesy: Center for Knowledge Societies (CKS), Patna, Bihar.

~ To the mother and child present in all of us, To the women who have or are about to tread on the journey to motherhood and above all, To the most magical fruits of â&#x20AC;&#x2DC;labourâ&#x20AC;&#x2122; - the children, especially those have been deprived of adequate healthcare... Such in the hope that a simple artefact as an improved health record can lead to the promise of a better future and a healthier tomorrow. ~

This is done in tandem with a

personal front, conducting field

design studio/firm which acts as

work in Bihar, following diverse

the student sponsor and a faculty to

research protocols like group

guide the student throughout the

discussions, visiting RI sessions,

Dip process.

personal interviews, shadowing

In this particular diploma opportunity, the Records for Life project with the Center for Knowledge Societies (CKS) along with the Bill and Melinda Gates Foundation (BMGF) and the World Health Organisation (WHO)

PROJECT SYNOPSIS

provided a platform for bringing the worlds of health, design research, design together. The Diploma Project is the final project in the curriculum of the Post Graduate Diploma Program. The Diploma Project (or Dip as is it is called) entails a four to six month internship in the industry, focussed

The project brief and scope of work, laid out in phases, revolved around understanding how a health card figures in the health ecology of three countries, namely-Bihar, Kenya and Indonesia. The second

on one project, involving a live brief.

phase involved selecting a few cards

The curriculum is designed to help

sourcing competition and testing

students explore their knowledge base and skills in a hypothetical scenario throughout their academic tenure in the various projects they do, however, the Dip enables students to work in the industry and actualize all their design know-how and skill sets in reality.

from various entries of a crowd them in these respective countries to compare and understand various aspects of the chosen cards that work with the target audience and lastly, drafting design recommendations for a universal card template that could represent the health card globally. On a

exercises, interacting with the users of the card, and breaking down the data in the post field work phase through failure case analysis and group discussions with people from different research backgrounds happened to be high points of the research phase in the project.

Image courtesy: Center for Knowledge Societies (CKS), Patna, Bihar.

ACKNOWLEDGEMENT My guide and mentor for this project ~ Tarun. Since day one you have been such a positive influence in my life as a student at NID. I began my graphic design journey here, with you as my guide and Iâ&#x20AC;&#x2122;m ending it with you, which shows the amount of respect and appreciation I have for you as a faculty. This was a very ambitious and overwhelming project for me and had it not

been for you, I would have been

instrumental in shaping up my

your insights, feedback,

completely lost. It takes a lot of

graphic design foundation. For all

forthcomingness, heartfelt

courage and gumption to guide

this and so much more, thank you!

conversations and time.

All the other faculty at NID with

Skye Gilbert, Amanda and Almeera

whom I have interacted at any level,

from BMGF ~ Thank you for being

you for you to say yes.

in your own way you have taught

understanding and encouraging

me something valuable every time

clients. It really helped!

You have had immense faith and

esp. Rupesh, Tridha, Anil, Ajay,

words of encouragement for me,

Suresh, Prabir, Sanjay Basvaraju,

even when I doubted myself. I have

Mona Gonsai ~ a big thank you!

learnt so much from you and I hope

The health workers, parents and

to continue to do so. You have been

their relatives ~ Thank you for all

sensitive projects as puberty and maternal and child health but all it has taken me is one meeting with

The Primary Health Centres and all their officers ~ Thank you for being cooperative, helpful and sharing your experiences with us.

Image courtesy: Center for Knowledge Societies (CKS), Patna, Bihar & CKS Office, New Delhi

The caretakers, office staff and

timely help, feedback, support and

for being there throughout all the

feedback and just being there when

me and made me a part of your

drivers in Patna, Bihar, who were

encouragement during the project.

phases of the project. I’ve had such

I needed you guys, esp. Neharika,

family for those six months and

present for us the whole time,

My mentor, Divya ~ Thank you for

an amazing time with you guys,

Yadvi, Ankita, Deepti, Tawfik,

because of you I hardly missed

taking care of us and making us feel

being so wonderful, patient and

both in terms of learning and fun!

Karthikeyan, Jyoti and Jasleen.

home. You guys made me feel so

at home, thank you. It meant a lot!

encouraging and helping me at

It has been a cherishable experience

every step of the project. Design

to work with all of you.

Shilpa and Rashi, my two pillars of strength, I’m so glad that despite all

Mom, Dad and Devina ~ You are

My GD batchmates, juniors and

this distance you both have always

the reason for me staying focussed,

colleagues at NID ~ Thank you

been there to help me through

grounded and achieving anything

for everything-providing me

everything, work or otherwise.

in life. There aren’t enough

The Center for Knowledge Societies team ~ Abhitosh, Pooja, Heena, Anusmita, Shikha, Deepani, Aditya Dev Sood, Namrata, Ekta, Alok, Urwashi, Pranav, Deepshikha,

Research was a completely new field for me and you made it so fascinating and exciting. It was a real honor working with you.

with accommodation during

Shivani and all other members of

My project team ~ Adithya, Simran,

guide visits (Shivi, Alpika, Smita,

the organisation, thank you for your

Shreya, Utsav and Farid. Thank you

Rashmi), sharing your thoughts and

Mausi, Mausaji, Nanna, Prateek, Pranav and Theeta ~ You welcomed

comfortable and happy!

‘thankyous’ or words in this world to express how much you mean to me. I love you guys so much!

Image courtesy: Interior Architecture & Design, interiorsfarnham. wordpress.com

Source: www.nid.edu

The National Institute of Design

Over a span of the last 50 years, the

(NID), India is internationally

institution has made it a point to lay

acclaimed as one of the foremost

emphasis on learning and to pursue

multi-disciplinary institution of

innovation led designs through

design education and research.

the development of the mind and

It is an autonomous institution

skills of designers. This technique

under the aegis of the Ministry

has motivated students to perform

of Commerce and Industry,

better and has given them an edge

Government of India.

over other design professionals.

National Institute of Design has

The institute’s client servicing

also been declared ‘Institution of

team facilitates students in getting

National Importance’ by the Act

involved with real life projects,

of Parliament, by virtue of the

which in turn adds value to the

National Institute of Design Act, in

upcoming professionals giving

July, 2014.

them a taste of actual situations.

NID has taken five decades of pioneering hard work, consistently, by the academic community at the institute to develop a system of education which lays more emphasis on educative learning than on mere instruction.

Center for Knowledge Societies (CKS) office (in renovation), New Delhi

THE CLIENTS Center for Knowledge

CKS is an innovation consulting

Societies Consulting

practice with more than a decade of

Pvt. Ltd.

experience in different technology, service and product categories, including public health, medical technology, education, financial inclusion, livelihoods, agriculture, telecommunications, aviation, automobiles as well as several others. It has an outstanding reputation for synthesizing different kinds of knowledge, including ethnographic, qualitative, visual, design, with user perspectives and needs to curate design learnings and generate new product concepts and business opportunities. Official website: www.cks.in

THE CLIENTS

Bill & Melinda Gates Foundation

Additionally, the foundation would

(BMGF or the Gates Foundation) is

have part in all of the top designs

one of the largest private foundations

being piloted and scaled in as many

in the world, founded by Bill and

as 10 countries by 2018.

Melinda Gates. It was launched in 2000 and is said to be the largest transparently operated private Bill and Melinda Gates Foundation

foundation in the world. The primary aims of the foundation are, globally, to enhance healthcare and reduce

Image Courtesy: www.shawngroves.com

extreme poverty, and in America, to expand educational opportunities and access to information technology. The foundation, based in Seattle, Washington, is controlled by its three trustees: Bill Gates, Melinda Gates and Warren Buffett. Other principal officers include Co-Chair William H. Gates, Sr. and Chief Executive Officer Susan Desmond-Hellmann. Skye Gilbert from BMGF was our point of contact for this project. The role of BMGF along with CKS in this project was launching a crowd sourcing competition, seeking help to provide ideas for redesigning the child health record, so that accuracy increases, records become easier to interpret and use, and health professionals and families alike value them. To encourage participation and ensure maximum impact, BMGF recognised the top entries with awards of up to fifty thousand dollars.

Official website: www.bmgf.org

THE TEAM

Simran Chopra

Project Head: Divya Datta

Director of Innovation, CKS Head of Bihar Innovation Lab Bachelor of Design, Fashion Design National Institute of Fashion Technology, New Delhi

Adithya Prakash

Project Manager: Simran Chopra

Farid J. Bhuyan

Post Graduate in New Media Design National Institute of Design, Gandhinagar The Team: Farid J. Bhuyan

Masters in Sociology Kirorimal College, New Delhi

Shreya Anand

Utsav Chaudhury

Masters in Anthropology University of Delhi, New Delhi Shreya Anand

Masters in Sociology Panjab University, Chandigarh Adithya Prakash

B.A. in Entrepreneurship with a minor in Cultural Studies

Utsav Chaudhury

FLAME, Pune

GUIDE PROFILE

Tarun Deep Girdher Senior Faculty, Graphic Design

His work and musings on the world

Head of the NID Print Labs

of design and more can be viewed

Head of NID Publications

on ~

National Institute of Design

http://tarunonlife.wordpress.com

Tarun has been a senior faculty at the National Institute of Design, Ahmedabad, for over 14 years. He specialises in teaching typography, publication design, illustration and printing technology. Image courtesy: Dr. Deepak J. Mathew

His interests also include hand

www.issuu.com/tarundg https://www.behance.net/tarundeep

STUDENT PROFILE

Anupriya Arvind

lettering, book binding and

PGDPD - Graphic Design

observing social behaviour. Though

Batch of 2011

he has mentored projects in an array of diverse fields, he has a

I am a graphic design student

passion for design interventions

in the final semester of my

in socially relevant topics like

tenure at NID. I have attained a

education, health, gender studies.

Bachelors Degree in Design from the National Institute of Fashion

Visual identities for Right to

Technology (NIFT), New Delhi, in

Information, National Book Trust and Uttar Pradesh State Organic Certification Agency; and several publications on disability, Disaster Risk Reduction and Gender are some of his well known works.

Communication Design in 2011. Image courtesy: Imon Raza

Without a hiatus, I landed up in NID just two weeks after having finished my graduation. During my course of time here, I have tried to work on varying projects ranging from puberty to Khadi papers

identity re-design and branding to developing an interface for student housing. I have also tried my hand at doing comic art and sequential storytelling to hone my illustration and narrative skills. I am a voracious reader and an avid illustrator. I love working with mixed media to draw and paint whatever I see around me. I also indulge in hand lettering, and maintaining diaries and travel journals is one of my passions.

PROJECT BRIEF & PROPOSAL The project brief was spread out in

This report would include

two major phases ~ Design research

qualitative and quantitative

and Design -

data on how concept prototypes

The first phase would require an evaluation framework design wherein an evaluation form would have to be designed which would be employed by expert technical reviewers to provide their inputs on the entries. This would be followed by creating an ethnographic enquiry i.e. create field guides, interactive research tools, data reporting templates and any other tools that are needed. These questions and probe points

have performed against a set of evaluation indicators in a focus group setting, submissions that emerge as most promising, features that emerge as valuable, as well as underlying patterns to user preferences. This data would provide an insight into what are the highest performing visual design and iconography styles, information hierarchies and formats. This would directly feed as strategic inputs into the WHO guidelines.

would be valuable during the study

Last part of this phase would

to facilitate better interaction and

involve creating a workshop for jury

extract relevant information from

members from the Gate foundation

local experts and users.

and other organisations who would

The next would be field work including travel to the location and

evaluate the final entries and choose the winners.

conduct protocols and focus group

The second phase would involve

workshop with the users.

designing a health card template

The post field work would include creating field report wherein all field findings would be documented through extensive notes, photographs, and audio recordings.

based on field findings , various workshops conducted before and the guidelines drafted by the team.

Phase II : Design Phase I : Design Research

November 2013

December 2014

January 2014

February 2014

March 2014

April -May 2014

June - July 2014

August 2014

Information collection

Drafting Dip doc

on healthcare systems, User profiling, Field guides

September 2014

Drafting Dip

Evaluation criteria,

Re-editing final

Evaluating entries, Prototyping entries

report, Framing

Field work, Visual

Second field visit

culture mapping in Bihar

Analysis of data,

Creating the

Drafting design

final report

recommendations

design criteria

to Bihar

choreography, Creating the final report

card mockups

Design concepts for the card

and often students need to re-visit their timelines. The project timeline given by CKS was from November

Creating the London workshop

doc (Vol. I),

(Vol. II), Final

2013 ~ March 2014. However after

PROJECT TIMELINE

Project timelines are created to help students to organise, meet deadlines and finish projects on time. However, working on field requires some re-calculation

having done the first stretch of field work and working on the final report, another field visit seemed essential. Hence I joined another team and revisited Bihar. The design phase of the project began after I came back to NID as it was not officially a part of the original project brief.

CONTENTS: VOL. I

1. INTRODUCTION

1.1 Records for Life: The crowd sourcing competition

1.1.1. The healthcard challenge

1.1.2. How will an improvised Health card help?

1.1.3. Records for Life: A design contest that can save lives

1.2. Why the crowd sourcing approach?

1.2.1. Crowdsourcing generates big numbers; ensures crowd attention

1.2.2. Crowdsourcing links Design and Health information

1.2.3. Crowdsourcing is a platform for knowledge creation and sharing

1.3. Problem statements that the project aimed to understand

2. UNDERSTANDING THE CONTEXT

2.1. Health ecology of Kenya, India and Indonesia

2.2. Geographical, demographics, economic and growth

projections, livelihoods for each country and Rationale behind

choosing the cities under research in India, Indonesia, Kenya

3. APPROACH AND METHODS

3.1. Process map

3.3. Field and Discussion Guides

3.2. Field Partnerships and User profiling 3.4. Expert evaluation framework: Form structure and Parameters 3.5. Scenario and Persona building

3.6. Evaluation Level two: Parameters and Structure for the CKS team

3.6.1. Creation of a four layered process of down selection

3.6.2. Incorporating technical reviewers feedback

3.6.3. Diversity basis critical parameter

3.7. Disaggregating the card and Top 30

3.9. Building the script and Timeline for the focus group discussions

3.8. Cue card stimulus for focus group discussions 3.10. Process constraints

CONTENTS: VOL. I

4. FIELD WORK

4.1. Moderation and Note taking: Process and Challenges 4.2. Picture diary and Visual mapping from field work

5. FIELD INSIGHTS

100

5.1. Relationship with the card

5.2. Cue card based field Insights cross locationally

5.2.1. Unique Identification

5.2.2. Immunization Schedule

5.2.3. Growth charts and Healthcare information

5.2.4. New information fields

5.2.5. Material, Form and Colour

6. REFLECTIONS AND THE WAY AHEAD

123

6.1. Making connections from data 6.2. Looking at the larger picture

7. RECOMMENDATIONS FOR DESIGN

7.1. Concerns for validation

7.2. Systems integration

7.3. Final design recommendations

140

7.1.1. The record as a system and in a system 7.2.1. Insights from the London workshop

7.4. Design criteria

8. CONCLUSION FOR VOLUME ONE AND INTRODUCTION TO VOLUME TWO

155

CONTENTS: VOL. II

8. INTRODUCTION TO VOLUME TWO

9. CONCEPTUALISATION

9.1. Different concepts and Aproaches

9.1.1. Visual metaphors and Illustrations based on visual mapping

9.1.2. Physical format and Size

9.1.3. Paper and Printing

9.1.4. Type and Color

10. CONTENT STRUCTURE

10.1. Content Categories

10.2. Content Architecture

11. FINAL PROPOSED HEALTHCARD FRAMEWORK

12. CONCLUSION

13. REFERENCES

14. ANNEXURE

14.1. Field work guidelines

14.3. London workshop agenda and Final evaluation form

14.2. Questionnaires for all users and Locations 14.4. The Records for Life winnersâ&#x20AC;&#x2122; certificate 14.5. Stakeholders and Key players

15. CREDITS

A rickshaw ride along the Boring Road, Patna, Bihar

Brainstorming sessions at CKS office, New Delhi

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

INTRODUCTION

However, to enable these functions,

utility, and hence did not associate

child health records have to be

any value to the card. Additionally,

available, accessible and utilized by

this fragile paper-based card, being

caregivers and health providers.

the sole record of a patientsâ&#x20AC;&#x2122; health

Unfortunately, child health records are frequently absent from households. Prior research had identified many challenges of varied nature ranging from design and content, comprehensibility, to symbolism, to material constraints, to value perception and utility

1.1. Records for Life: The crowd sourcing competition desired levels of service provision and coverage. The child health record is a critical component of the current health information system; it is the key artefact through which recipients and their

of the immunization card. Many families never received child health records for their children. Even when they had the records they were not always accurately filled out hence not very helpful.

health information is presently

Many recipient families were unable

tracked. Families rely on this record

to comprehend health information

to know when their child needs

(mentioned on the card) as the

care, and health professionals use

information architecture and the

this record to ascertain a childâ&#x20AC;&#x2122;s

visual design of the current cards

1.1.1. The healthcard challenge:

health history and what they need

was not user friendly, resulting in

Among the many barriers to

during a given visit. The records

recipients missing important due

are critical to ensure safe and

dates. Due to this, many times

effective vaccination because

recipient families misplaced the

they identify children who need

health cards or did not carry them

to be immunized, have missed

when they migrated, as they did

immunizations or are off schedule.

not understand its significance and

routine immunization, tracking children and their health information has emerged as a relatively critical barrier over the years, particularly in achieving

information, often put their data at risk by damage or misplacement. These fundamental failures caused vaccines to be delivered in the incorrect sequence or even service refusal, leading to intermittent or complete drop-outs in the RI cycle, which ultimately resulted in low coverage rates.

Mother with a Bihar healthcard after immunization, Begusarai, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

obsolete due to implementation

are valued by health professionals

card prototype after the contest

of a combination of a biometric

and families alike. To assist

(if that is considered relevant by

identification system and fully

WHO and UNICEF in this work,

WHO/UNICEF

digitized health information

create the guidelines and bring an

system. At that point, the records

innovative lens to this problem,

will play an important role in

the Gates Foundation launched

the transition of information

an international â&#x20AC;&#x2DC;Health Record

from a traditional, paper-based

Redesignâ&#x20AC;&#x2122; contest with these goals:

information system to a digital one. 1.1.3. Records-For-Life: A design contest that can save lives: In 2014, WHO and UNICEF launched an initiative to evaluate and improve the design and use of child health records, with the goal of publishing technical guidelines in 2015, to help countries determine how to improve record prevalence and accuracy, make records easier to interpret and use, such that they Looking at health card entries, CKS office, New Delhi

~ Improve the understanding of driving factors of records accuracy and use this knowledge (via the testing and discussing of health record prototypes in focus groups.)

~ Raise awareness among global partners and country stakeholders on the issues surrounding child health cards. ~ Generate a repository of ideas and concepts for the improved design of the child health cards. ~ Build a databank of individuals who have innovative ideas and could be recruited to design a full

1.1.2. How will an improvised health card help? Over time, child health records will track more and more data as countries increase the number of vaccines that they provide for children. As a result, accuracy is likely to decrease over time without applying thoughtful design principles to the cards. Finally, records may over time become

Current Health card used in Bihar, Parsa Bazaar PHC, Patna, Bihar

25 and students majoring in either

via the questions that were received

landscape of routine immunization,

design or public health. A standard

in the Gates email account (two

health and service delivery through

email laid out information about

months after launch, the reception

a single lens of a health record

submissions requirements, the

of emails was an average of five to

across three diverse locations â&#x20AC;&#x201C;

evaluation process and how winners

ten emails per day; this reached

India, Kenya and Indonesia.

of the contest would be honored.

nearly twenty emails per day by the

This information was blasted to nearly 20 design blogs, and over 85 design organizations, the Global Immunization Newsletter, and the top design and public health universities around the world. India and China had explicit outreach strategies. The impact

INTRODUCTION Contd ...

1.2. Why the crowd sourcing approach?

academic and professional entrants. Out of the 314 submissions, 144 met minimum requirements, which

social well being. Aligning that with a crowd sourcing platform to generate creatively designed health cards from the people themselves

design and Health information:

effective way to address a critical

re-tweeted numbers, and click-

The contest being an initiative of

through rates on the Gates website. (One of the collaborative design

their newsletter, indicating that the

attention:

messaging had high initial appeal

The Records for Life contest

for the target audience.)

firms or individual designers,

countries and an even mix of

contributes to both economic and

of questions that were received,

big numbers; Ensures crowd

space, design companies and

submissions from 41 different

life expectancy, and in turn, it

1.2.2. Crowd sourcing links

1.2.1. Crowdsourcing generates

professionals in the public health

of good health and increased

mechanism resulted in 314

upon which we lay the foundation

based on the volume and types

has a 42% click-through rate in

for submissions, these included;

Hence, the crowd sourcing

and testing them with various user

firms confirmed that this contest

targeted three primary audiences

Immunization is the prerequisite

were chosen to be evaluated.

of this strategy was estimated

contestâ&#x20AC;&#x2122;s closing week).

It was known early on that this contest had garnered high engagement and interest with a number of colleges and universities

Bill and Melinda Gates Foundation, had a two-fold mandate; (a) global crowd sourcing platform to revaluate and redesign a child health record in order to better meet the needs of the health care providers and caregivers (b) focus on immunization, health

sets came out to be a smart and issue in the healthcare sector. It is important to discern that to achieve such goals every component of the immunization chain must function properly and in harmony with each other. The health record in this nexus was found to be not only an effective and inexpensive method of record keeping but also

care information and artefacts.

a point-of-care information for

Partnering with CKS, this

health workers ability to make

competition moved into viewing the

better clinical decisions, give power

resource that can augment the

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

history and its potential

looked at the entries from various

contribution to child health as

parameters at multiple levels) to

a source of health monitoring

reach a number of sixty entries.

data, the team found challenges in and around the card which was counterproductive to the concept of routine immunization and hampered the card from fulfilling

segregated them into cue cards

Thus, The Records for life project

of thirty, ranging into a wide array

aimed to improve the accuracy,

of options based on materials,

value and easy interpretation of

forms, structure, color, information

information and visuals for the

fields, immunization schedules and

health workers and beneficiaries.

healthcare information.

1.2.3. Crowdsourcing is a

Thus this crowd sourcing contest

finally brought down to a total tally

served as an important first step to better our understanding of how

The great thing about crowd

people perceive health, information,

sourcing ideas is that it forms

technology and design together and

a viral, virtual and dynamic

helped map out the teamâ&#x20AC;&#x2122;s approach

network of people, information and

into field work, analysis and insights

knowledge sharing.

and recommendations in a more

For the contest to actualise its of their children and support the

data fields and visual language and and complete cards, which were

and sharing:

to the parents in the health care

based on parameters of design, key

its intended purpose.

platform for knowledge creation

Health card prototypes during focus group discussions, Patna guest house, Bihar

The team disaggregated these cards

intended purpose, the chosen 144 entries were filtered by a panel

public health monitoring system.

of healthcare experts and design

Despite its potential to provide an

a thorough CKS formulated

adequate record of immunization

evaluation framework (which

professionals and underwent

dynamic and productive manner.

27 1.

INTRODUCTION Contd ...

1.3. Problem statements that the project aimed to understand The Records for Life contest

~ The current card is not valued by

~ No reminder or recall system

commenced with an effort to

recipients as it fails to deliver the

built into or along with the card

address certain fundamental issues

correct meaning and importance of

to easily remind recipients for

i.e. prevalence, accuracy and use

routine immunization.

vaccinations incase information

of the child health records. Time and again it is observed that the child health records are unavailable during household visits or at health facilities and even when they are the

~ Families often forget to take the card during immunization. ~ Since the card is solely paper

gets lost from the card. ~ The material of the cards make data filling difficult. Information gets wiped off easily.

data in it is often inaccurate.

based, it is quite fragile making it susceptible to damage from water,

~ Format of the card is not user

As such the child health records

rats, oil stains etc.

friendly, making handling of the

fail to fulfil the vital function of being a source of information for both health workers and parents. Along with these apparent issues the contest also tried to understand the root causes of the child health records not being distributed, retained and utilized to its full potential. However the basic problems centered around the card.

~ No scope of easy digitization of data from the card. Human error is a big risk. ~ The information in the card is scattered and incoherent which is why mothers are not able to read or comprehend it, another reason why the card fails to hold importance.

card difficult, wear and tear easy, and data filling time taking. ~ Information given in the card is too concise, often missing, and at times unsystematic.

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Current health card of Bihar, (close up of healthcare information and immunization table sections).

29 2. UNDER-

STANDING THE

CONTEXT

2.1. Health ecology of Indonesia, Kenya and India

Bihar (India)

Kisumu (Kenya)

Bandung (Indonesia)

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

while posyandu are the monthly

geography makes reaching remote

organised health camps that are

regions very difficult which is why

specially meant for pregnant

rural areas have far fewer doctors

women, children and the elderly.

than urban areas.

Posyandu also offers free

Well-equipped hospitals are also

vaccinations yet beneficiaries rely

very scarce in the rural communities.

more on Puskesmas. Posyandu

The only remote areas that are well-

is more about health care

equipped are seats of provinces,

consultation whereas Puskesmas

districts, and sub-districts.

deals with vaccinations. They serve as a support mechanism for each other, as well providing full fledged

Health-service infrastructure includes government health

Map of Indonesia, locating Bandung

services, foreign aid, non-profit health organizations (NGOs), religious organizations, and the private sector.

~ Dengue (food + water borne)

From the infrastructural point

~ Malaria (food + water borne)

of view Indonesia has a three tier

~ Typhoid Fever (food + water borne)

system for health care;

~ Bacterial Diarrhea (water borne)

~ Ministry of National Health ~ Provincial Level Health Office

Furthermore, the health care

high birth rate amongst women.

Community health centre is

organised into three levels i.e.

Indonesia:

known as the Puskesmas. In

~ Village level: general medical care

Indonesia had a three-tiered system

Indonesia there are 9,321 units of

~ Sub-district level: specialized

of community health centers in the

puskesmas. The health care system

medical emergency care

in Indonesia is essentially a two

~ District level

Posyandu. Puskesmas are the health

of public to private health-care

clinics that offer vaccinations

expenditure by the people.

and other health care services,

Vaccination and maternal health: ~ The high Muslim population in

The basic health structure in

There is about a 75 : 25 percent ratio

~ Hepatitis B (food + water borne)

~ District Level Health Office

services in the rural areas are

part system i.e. Puskesmas and

~ HIV/AIDS

health care services.

The health center or the

late 1990s which has continued.

Major diseases in Indonesia:

Rural areas have limited medical facilities; emergency services are especially scarce. The countryâ&#x20AC;&#x2122;s

Indonesia is responsible for a very

~ As home births are legal in Indonesia, the women still use midwives for home births both in urban and rural areas. ~ Routine vaccination is given to children below age 5 years as per World Health Organization World (WHO) recommendation.

Kenyatta National Hospital

The health sector in Kenya is

According to the government

Demographic and Health Survey

governed by two ministries, the

reports there are more than 5000

2008-09, 77% of children age 12-23

Ministry of Medical Services

health facilities in Kenya.

months had been fully vaccinated.

Health and Sanitation.

The government oversees 41% of

Only 3% of children had not

health centers, NGOs run 15%, and

received any vaccines.

Under the current framework

the private sector operates 43%.

and the Ministry of Public

the countryâ&#x20AC;&#x2122;s health system

Provincial hospitals District hospitals Health centres | Maternities | Nursing homes Village Dispensaries

is organized in a hierarchical pyramid (as shown in the figure). Community health centers and village dispensaries comprise the largest and lowest level of the pyramid. District health centers and provincial hospitals are fewer and higher on pyramid, and the Kenyatta National Hospital in the

Community

The 6-tier public health structure of Kenya

The public health structure in Kenya:

According to the Kenya Health Policy Framework Paper of 1994 the implementation of policies have been done in two phases; ~ The National Heath Sector Strategic Plan which covered the period from 1999-2004

capital city of Nairobi sits at the top.

The government operates most of the hospitals, health centers, and dispensaries, while the private sector operates nursing homes and maternity facilities catering to high

96% of children of all ages had received the BCG vaccines. The vaccination rate for the first DPT-HepB-Hib dose was also at 96%. In comparison to 2003,

income clientele.

the proportion of children aged

Immunization coverage and MCH

which was 73% rose to 85% in 2008.

indicators:

According to the Kenya

between 12-23 months vaccinated,

The proportion of children fully immunized had increased from 57% in 2003 to 77% in 2008-09. The proportion of children who had not received any immunization had also declined from 7% in 2003 to 3% in 2008. In spite of fact that 77% of children had received full immunization, only 65% were fully immunized by their first birthday.

~ The second covers the period from 2005-2010.

Map for Kenya, locating Kisumu

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

The KDH survey also demonstrated

care indicators actually declined

In the last 3 years, however, Bihar

that immunization coverage was

compared to the rest of the

has seen substantial improvement.

significantly affected by the birth

northern Indian states.

order of the mother.

New health initiatives by the

Bihar is the third most populous

National Rural Health Mission

The first born children were

state in India with over 100 million

(NRHM) such as Muskaan in 2007,

more likely to be fully vaccinated

population and more than 40%

have contributed to an increase

than those of 6th or higher birth

of the people in the state live below

in routine immunization rates

order (84% compared with 62%

poverty line.

in Bihar from 20.7% to 41.4 %2

respectively).

When it comes to the health

Full vaccination among urban

care sector, Bihar suffers from a

children was seen to be higher

plethora of constraints in providing

than among rural children (81%

adequate health care services

compared to 76%).

to the people. More than 75% of the children under 3 years of age are anaemic while fewer than one third of them are breast fed. 50% of children under 3 years of age, suffer from stunting due The health structure in Bihar; An ANM vaccinating a child, Parsa Bazaar, Patna, Bihar

India:

India is home to one of the largest RI efforts in the world â&#x20AC;&#x201C; based on the number of fully immunized children, the volume of vaccines delivered, and the geographical spread of the communities served. Over a fifteen year period ending in 2005, Biharâ&#x20AC;&#x2122;s neonatal health

between 2004-07. Bihar has been making significant progress, with immunization coverage increasing even upto 54.6%3 between 200809, with firm commitment from the State Health Society Bihar (SHSB) and technical support from UNICEF and WHO, constantly endeavoring to improve immunization coverage in the state.

to malnutrition. According the

Local experts point out that

NFHS, the under 5 mortality rate

merely implementing the current

in Bihar was registered at 84.8 per

system correctly would continue

1000 live births and only 32.8% of

to increase immunization rates,

the children had received complete

perhaps even up to the highest

immunization. As a result Biharâ&#x20AC;&#x2122;s

levels in north India (~75%).

infant and maternal mortality rates are among the highest in India Bihar is also one of the most vulnerable states for the spread of HIV in India (UNICEF).

Source: The Vaccine Delivery Innovation Initiative Report, CKS, Published ~ 2009-2010

33 results, Kenya, Indonesia and India were chosen.

2. UNDERSTANDING

CONTEXT THE

The selection of specific rural or peri-urban locations in these countries was based on parameters

Contd ...

2.2. Geographical, demographic, economic and growth projections; livelihoods for each country and Rationale behind choosing the cities under research in India, Indonesia, Kenya

such as current status of the public health care infrastructure, immunization coverage status, socio-economic conditions, cultural and ethnic diversity, the geographic location, literacy levels, and political and administrative factors amongst others. Based on all the above mentioned parameters, the following locations were chosen: Kisumu, Kenya:

Kisumu is the third largest city in Kenya with a population of 409,928 (2009 census). Present day Kisumu Images from all locations, Parsa Bazaar, Bihar; Kisumu, Kenya and Bandung, Indonesia.

Since the contest aimed at improving the vaccination record, globally, with special focus on developing countries, it seemed apt to hear from mothers across three major regions, and based on both, what was feasible given linguistic and timing constraints, and what would yield the most representative

consists of 25 sub locations that can be grouped into 10 main locations (Township, East Kolwa, Central Kolwa, South-West Kisumu, North Kisumu, Central Kisumu, East Kisumu, West Kajulu, East Kajulu, and West Kolwa).

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Keeping the selection criteria in perspective. Kisumu was found to be a suitable research location. In terms of demographics, it had a larger proportion of its population residing in urban areas i.e. 52.4 %, while the remaining 47.6% were living in rural, peri-urban and fringe populations. The health care indicators for Kisumu were acceptable; the IMR and MMR was registered at 95 and 149 per 1000 births ( as compared to the national numbers of 52 and 74 per 1000 births). Only 65% of the children under one were fully immunized in Kisumu in 2008. Parsa Bazaar PHC, Patna, Bihar

Kisumu experiences one of the highest incidents of food poverty in Kenya and child mortality tends to be highest among the deprived. It also has the highest HIV rate in Kenya which is one of the leading causes along with malaria, malnutrition and diarrhea.

Patna, Bihar:

the public health infrastructure,

and hint of rural tendency was

caste, cultural and ethnic

needed. Patna, an urban area in

representative of the current

diversity, socioeconomic status,

a continuing expansion mode,

education, geography, political and

has many peri-urban areas like

administrative factors, and others.

Patna Sahib, Parsa etc. have lower

In many ways Bihar is loopholes in of the health care system in India. For the purposes of this study the fieldwork was carried out in a location called Parsa, in the

Based on earlier studies, it was

district of Patna.

understood that in rural locations,

The choice of locations offered

private services and other factors

maximum diversity in terms of key variables, including robustness of

migration rates, lack of access to affect RI success. However for this study a mix of urban, peri-urban

immunization coverage than rural areas, hence it was chosen the place of focus in Bihar.

Litti-chokha is one of the relishes of the Bihari Cuisine, Mauryalok, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Special ‘Bandung’ chicken platter, Bandung, Indonesia

after Jakarta and Surabaya. The population is 2.4 million (2010). The city is surrounded by volcanic

~ HIV/AIDS ~ AFB+

is of Sudanese descent; Javanese people are largest minority, other minorities include Minangkabau people, Chinese, Indonesian, Muslim and Batak. Sudanese is spoken as first language and Indonesian is the national language. Bandung is accessible through highways from Jakarta. It is prone to flooding, severe landslides, water pollution, garbage pile up and air pollution. The village is the lowest level of administration, known as

Indonesia has a fair share of its population residing in both urban, rural as well as fringe areas. The urban population constitutes 50.3% of the total population while the rest 49.7% lives in rural areas. Bandung , Capital of West Java, is Indonesiaâ&#x20AC;&#x2122;s third largest city

~ Tuberculosis (TB)

is divided into 26 sub districts, 139

Most of Bandungâ&#x20AC;&#x2122;s population

Top view of Bandung, Indonesia

are:

mountains. The city administration villages; headed by a mayor.

Bandung, Indonesia:

Communicable diseases rampant

Under 5 health care coverage (basic immunization) is 88% overall. The number of TB cases are 725/100,000 of the population. HIV rate has increased from 859 in 2005 to 21,031 in 2011 and 29,879 till December 2011. The number of males is higher than that of females. Population growth rate per year has declined because of family planning programs. Infant mortality rate is 26% per 1,000 live births. 27 provinces,

Kelurahan, Desa.

81.8% in Indonesia have medium

Major diseases prevailent here

pneumonia is 13.2%.

are:

~ Diarrhea and Gastroenteritis ~ Dengue and Hemorrhagic fever ~ Typhoid fever ~ Pneumonia ~ Dispeptia

UMR. Death of under 5 due to

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

APPROACH & METHODS 3.1. Process map

In design, design methodologies

The ensuing table shows the

of conducting research and design

methodology that was followed for

processes are individualistic,

this project. The terminologies and

depending on projects or persons,

tools used are specific to what CKS

yet, what ties everything together

holds themselves true to. Though

is that a process is always in place.

in the aftermath, many stages were

At CKS too, a particular research

added to this process and timelines

methodology is followed in all their

as stated, too changed, yet this was

projects, with minor changes here

the skeletal framework of what the

and there depending on the client

team worked upon.

or the project. For Records for Life, the team followed their research process with specific research tools. However being the designer in the team, blending my understanding of design with their research processes was a challenge which I tried to accomplish.

Secondary Research 4 weeks | 6 expert interviews, Literature review and detailed location selection process

Design Entries Technical Evaluation 1.5 weeks | Creating an online evaluation form for designers and health experts for first level of entries evaluation.

Evaluation Process Evaluation Process 2 weeks | Evaluating entries and downselection, Developing cue cards

Research Design Creating protocol guides, User Profiling

Focus Group Testing of Prototypes 1.5 weeks | FGDs, Testing, Validation

Data Synthesis and Analysis 2 weeks | Field Insights, Analysis, Data linkages, Theme creation

Expert Evaluation Jury 2 weeks | Compilation of Data, Workshop guide, Judging & evaluation criterias

Strategic Design Recommendations 3 weeks | Report writing, Drafting recommendations

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

3. APPROACH & METHODS

Contd ...

3.2. Field partnerships and User profiling

The profiling and interviewing

critical that the beneficiaries were

process was most crucial as it

involved in the immunization

was essential to get respondents

process and acquainted with the

that matched the parameters and

advantages and the loopholes in the

represented the user group. The

current child health record.

interviews were managed by the The entries that were selected from the contest were diverse in

CKS team in India and in other locations by the other field partners via a list of questions specifically

Since the geographical diversity had to be accounted for, the level of literacy was kept flexible keeping in

designed called a screener.

mind the local literacy levels.

to validate the various evaluation

When choosing the health workers

The family type was also an

criteria. In order to achieve that, it

and mobilizers, it was paramount

was quintessential to create a User

for them to be literate and due to

Profile guide which would elucidate

the diverse nature of the research

the various user groups such

locations, the level of literacy was

as the beneficiaries and frontline

expected to be varied.

to single mothers. As such the

The age of the health workers

types were chosen to have a fair

was also equally important as it

representation in the outcome of

was essential for them to have

the study.

nature and design and it was vital for them to be tested on the field

health workers. The guide was designed to transcend various parameters. The sample distribution was representative of a wider target audience and based on the following parameters: Age | Literacy | Experience | Health workers involved in vaccination and who dealt with immunization cards. The beneficiaries (mothers and fathers) were profiled based on the following parameters: Age | No. Of children | Literacy | Family Type

substantial exposure in working with the child health record, therefore a fair mix of experience was preferred with health workers aged between late 20â&#x20AC;&#x2122;s to late 40â&#x20AC;&#x2122;s for the focus group discussions. While choosing beneficiaries, an important factor that was kept in mind was the number of children and the age of the mother. It was

important factor especially for mothers as it was easier for mothers in an extended or joint family to learn from their elders as compared respondents from both family

User Profiling for Health Workers

User Profiling for Beneficiaries

Health workers with diverse literacy levels, with diverse

Beneficiaries with diverse literacy levels, family type and no.

mobile usage and coverage areas were chosen.

of children were chosen.

in Bihar, Indonesia and Kenya:

Health

Worker

Experience Level

Age

HW 1

HW 2

HW 3

1-2 years

3-5 years

6-8 years

< 30

31 - 35

41 - 45

years

* All the health officials were ensured to be government workers having experience in working with immunization cards. There names have been

HW 4

8-10

years

45 years & above

HW 5

5-7 years

41 - 45 years

HW 6

Beneficiaries

3-5

Age

31 - 35

Literacy

years

Family

Benef. 1

Benef. 2

Benef. 3

Benef. 4

< 30

31 - 40

41 - 45

31 - 40 years

years

10th

Graduate

years

12th Pass

Nuclear

years

12th Pass

Nuclear

Type

Family

No. of

1-2

2-5

Age of

0-1

1-3

years

Pass

Joint

Family

Benef. 5

Benef. 6

< 30

31 - 35

Graduate

12th Pass/

/Post

Graduate

Nuclear

Joint

Family

years

Graduate

Joint/

Nuclear Family

protected as part of the consent form signed by them to particpiate in the discussion.

Children

years

above

3 and

above

3 and

2-5

1-3

2-4

years

* The FGD had a representative mix of mothers and fathers who are responsible for taking their children for immunizations. Their names have been protected as part of the consent for they signed.

years

2 and

above

3 and

above

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Shreya Anand from the Bihar team speaking to mothers, Bihar Sharif, Patna, Bihar

Brain storming board, CKS office, New Delhi

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Brainstorming and research, CKS office, New Delhi

3. APPROACH & METHODS

Contd ...

3.3. Field and Discussion guides Three discussion guides were

into doing quick exercises, filling

created for the focus group

tables, voting etc. The discussion

discussions of the three user groups

guides began as a ready script but

~ The ANMs (Auxiliary Nurse

later they went onto being more

Midwives) or nurses, the ASHAs

of a roster of pointers to carry

(Accredited Social Health Activist)

the discussion forward in a more

or midwives and the beneficiaries

dynamic and fluid manner. They

(mothers and fathers).

were created in english as the

Before discussions on creating the guides began, a lot of research on existing field guides was conducted which were a part of the CKS data bank. Some of them belonged to the BBC project and the LirneAsia Project. The team sat down with the questions in those guides and looked at tone of voice and type of questions that were deemed suitable for a disucssion guide. However, this focus group discussion was treated more like a workshop of two and half hours, as the participants had to indulge Snapshots of discussion guides for FGDs in all locations

in more than answering questions

Indonesian and Kenyan team were working with translators and the Indian team had team members to verbally translate the questions in Hindi for benefit of the users.

The guides in detail with all the questions can be refered to, in Vol. II of this document under the chapter ~ Annexure: Questionnaires for all users and Locations

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

experts to calibrate the entries better. Incorporating a qualitative aspect to the questionnaire allowed

Pinning down criteria for evaluation, CKS office, New Delhi

for a more comprehensive and apt response from the technical expert for the design entries. The first section focussed on assessing the entry for its ability to create a unique patient identity and share a range of health care information such as; the childâ&#x20AC;&#x2122;s vaccination status, immunization history, and the next due dates. It also intended to measure the ease of filling that information and adding new information on the

3. APPROACH & METHODS

immunization card. The second section concentrated on evaluating the ability of the design

Contd ...

3.4. Expert evaluation framework: Form structure and Parameters

entry to create value for parents The first level of evaluation for the

design entry on a 5 point scale or

design entries was done through

through a qualitative response.

an online technical evaluation

The questions were purposefully

questionnaire. The questionnaire

framed to encapsulate the eligibility

was structured to address the

criteria for the entries in the

key criteria both from a design

design contest. Furthermore a

and health care perspective. The

five point scale was chosen to

questionnaire was divided into 5

help aggregate the responses for

broad sections, each of which had

each entry methodically, and at

a range of questions to assess the

the same facilitate the technical

and health workers alike as being a reminder for future immunizations, as a medium to communicate the significance of child health, and its ability to offer value beyond the its immediate practical value which could act as a source of motivation. It would be important to indicate at this juncture that the first two sections of the questionnaire were

Brain storming on the evaluation criteria, CKS office, New Delhi

common for both designers and health care professionals. The third section was designed differently for designers and health care professionals. The design dedicated section was focused on evaluating the clarity of information, adaptability to different media, usability of the form and the suitability of material. On the other hand the health care section was focussed on bringing forth descriptive responses for sections that could be confusing or misunderstood by the beneficiaries. The fourth section was structured to highlight the most promising features as well as get an overall rating of the design entry on a five point scale. The fifth and the final section was completely dedicated on receiving a qualitative feedback for the design entries.

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

3. APPROACH & METHODS

beneficiaries. Factors such as name,

helping to understand the mindset

age, family type, diversity in traits/

of the users and was beneficial in

characteristics of the individual,

the following research tools that

employment status and work

were employed for evaluation and

experience along with situations

field work.

relating to the usage of the card were included in the exercise.

Contd ...

3.5. Scenario and Persona building For a better and detailed understanding of the respondents, the team conducted a quick scenario and persona building exercise based on secondary research and previous experience on field. Commonly used as an exploratory method for decisionmaking, scenario and persona building are design research tools to help build alternative visions of possible futures/situations that different types of respondents may face, with respect to a particular problem area. These tools help to highlight discontinuities from the present, reveal choices available and

Cross locationally, a total of 12 scenarios and 11 personas were developed for 3 countries. Situations faced by FLHWs with respect to filling and handling of health cards, identification of the child, dealing with the cards in emergency situations, creating awareness about getting immunizations, were looked at. Education levels, social dogmas, awareness about the card, seriousness towards the routine immunizations, behavioural patterns while getting immunizations etc. were some of the situations considered for the users (mainly beneficiaries).

their potential consequences.

Pre-empting how the different

The user profile consisted of

in various situations based on

Frontline health workers (auxiliary nurse midwives, ASHAs) and

kinds of users relate with the card their knowledge and experience proved to be an important aspect in

What is a persona and scenario? CKS office, New Delhi

Laying out the personas, CKS office, New Delhi

11 personas, 12 scenarios, 3 countries, CKS office, New Delhi

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Divya Datta, Aditya Dev Sood and Suruchi Sharma during a group discussion, CKS office, New Delhi

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

3. APPROACH & METHODS

Contd ...

3.6. Evaluation level two: Parameters and Structure for the CKS team 3.6.1. Creation of a four layered process of down selection: The evaluation structure was devised as a proficient four tiered process taking into account all aspects of an effective evaluation framework. Rather than taking selection as a criteria, elimination was opted for using as a tool for downselection of entries. The team was divided in 3 groups of two members each. Each group was expected to look at 60 to 70 entries (total between 180 - 210) with each evaluation group spending between 5 to 7 minutes per entry. The first level looked at the card in terms of overall innovation. The down selection process aimed at selecting cards that had one or more features that were innovative and worthy of merit testing.

Citing parameters for design evaluation, CKS office, New Delhi

3.6.2. Incorporating technical

included scope for reviewers to tag

reviewers feedback:

the most promising design features/

The second level incorporated the

aspects/attributes of the card and provide comments against relevant

technical reviewers feedback and

aspects of that particular entry that

the testing of cards on the basis

merited field testing.

of diversity with respect to the key criteria of cue cards.

The third level looked at testing cards against technology. The

Entries which scored 20 or more out

parameters that were devised for

of 40 in the reviewers list were sent to the next level.

this level were:

A loop counter was created for

technology it incorporates and

~ Testing the card on any kind of whether the same is feasible or

re-checking entries that were

contextually appropriate to be

redundant at the first level and yet

implemented on the field.

made it the to second level to ensure

~ Testing the card on its potential

that every entry was properly vetted.

to speed up data consolidation. Evaluating card entry prototypes, CKS office, New Delhi

3.6.3. Diversity basis critical

used for growth chart / health care

parameter:

counselling information

The entries were also evaluated

~ Efficacy in communicating the

based on their diversity according to the field testing parameters and

significance of immunization for child protection

categorized for cue-card testing.

~ Potential to provide value to users

The categories were namely -

~ Material and Form

~ Method of establishing the patientâ&#x20AC;&#x2122;s unique identity ~ Efficacy of the immunization schedule design / representation ~ Efficacy of the visual metaphors

~ Clarity of information

The entries which scored less than an overall rating of 3 out of 5 from the reviewers feedback, were not sent to the next level. This level also

After being vetted through all these levels, the cards that qualified in individual packets were re-looked at and discussed with the team and top thirty cards were selected for field. Cards which were heavy on technology and could not be tested on field, were marked separately for the London jury workshop.

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

different design propositions within the same design category. These categories also addressed those elements or sections of the card that are important for both, the Front Line Health Workers (FLHWs) and Beneficiaries. The categories finalized were: ~ Methods enabling Unique Identification:

This category identified and tested Brainstorming on the thematics for cue-cards, CKS office, New Delhi

the several different methods of improving unique identification and tracking patients that the design entries proposed and linking and verifying a child to the health card.

APPROACH & METHODS Contd ... 3.7. Disaggregating the card and Top 30

3.7.1. Cue card stimulus for focus group discussions: The core information and design elements that came together to form a complete record were disaggregated to form design categories on which the card could be tested. Component cue cards were created to represent the

~ Visual Representation of the Immunization Schedule:

This section was tested to bring out insights of respondents on temporality of data, ease and patterns of filling, visibility, alignment of data with respect to time, sequentiality of information, authenticity and validity. ~ Visual Metaphors employed for Growth Charts and Health care Counselling Information:

This section covered two sub-

sections - growth charts and

format, form and structure

healthcare information. The

of a health record, durability,

reason for testing this section

maintenance and material of the

separately was to look at context

record amongst the users.

and comprehension of visuals. For instance elements like abstraction

Splitting the card in these sections

of visual imagery, visual style and

also gave rise to varied user

their interpretation were analysed.

perspectives within the same

~ New Information Fields:

location and cross location. The process not only looked at a better

This section identified and tested

comprehension of the specific

those aspects of information that

sections of the card but also helped

were not included or thought of in a

accumulate various types of cards

health card.

with different styles of rendering

~ Use of Color:

information (written or visual) of the design category.

This section was split in two ways â&#x20AC;&#x201C; Looking at color as an

The cards could then be tested on

aesthetic and as function. Aesthetic

the parameter of diversity within

understanding of color gave insights

one design category. This cue card

into a userâ&#x20AC;&#x2122;s visual, cultural and

based exercise was followed by

social mind set. Certain colors

presentation of full cards and then

were associated with more strongly

voting in the FGDs.

than the others. Looking at color as function helped in understanding of color in terms of information coding and aligning with time or other factors. ~ Material and Form:

This section identified and tested the aspects perception of physical Brainstorming on disaggregating the card, CKS office, New Delhi

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

3. APPROACH & METHODS

Contd ...

3.8. Building the script and Timeline for the focus group discussions As mentioned earlier, the script style for creating the focus group workshop and guides was rejected as the discussions happened and a more fluid approach was adopted. The timeline for the entire workshop was settled at two and half hours including the introduction and the break. The workshop was split in two halves - discussing the cue cards based on various parameters of the card and understanding usersâ&#x20AC;&#x2122; mind set towards current cards and other general discussions around the card. The later half was dedicated to discussing and voting on the top 30 entries in various stages. It also involved a few exercises for ANMs on filling the immunization tables

Breaking time into sections for the FGD workshop, CKS office, New Delhi

in the cards they chose. Some spare time was also kept aside for questions/queries from the users

and other discussions that would follow. A fifteen minute break was kept as the breather in between. The team also conducted dry runs with other CKS team members play-acting the users while the chosen moderators for each location conducted the trial workshop. The workshop script was created in a very dynamic format which made it possible for the teams to call for a break at any time of the workshop if users seemed overwhelmed. The details of the focus group workshop and moderation have been laid out in the next chapter.

Discussing the FGD timelines, snippets from the brain storming board and notes for planning the FGDs, CKS office, New Delhi

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

English. However in Indonesia,

necessarily support all the findings

focus group discussions. Socio-

where the language is Bahasa and

from a qualitative point of view.

economic, cultural and preconceived myths stood as barriers

India where the language is Hindi,

APPROACH & METHODS Contd ...

3.9. Process constraints The project was focused on working in three different countries which were very different from each other in almost every aspect, with the only similarity being that they are

Further on, there might be

prototypes could not be read by

interesting but seemingly irrelevant

respondents and their responses

insights as well as contradictions

Confusing and cumbersome

were largely based on a visual

to some of the quantitative findings

neighbourhoods made tracking

reading of the prototypes, hence

but such findings were subject to

recipients difficult as well.

translators had to work extra

the individual characteristics of the

hard on making respondents feel

research respondents, which had to

comfortable and comprehend the

be respected and represented.

information on the test cards. In certain cases, some findings were The cultural orientation and health

not to be considered as conclusive

care structure of the respective

because of the nature of the data.

locations had to be understood quickly in order to align the

The data was highly subjective

of the world.

research agendas accordingly.

and could vary for different

As the work was within the limits

Limitations of the qualitative

all part of the emerging economies

of a pre-defined timeline, the design analysis phase had to be rapidly condensed; phases of design and prototype localization had to be eliminated i.e. the prototypes

research:

respondents. The reliability of such data could not be guaranteed. However, an average was sought

There are certain limitations of this

from most of the respondents and

qualitative research which need

the results presented were largely

to be put forward at an early stage

agreed upon.

for the reader to be able to better understand the qualitative aspect of

The findings needed to be cross

language of the regions.

various quantitative findings.

checked and given the average

There were not many barriers in

Since the sample of this research

were not translated into the local

Kenya where respondents conversed comfortably and were using a child health record that was printed in

in engaging users for the discussion.

much of the information on the

perception, what was said by any users was represented in actuality.

was considerably smaller than that in the quantitative phase, there was

Another challenge was convincing

a chance that the findings may not

users to agree to be a part of the

Shreya Anand from the Bihar team speaking with mothers, Phulwari Sharif, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Walking through the Parsa neighbourhood to engage users, Parsa Bazaar, Patna, Bihar

61 4. Day 1: FGD with ANMs, CKS Patna guest house, Boring Road, Patna, Bihar

FIELD WORK

4.1. Moderation and Note taking: Process and Challenges The user profiling and interviews

photographing the users.

with users to engage them for the

The other two locations, Kenya and

FGD having being done, the field

Indonesia, had field partners with

work began with conducting the

their translators who moderated

discussions. The user sets were

the sessions, while the CKS team

spread out in six days ~ ANMs for

members acted as prompters.

the first two days ( 6 per session = 12), ASHAs on the third day (6 users) and beneficiaries for the last three days (6 -7 per day = 18 - 20).

Process of conducting the focus group discussions:

In an effort to validate the efficacy of the design entries, focus group

Moderation for the Patna team

discussions were conducted by the

was split between Shreya and I,

team in a controlled environment

she, taking on the first half of

with the health care workers and

the discussion and me, the latter

beneficiaries.

half. Utsav, the third member of the team, did the note-taking and

To infuse a sense of direction to the

audio/video recording. While

FGDs, detailed field guides were

the discussion was going on, the

written, which were only possible

team members were allowed to

through extensive secondary

also engage in note-taking and

research and brainstorming

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Day 2: FGD with ANMs, CKS Patna guest house, Boring Road, Patna, Bihar

led to better insights. The field

an ice breaking session with the

guides also incorporated the

respondents which would make

challenges faced by the health

them feel more comfortable

care workers and the beneficiaries

in sharing their stories and

in different stages of the

experiences with the current card

immunization process.

and the immunization process.

Furthermore, in order to have

The respondents were then asked

a better understanding of the

about any difficulties they faced

immunization card and its different

with the current card and the

sections, numerous cue cards

process they followed while getting

were created for most sections

immunizations. After getting a

of the card i.e. Unique Identity,

sense of the problems faced by the

Immunization schedule, New

respondents while handling the

information fields, Visual metaphor,

immunization records the next

color, material and form.

sequence of questions were built around them so as to better probe

The cue cards were then used

the discussion.

to frame the questions which sought to understand the level

After an initiation of the criticality

of comprehension among the

and fallouts, the respondents were

respondents and their reasons for

introduced to the selected cue cards

choosing a specific cue card.

of specific categories. For example, Unique Identification was the first

sessions which were undertaken to Day 3: FGD with ASHAs, CKS Patna guest house, Boring Road, Patna, Bihar

comprehend the current health care systems in all the three locations. Such efforts assisted in framing better questions which eventually

The last part of the field guide dealt

section that was introduced. The

with the entire card in which the

sequencing of the sections was laid

respondents were asked to vote for

out on the basis of the interaction

their favorite cards.

that took place while accessing the card in the immunization process.

The process followed in the FGDs was to initiate a discussion around

For each section the respondents

the current card and conduct

had to choose their most and the

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

least preferred cue cards. The rating

information filled in by the health

system further allowed us to get a

workers in the new format provided

feedback to what was most liked

by the suggested entry. This process

and the reasons for the it.

helped us to know their preferences regarding different categories.

The FGDs were designed keeping in mind the different needs and the

After the completion of the cue

interaction which health workers

card categories pointing out

and parents had while using the

specific criteria, the focus was to

card. For example, the health

understand new information fields.

workers selected the cards that

This was done in order to know

were comprehensive, easy to fill and

what the users felt missing in the

also easy to maintain. They also

card and what additions should be

voted keeping in mind their work

made to the card in order to better

schedules and the beneficiariesâ&#x20AC;&#x2122;

inform them.

level of understanding. This was followed by a discussion The ANMs were asked to fill sets of

on form and colour, which had

immunization cue card categories

functional, aesthetic and cultural

which helped understand the time

aspects playing a role in the

taken to comprehend a new chart

selection. This was evaluated

and the proficiency with which they

using entire cards. In this activity

could fill the same. Thus evaluating

the respondents chose the design

the design entries on the level of

entries which fulfilled the needs

details provided, keeping in mind

or the criteria they had indicated

the task at hand.

earlier in the FGD protocol.

The beneficiaries on the other hand

The final stage was a three step

were presented only those cue cards

individual and collective voting by

that were selected and filled by the

the users from the top 30 cards for

health workers. The main agenda

choosing the final design entry.

being if they could interpret the

Day 4: FGD with mothers, CKS Patna guest house, Boring Road, Patna, Bihar

Day 5: FGD with mothers CKS Patna guest house, Boring Road, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Day 6: FGD with fathers, CKS Patna guest house, Boring Road, Patna, Bihar

Setting just before an FGD, CKS Patna guest house, Boring road, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

FGDs with nurses and parents, Kisumu, Kenya

Focus group discussions with ANMs, Bandung, Indonesia

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Behind-the-scenes after FGDs in all locations, CKS Patna house, Patna Bihar; Bandung, Indonesia and Kisumu, Kenya

4. FIELD WORK

Contd ...

4.2. Picture diary and Visual mapping from field work Along with conducting focus group

Understanding the visual context

Following are some of the pictures

discussions, understanding the

also gave a preview into how

from the visual diary and notes

visual context of the location that

people react to and perceive the

on what could be partaken from

the team was in, was also needed.

information disseminated to

each of the photo collages. After

them; associate with color and

obtaining pictures and having

This comprised of observation

type and respond to other visual

discussions from team members

and travelling around the city

stimuli that are thrown in front of

of other locations and hearing

with cameras and capturing

them everyday. Hence, along with

their experiences, visual language

whatever emoted the visual

engaging users to participate in the

sensibilities were extrapolated

culture of the place ~ people,

study, the members also indulged in

and decoded for their locations.

clothing, architecture, wall art,

a bit of visual mapping of the city.

However being was a part of the Bihar team, it held a special place in

books, posters, magazines, notices,

my visual diary.

food, colors, patterns, artefacts,

Personally, as a designer, this was

way finding systems (signages)

really exciting as it not only gave

etc. This exercise was important

a chance to understand the visual

From the discussion that ensued,

more in terms of design; as a foray

nuances of the city, but also to

what came out to be most

into the visual aspect of the place

explore and find art and design in

fascinating were the points of

which would help while drafting

the most uncommon, unknown and

distinction and similarity for each

design recommendations, and later

unprecedented places.

of these locations.

creating the card.

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Pictures from Kisumu and Nairobi, Kenya

Pictures of hoardings, markets and posters from Nairobi and Kisumu, Kenya

Kisumu KENYA

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Kisumu, Kenya is a land of solid

objects. It was seen that the

and bold colors along with a

undertone of all communication

few fluorescent accents. Most of

revolves around health, maternal

the visual communication has

and child healthcare, nutrition and

applications of deep, dark colors

hygiene. This was not surprising

like mauve, purple, maroon broken

keeping in mind the challenging

by contrasting colors like yellows,

conditions of health standards in

lime greens and orange.

Kenya. The visual imagery seen in the surroundings is also reflected

As seen in these photographs,

in the Kenyan health card issued to

most of the buildings have a

the recipients.

base color palette of red or some implication of red, and not just in

The Kenyan healthcard has a bright

the architecture, but also in their

purple background with an image

print material.

of a mother feeding her child on the centre of the cover. The cardâ&#x20AC;&#x2122;s

Type setting for most

format is a centre-stapled booklet

communication (any media) is

with information printed in solid,

display or bold (san-serifs). Print

bold sans-serif type. The booklet

material seems to rule. However at

is majorly in english but in a few

times, walls and sidewalks too form

strategic places, it is translated in

a background communication.

Swahili, however in the latin script.

The illustration style is a mix of detailed drawings along with real time photoshopped everyday Poster for awareness on a Polio Campaign, Kisumu, Kenya

Current Kenyan health card, Kisumu, Kenya

Bandung INDONESIA

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Indonesia is an interesting blend of

evident in many places of Bandung

the Posayandu. They both have

system and chaos. At one end are

and Jakarta as seen in some of

separate cards. The Posyandu card

high rises, super slick malls and

the images. The farmersâ&#x20AC;&#x2122; markets,

is a simple tent-fold card whereas

posh locales while the other end of

vendors selling sea-food in their

the Puskemas card is the health

the spectrum has kiosks, farmers

dens and fruit bazaars, all showcase

card similar to those used in the

markets and rustic tapestries.

the colorful, rustic aspect of the

PHCs in India.

Despite the mall culture, kiosks,

Indonesian culture. As seen in the picture later on,

standies and portable carts still find Going back to the systematic nerve

the Indonesian healthcard too is

of Bandung and Jakarta, color

a booklet with health information

Similarly, besides all the print

coding is an important aspect.

laid out against a pale blue

signages and magazines, graffiti

Autos in Jakarta are color coded

background. The illustrations are

and hand painted signages too

depending upon the area within the

in watercolors, detailed and in a

exist in the visual mix of the city

city that they service. Also observed

step by step iteration in the local

of Bandung. The color palette has a

with respect to the railway system

language of Bahasa.

mix of sedate, dull colors and bright

presently in use in Jakarta city

pastels. Anime and Manga art have

wherein railway stations are color

a major impact on the cityâ&#x20AC;&#x2122;s visual

coded differently from one another.

root in the Indonesian culture.

culture. The DIY (Do-It-Yourself) lifestyle too has influenced people

This too is reflected in the

in their artistic tendencies.

healthcard for Indonesia. The health

Japanese and Chinese (in the form

system (as mentioned before) is

of communist undertones) are

in two parts ~ the Puskemas and Image of a sea-food flea market, Bandung, Indonesia

Pictures of signages, tees, video games, posters and DIY (Do-it-yourself) kits, Jakarta, Indonesia

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Pictures of metro stations, mannequins, flea markets and kiosks, Jakarta, Indonesia

Picture of street food and drinks carts, Jakarta, Indonesia

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

View of the city life, Jakarta, Indonesia

Pictures of various types of artwork styles ~ Graffiti, vectors and real-time sketching, Bandung, Indonesia

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Image of an old style general store, Bandung, Indonesia

The Puskemas healthcard, Bandung, Indonesia

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Bihar DIARIES Patna : A Special Report

Image of a evil ward-off hanging, Phulwari Sharif, Patna, Bihar

85 Bihar reflects a fine example of the

everywhere. Farmers markets are a

depends on the message being

rich visual tapestry that India is all

popular scene on the highways with

communicated.

about. The colorful albeit vibrant

a wide palette of colorful vegetables

landscape bleeds the variety of

and grains. The villagesâ&#x20AC;&#x2122; raw and

Hand-done and hand painted

costume, the interesting blend

rustic aura of the villages with

typography has survived in this

of skyscrapers and villages and

vividly and creatively formed huts

day of digital media. Fascinating

the array of patterns and motifs

are an interesting sight.

characters, new forms, 3-D renditions in English or Hindi form

everywhere. Traditional decorations adorn everything and this crazy

The print media may have reached

the backbone of letters sprawled on

plethora of visual imagery is what

the villages in the form of posters,

the walls. Visibility and reaching

showcases the Indian culture.

notice and billboards, but wall art

a wider audience is one of the

continues to be the focus of the

major reasons for wall art being so

visual culture in Patna.

popular. The color palette for this

Patna, being the capital of Bihar,

art is very diverse - kaleidoscopic

has system and some order at the centre, but the outskirts still thrive

Graffiti may not be the best way

to be apt. Wall art is accompanied

in chaos of sustenance. However,

to describe the wall art seen

with floor art and ornate house

there is a method to this madness

across the villages, as most of

doors and windows.

as well. The travels through the

the communication is driven by

outskirts of Patna into smaller

awareness and not rebellion. Be it

Another aspect of the visual

locales of Bihar Sharif, Phulwari

vaccination drives, birth control,

culture in Bihar is superseded by

Sharif, Pun-Pun, Mokama and

personal ads or family planning,

superstitions and religion which

Parsa Bazaar showed the amplitude

everything has found place on the

accounts for many artefacts found

of the visual grid that Bihar offers.

canvas of homes and streets alike.

in and around peoplesâ&#x20AC;&#x2122; homes. Wall

The natural landscape of Bihar is

The illustration style too varies

as calenders, evil charms etc are all

very rich, both in vegetation and

from being direct and detailed to

examples, part of the visual culture.

colour. Crops and flowers flourish

abstract and emotive. It mostly

hangings, posters of various Gods

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

View of the peri-urban life, Parsa Bazaar, Patna, Bihar

A grandfather speaks about the situation of immunization, Phulwari Sharif, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Image marking the place for immunization, Parsa Bazaar, Patna, Bihar

Images of religious home artefacts, truck and rickshaw art, posters on vaccine awareness, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Images of various type styles of posters on awareness and communication, Patna, Bihar

Wall art poster for disposing placenta and dead foetuses in the correct place, Begusarai PHC, Begusarai, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Wall art awareness poster for family planning, Bihar Sharif, Patna, Bihar

Mix of digital and hand done posters outside a school, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Pictures of livestock, facades, religious artefacts and awareness wallart, Patna, Bihar

Wall art awareness poster on contraceptive methods, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Colorful facade of a building, Patna, Bihar

Digital poster hoarding on awareness of safe and clean drinking water, Patna city, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

One of the best kiosks for egg rolls, Hadtaali chowk, Patna, Bihar

Another aspect of the visual culture

the type of vaccination given. The

is â&#x20AC;&#x2DC;truck artâ&#x20AC;&#x2122;. It is a decorative

language used in the card is a mix

and unconventional canvas for

of hindi and english (mostly hindi)

storytelling through illustrations.

like most of the communication

The topic of these artworks

seen in Patna.

vary from Bollywood icons to witty, tongue-in-cheek quotes,

The card has many flaws like being

superstitious sayings.

cramped, muddled and confusing, but in its own way it resonates the

However it has transcended from

spirit of the Indian visual culture.

trucks to other vehicles as well. In Patna this was particularly seen in the rickshaws that run in the city, in the form of colorful, embroidered head and back covers. All this is reflected in the health card for Bihar. The interesting aspect of India is that all the states have their own renditions of the healthcard e.g. the healthcard of Gujarat is different from that of Madhya Pradesh and so on. Hence, the Bihar healthcard denotes the nuances that reflect Bihar as a state. The card is a multiple zigzag fold card with information on both sides. As seen in one of the earlier pictures, the healthcare information is illustrated through detailed drawings showing a typically Indian mother with her child. The immunization schedule has colorful boxes with detailed drawings of

The immunization schedule from the Bihar healthcard, Patna, Bihar

100

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

with a new card. This results

of the immunization process.

in breakdowns in service, since

The card was also utilized by the

beneficiaries often expect that

beneficiaries as a source of health

the PHC has maintained complete

care information.

health records.

FIELD INSIGHTS 5.1. Relationship with the card

In all three locations, the health

the beneficiary. There was low

workers and beneficiaries shared

awareness of the purpose that is

their review regarding the existing

fulfilled through the health record.

cards. In all locations the perceived

The health workers mentioned that

importance was very different.

they depended on their registers

It was observed that in Kenya and

rather than the health record in

Indonesia, beneficiaries perceived

order to search for or write data esp.

the health record as being an

unique identification information of

artefact of importance and a

the baby.

signifier of the responsibility that the parent feels towards the child

Additionally in Indonesia,

health and safety.

beneficiaries associated the health card with the center that issues the

However in India, the health

card. As a result beneficiaries often

record was not valued as being

do not carry the card with them

an important information

in case they migrate to a new area,

artefact from the perspective of

since they expect to be provided

It was observed that in Indonesia and Kenya parents vested the onus of immunization on themselves. In fact in Kenya, it was observed that mothers were often admonished for missing a vaccination date. As a consequence parents tended to fudge the data and that came out as being a serious concern. However in India the beneficiaries often perceived the onus of immunization of the child as vesting with the health worker rather than themselves. They because of low literacy, were heavily dependent upon oral dissemination of information from the health workers; any form of card engagement was minimal. In Kenya and Indonesia, due to relatively better literacy levels, the health card was more successful in aiding the health worker in communicating the importance

Discussion on the Kenyan healthcard during an FGD with the nurses, Kisumu, Kenya

102

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

5.2.1. Unique Identification

wiped. As a result health workers

In the vaccinations process, the

were often left with incomplete

initial phase is the identification of the child. It is the most critical step to ensure successful routine immunizations. Unique identification is a key parameter for

information to link the baby with the record. (b). Absence of the card as first level of identification:

(c). Judgement based decision making:

Cross locationally, ambiguity in linking the child with the record made the decision making process for identifying the child heavily dependent upon the judgement of

In all locations, it was observed

the health worker or the influence

that many times parents did

of the mother. This judgement

not carry the health card with

based-decision making becomes a

them for routine immunizations,

challenge, especially when there is

which proved to be a significant

a communication gap between the

challenge especially in India.

beneficiary and the health worker.

missed vaccinations.

As a result of this, the card was

It also increases the risk of an

perceived by health workers as

incorrect vaccination being given to

~ Challenges with Respect to

being undependable as a primary

the child.

Identification):

identity. Hence personal artefacts

information on the card:

became more integral for linking

confirmation of the vaccines that are given and the ones that are due. Barriers in identifying children correctly, can create problems in tracking vaccination history. Thus increasing the threat of repeat or

Identifying the Baby (Unique

source of verification for the childâ&#x20AC;&#x2122;s

(a). Securing of critical

like health workerâ&#x20AC;&#x2122;s registers

In India it was observed that

the child to the card.

record lacked durability, so critical

the material used for the health information was often smudged/

5. FIELD INSIGHTS

Contd ...

5.2. Cue card based segregation of field insights (India, Indonesia, Kenya)

(d). Fragmented patient identity

~ Responses to new design entries:

information:

The design entries, that were

In Kenya it was observed that vital

submitted to the contest, proposed

information, needed to link the

several different methods of

child with the card is spread across

improving unique identification

The dual health structure in

different pages of the booklet. This

and tracking patients ranging from

Indonesia of two health clinics i.e.

leads to an increase in time taken

addition of photographs, marking

posyandu and puskesmas, with two

to identify the child. Also multiple

of birthmarks, biometric prints, bar

separate health records also created

identity information/codes given

and QR codes and the addition of

confusion in identification.

to a patient for different public

two addresses.

systems increases the risk of error.

(a). Photograph as an identifier:

In all locations under study, it was perceived that the photograph of

103

the family on the record was the

of arranging for the photograph

easiest and most convenient form

should be on the health clinic

of identification. It was also looked

or upon the beneficiary. In

upon as a factor to increase the

Indonesia, beneficiaries perceived

emotional association of parents

the photograph card as being an

with the record.

effective alternative in case of any

Functionality under duress: A key driver of choice for the

photograph card was that is was valued for being a unique identifier, helping identify the child even if

constraints to the implementation of technology. Perceived disadvantages of the card:

In Kenya, nurses perceived that the

the card was torn/spoilt. It also had

photograph was not a good option

the ability for applicability across

for identification, as the baby grows,

diverse situations. Health workers

his face changes over time in the

from India valued the fact that the

first two years. The photograph was

photograph would be useful to

also not deemed very durable as it

identify the child even if the child is

could be easily damaged by routine

accompanied with any relative.

wear and tear.

In India, in addition to the above, perceived ease in implementation was a key driver of the decision to choose the photograph since given the current infrastructure constraints in the public health sector in Bihar, health-workers perceived this to be the easiest to implement. However group consensus was not reached on whether the onus of responsibility

Photograph as an identifer ~ The sapling card

104

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Biometrics footprint ~ Records for Life: an innovative, compact, and durable redesign of the child health record, submitted by Katy Harris on behalf of Fathom Information Design

As a result, beneficiaries perceived

PHCs. In India, nurses considered

the footprint to be an initiative

the footprint card to be extremely

that could be easily implemented

time consuming.

since this information was already being collected at present by health

It was perceived that once the child

clinics when the child is born.

became older it would be harder to cross reference their identification

Another driving factor behind the choice of the footprint was the fact that it was associated as being unique to the child. Additionally the footprint was used as a unique identifier, it also became accessible to the beneficiary as a valuable memory artefact, which would improve the emotional value of the card, thus aiding them in the retention of the card. Disadvantages of biometrics: (b). Biometrics footprint:

In Indonesia, this card was greatly valued by beneficiaries as being a signifier of the unique identity of the child. Permanency and accessibility of data were key associations that were made by beneficiaries with respect to this card. Another factor contributing to this selection was the fact that the footprint of the baby is collected at birth at the PHC in Indonesia

Beneficiaries in Indonesia were cognizant of the fact that the footprint as a data point is limited in nature especially for informal deliveries. Additionally in India, health workers perceived that the data collected through the footprint, could only be used at the center that collects that information. They were unable to imagine how this information could be made available across other

through their footprints.

105

(c). The birthmark as an identifier:

under study, health workers

The idea of noting the birth-

were cognizant of the benefits of

mark as an identifier was largely

including information about the

in Kenya by beneficiaries and

perceived as unfeasible across

birthmark on the card. Health

nurses. The card was perceived as

locations. Both health-workers and

workers were more comfortable

resulting in ease of identification

beneficiaries were unsure about the

with this information playing the

of the credentials of the child.

permanency of the birth-mark, and

role of a backup identifier rather

Accessibility of information in

were therefore doubtful about its

than a primary identifier (and

one place was valued greatly by

suitability as a primary identifier

therefore recorded in the card as a

nurses with respect to this card.

since it might not be there for all

footnote rather than a visual.)

One reason for this was that it

children or might fade away. Ambiguity over what constitutes a birthmark:

Health workers perceived that people may be many types of marks so there was a confusion as to what constituted a birthmark and how it would it be identified. It also

(d). Bar code as an identifier: The barcode was most liked

reduced the criticality of the beneficiary maintaining the health The Birthmark as an identifier ~ Visuals Save Lives, submitted by Rafael Vivas, Nati Rodriguez, Lucia Arnaud, Quique Ciria, Alvaro Ortiz, Fernando Casado, Nadia Revelo and Javier Arnaiz on behalf of VISUALIZAMOS

record safely, with respect to the immunization schedule.

projected concerns over process efficiency, in other instances, health workers in Indonesia were unsure about whether the birthmark would be a time efficient way of identifying a child Social Stigma:

Beneficiaries in India were uncomfortable with the idea of their child being inspected for a birthmark every time a vaccination had to be done. In all locations

QR code card ~ Records for Life â&#x20AC;&#x201C; submitted by Gopika Parbhu, Sara Corrigan-Gibbs, John Hanawalt, and Matthew Scharpnick on behalf of Elefint Designs

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Broader perceptions around Technology:

In Indonesia and Kenya, technology was perceived as being sophisticated and desirable. It was observed that an aspirational value was associated with technology. In Indonesia, users preferred that technology should play a passive role, to identify the baby in instances when the card was lost/ torn. In fact, beneficiaries preferred if technology was implemented at the end of the health provider, in order to reduce the implications of losing the health record. Kenyan users were more accepting of technology. In India although technology was perceived as being desirable, responses were subdued due to apprehensions over infrastructure constraints. and that everyone might not be able to understand code scanning. Additionally it was observed that both beneficiaries and health workers were unable to distinguish between the functioning of a bar code and a QR code.

FGD with mothers and children in Kisumu, Kenya

107

FGD with ANMs filling in the immunization table in the entry. Patna guest house, Patna, Bihar

5.2.2. Immunization Schedule: Immunization schedule is one of the most important sections of a card. The immunization schedule is determined in tabular form

challenges in terms of calculating

in all the locations. It plays an

the next due. The mothers often

important role for health workers to

changed the due date in case they

determine the due date for the next

missed the vaccination to avoid

vaccination and the vaccinations

getting scolded from the health

given. It is equally important for the

workers. Also, they felt a need

beneficiaries as it enables them to

for more space to add missed

keep a track of the vaccinations and

vaccinations and other information.

the due dates.

In Indonesia, the respondents

~ Challenges of understanding,

had high literacy rates and they

reading or filling the

preferred to read and check the card

immunization schedule:

for the next due date. When they

In India, the immunization

forgot about the immunizations,

tables are currently referred to by literate mothers only as a source of confirmation of whether their child has been vaccinated or not. They do not usually check the due date for the next vaccination as they know that mobilizers (ASHAs) are there to remind them. During the discussion, the mothers esp. in Bihar expressed their concern on comprehension and understanding of the table. They

felt that though it was important

to follow the flow of information

The beneficiaries from Kenya,

to know which vaccines had been

on the card. The health workers,

felt that the terminologies

administered, they were not

felt that the current card did

and abbreviations used in the

able to attach the importance of

not have enough space to add all

immunization schedule were too

understanding of the table and

information. The information

complicated for the parents to

always felt a sense of dependability.

added sometimes got rubbed off

understand. They mentioned that

and they also felt the need to have

semi-literate people also found the

The current immunization

a description of each vaccination

schedule difficult as it was too text

schedule was confusing for the

given, as beneficiaries often asked

heavy and fairly complicated.

mothers as the data was given both

them questions related to that. They

They faced challenges like accuracy,

horizontally as well as vertically

felt that there was a lack of clarity in

authenticity and deficiency. They

making it difficult for mothers

the present card.

said that many a times they faced

they relied on the health system. For remembering the date they devised their own ways like making a mark in the calendar, putting phone alarms etc.

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

vaccines written in full form and not in abbreviations; they felt it was useful for both the nurses and the parents as it would reduce cases of confusion and be easier to explain to the mothers.

The Rainbow Record:

and the sign of the midwife.

card among the beneficiaries and

limitations like the boxes for filling

This was the second most preferred health workers. They mentioned that the cue card was clear, simple, the vaccination date and the next due date were clearly mentioned

the information to be too small, making it difficult to read the information filled in it. In all locations, both beneficiaries

The beneficiaries mentioned the

along with the signature of the

card was well illustrated and easy

health worker giving that particular

to understand even for the illiterate

vaccination to prevent data fudging.

concept of the signature to be an

The longitudinal approach of the

greater accountability within the

mothers. According to them the information was clear, concise and the information was well segregated. However, they stated a few limitations of the cue card, they felt that due date section was missing. They suggested a separate column for due date along side the date of current vaccination.

Visuals Save Lives, submitted by Rafael Vivas, Nati Rodriguez, Lucia Arnaud, Quique Ciria, Alvaro Ortiz, Fernando Casado, Nadia Revelo and Javier Arnaiz on behalf of VISUALIZAMOS

They also mentioned certain

card was better understood as it showed time and data filling in the same direction and aligned with the respondents understanding of time. The beneficiaries preferred the card as they found it to be detailed with space for additional vaccinations

and health workers attributed the effective medium to introduce system. In fact in Indonesia, health workers also perceived this to be an advantage, by claiming that the signature would help in identifying which centre had issued the health record in instances when the beneficiary has recently migrated to some place else.

~ Responses to new design entries: Visuals Save Lives:

This cue card was liked in all three locations by the health workers as well as the beneficiaries. The health workers felt the schedule was easy to understand because of the visuals and there was clarity of information. The nurses appreciated the card as it included sections of other vaccines, the names of

The Rainbow Record: Rapid Access Immunization Now: Better Our World, submitted by Andres Moros, University of Houston student

109

It was observed that the health care system in Kenya functioned in a manner that put the onus of responsibility of immunization on the parent. In the focus group discussions with health workers in Kenya, it was found that fudging of data was a big concern, since some mothers did that to avoid being shouted at by the health worker for missing a vaccination date. Reading the Information:

In India and Indonesia, the vertical alignment of listing vaccinations along with time was preferred as time was seen in phases, coming one after another. In Kenya as well, vertical orientation of time was appreciated. Nurses were often in a habit of filling in most documents like a checklist and therefore the increased comfort with reading and filling vertically aligned (timed) schedules seemed beneficial. FGD with nurses in progess, about the creative immunization cards, Kisumu, Kenya

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Adaptable, Accessible, Affordable: Reimagining the Child Health Record, submitted by Erica Schroeder, Hailey Oâ&#x20AC;&#x2122;Connor, and Laura Lightly

donated by the same animal, so that too would make it confusing for the health workers or parents to identify which vaccination had been administered. In the social context, this card in India was not liked as the idea of associating childrenâ&#x20AC;&#x2122;s health with animals was not considered appropriate. This card shows the immunization schedule designed like the veins of a leaf or branches of a tree growing in opposite directions. Though the card showed growth and progression, the users across all locations felt that it was too abstract and compact to either read or fill data. Also, the health information given was in a line

~ Creative Immunization

immunization schedule in a set

During evaluating the cards, the

received by any of the locations as

team noticed a few entries with

the users felt that relating animal

unconventional ways of designing

icons could be confusing as every

the immunization schedule.

vaccination was depicted as a

Collectively it was decided that a

separate animal.

schedule entries:

of animal icons. This was not well

few of these would be tested on field to hear responses from the users.

below an illustration depicting what a mother should do as her child grows with every vaccination. This was considered to be very concise information for something as important as healthcare information which needed to be detailed and comprehensive.

Also, the visual context of understanding animals changes

As seen in the previous image,

with various locations. Different

the card above showcases the

parts of one vaccination are

Redesigned Immunization Record, submitted by Deb Working

111

Personalized vaccination wheel and health record was thought to be difficult to interpret and gather critical information in India and Kenya. Additionally in Indonesia, parents were uncomfortable with the idea of using the wheel as a device to understand the next vaccination date. Users in India pointed out maintenance to be a problem as they felt children might perceive it as a toy, play with it/loseit or break it. Also, the notion of associating immunization with playfulness (the wheel being seen as a toy) might dilute the seriousness of the subject. Personalized Vaccination Wheel and Health Record, submitted by Moon K. Kim, Therese Boston, Sheila Isbell, and Margarita Gonzalez on behalf of Georgia Tech Research Institute

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5.2.3. Growth charts and Health

of healthcare involve the

section or they explain what it is for

care information:

engagement of the health worker,

and why is it important.

The section is rather

mobilizer and the parents. The

underestimated to the potential of help and information it can provide. The health workers and the beneficiaries both access this information but at different levels and situations. The section deals with the low engagement issues which are the outcome of low literacy levels and relevance of data. Beneficiaries who

beneficiaries heavily rely on the

It was observed that in Indonesia

information provided by the

and Kenya beneficiaries were

health workers. More often than

extremely comfortable with the idea

not, the information is verbally

of having a dependable interface

disseminated to the parents on how

on the card itself through which

to take care of the child and the

they could verify that their babyâ&#x20AC;&#x2122;s

growth pattern.

growth was progressing along expected lines, on their own.

The healthcare providers use the

Health workers felt that this was

card to reinstate the information

one section of the card where there

provided by them so that

was scope to reduce the dependency

beneficiaries can rely on the card

upon the them to communicate

information to its full potential.

for future reference. The illiterate

essential information.

The data also becomes redundant

to the card and are completely

The beneficiaries also felt that

dependent on the information

understanding graphs and charts

healthcare professionals give them.

was too complicated for them.

cannot read are not able to use this

after a while and the beneficiaries do not find it valuable to them anymore. They rely heavily on the

beneficiaries find it difficult to refer

Similarly health workers too found Sometimes the beneficiaries feel

the growth charts as being a toad

that the data provided in the card is

complicated to mark or explain to

not elaborate and does not address

mothers. Many times the height

friends to tell them.

the problems faced by them.

and weight data was filled in the

~ Challenges of ease in

verbal dissemination of this kind of information which they prefer the health workers or their relatives or

immunization schedule space itself Though the mothers understand it

as opposed to its given place which

understanding growth charts

is important to know the progress

created lot of confusion. Hence, a

and relating to healthcare

of childâ&#x20AC;&#x2122;s health and that is only

tabular format with numbers was

information:

possible by tracking the height and

preferred than graphs.

The existing challenges across

weight, they say that the health

locations around the sphere

workers do not fill the growth

A health card with growth of the childâ&#x20AC;&#x2122;s progress laid out in milestones along with healthcare information and vaccinations given in that phase, as a checklist.

113

~ Responses to new design entries: Health Care, Nutrition

Counselling Information:

Haiti Child Health Handbook Redesign:

Across all locations the beneficiaries appreciated this card as they found the data easy to understand, in a tabular format, one after another and not in the form of charts and graphs. Visual representation of warning symbols was understood and well received, which were realistic illustrations rather than abstractions. Negative affirmation is considered as being important and helpful. Visuals supporting the same were perceived as being the most adept form of communication. The health workers felt the card was easy to understand, comprehensive and the information was well represented in this illustrative visual style. They mentioned that even the beneficiaries would like and understand the card as the growth was shown in phases through detailed sequential images.

Haiti Child Health Handbook Redesign, submitted by Jacqueline Lee Oâ&#x20AC;&#x2122;Friel, Rebecca Perez and Regine Jean-Francois

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

The Picture of Health:

information. They were comfortable

on the growth chart was a cause for

in reading numbers rather than

concern amongst beneficiaries. In

strong visual language in the card.

interpreting a plotted graph line.

India as well, many times the height

The health workers appreciated The beneficiaries felt danger signs were important as it alerted them about their childrenâ&#x20AC;&#x2122;s health and informed them when they must

and weight data was filled in the This situation was quite opposite in

immunization schedule space itself

Indonesia where people were open

which created confusion.

to reading and interpreting graph

take their child to the hospital.

data as they seemed to understand

Graph Non-Literacy:

numbers in a tabular format was

by most parents as prevalent visual

without any interpretation or

The graphs were not understood cognition was not strong enough to interpret this kind of graphical

the information. However, written preferred as they could be read assistance. In Kenya the accuracy of the markings done by the nurse

The Picture of Health, submitted by Trip Oâ&#x20AC;&#x2122;Dell and Umberto Fusco

115

Danger gigns - Highly Valued

health care counselling as the

In Indonesia and Kenya, visual

and there are large beneficiary

representation of warning symbols

crowds leading to time constraints.

Information:

immunization process waslengthy

was understood and well received. In India, beneficiaries welcomed the

In Indonesia as well, the

idea of adding danger signs in the

beneficiaries thought that the

card because the present MCH card

ultimate source of information for

missed this information.

health care information were the

Key Information Section:

health workers, even if they could read the information themselves;

In Kenya and Indonesia users

they liked to cross check the same

liked the head circumference as

with the health workers.

one of the growth indicators, as its tracking could reveal specific

The health workers preferred

diseases. Also they thought that the

concise information and self

growth information would be more

explanatory visual language. On the

complete if this section was added.

other hand, beneficiaries preferred

Health Worker card preferences:

The health care counselling

comprehensive, explanatory visuals so even in absence of health workers they could get relevant information.

information boils down to the fact that the health workers do not have the time to explain everything to the beneficiaries so they would want a mechanism that could suffice the need. It can be done through self explanatory visuals as suggested by a few design entries. In India, health workers were unable to provide detailed

FGD with mothers while they inspect the danger signs given on the entries, Kisumu, Kenya

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

5.2.4. New information fields: In the new data fields section, the concepts that were selected to be tested on the field were based on the practicality and the overall effectiveness of the design. The entries that made the selection included concepts such as photographs of the child to depict growth and progress; certificate with a pledge for mothers; unique health information such as allergies of the child; an emergency helpline number and phone numbers of local health centres and nurses and a few more novel yet innovative concepts such as rotating dials which could work as an immunization schedule.

An entry with new categories of adding allergies, off schedule vaccinations and notes

117

Live till 5:

The second most appreciated concept was that of an emergency helpline number coupled up with the phone numbers of the health centre and the local nurse. Additional Information:

Furthermore, the idea of having unique medical information of the child on the card was well received by parents and health workers. The parents felt that having an additional space for vital information like allergies would not only make the health information on the card more comprehensive but also assist the health workers and doctors to administer the right kind of medication to their child. A Record for Life, submitted by Amanda Buck, Sally Maier, Chen Yu and Nate Gulledge on behalf of Maryland Institute College of Art

~ Responses to new design entries:

in the them. Additionally, the

The concepts that emerged strongly

concept would help communicate

A Record for Life:

before and after narrative of the

across locations were those of the

the benefits derived from the

childâ&#x20AC;&#x2122;s photograph and the helpline

vaccinations. Some parents also felt

numbers for mothers.

that the concept of before and after

The health workers felt that through

them more responsible towards

the photographs, parents would be able to see how well their child has developed and in essence instill a sense of accomplishment

would motivate them and make completing the immunization process and eventually lead to better up keep of the card.

A few mothers also stated that more often than not, they were completely unaware about the allergies of their child and hence such information would be really useful for them. The parents felt that the phone number would act as a bridge between the parents and the health centre. Moreover, they stated

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that having a contact number at their disposal would enable them to reach out to the health centre or the local nurse during times of emergency. The concept of an emergency helpline number was especially appreciated by mothers who felt that they were overtly dependent on the local nurses for even the most basic information, and hence having a helpline number would make life easier for them. FGD with nurses where they are talking about the card, Kisumu, Kenya

Live till 5, submitted by Diya Deb

119

5.2.5. Material, Form and Colour

with education. In Kenya and Indonesia, it was highly valued due

~ Material:

to familiarity of the format as their

material of the current cards was

format. It also epitomised a higher

An important issue around the difficulty in maintenance due to fragility of the card. The cards were subject to spoilage by rat bites, oil marks, stains, water splashes etc. Users expressed the need for plastic coated cards or cards with smooth covered surfaces which would ensure durability, protect information in the card, help in easy upkeep of the record and protect from any physical damage.

An entry with the bi-fold form

present cards were in a booklet standard of healthcare in India and Indonesia as it was associated with records of private hospitals. The bi-fold form:

Many respondents across all locations also chose smaller compact sizes over big sizes hence the bi-fold and pocket sized cards were major preferences for user sets primarily for their durability and ease in managing.

~ Form:

~ Colour:

of the card. It is the final physical

aspects, as an aesthetic and as a

The FDGs looked at colors in two

Form is the representational aspect

function in terms of coding.

format that binds information and visuals in tangibly.

Association, relation and

The booklet form:

identification:

format came out as the strongest

context came out as a strong

Across all locations, the social

Cross locationally, the booklet

driver for respondents in making

physical form of the card. It was

choices or suggestions about

appreciated by all user sets as it was

color preferences. Health workers

compact, manageable, portable,

suggested yellow and green for

handy and user friendly. In India, the form of a book evoked respect due to the reference associated

An entry with a pocket size form and a sticker as a reminder.

the entire card primarily because they are bright and would be

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

visually more appealing and easy

looked at the aesthetics of colour

colour coding system was already

to distinguish from the rest. The

in terms of its functionality. They

well ingrained in them culturally.

health workers felt that green was

expressed the need for lighter

easy to associate with health, as it

colours in the cardâ&#x20AC;&#x2122;s background

In Kenya, the need of identifying

was often seen in the hospitals.

so that information could be easily

information at a glance was a strong

written or read.

driver to prefer color coding. In

Green also signifies growth and nature. One instance in India was when a health workerâ&#x20AC;&#x2122;s reason for

Functionality of colour;

Colour aligned with time:

cards where colour coding was done according to vaccines, nurses mentioned that starkly contrasting

Nurses observed that mothers

colours should be used rather than

mothers were often asked to

would find it easy to associate

shades which might get confusing.

consume green vegetables in their

colours with time or more

diet, which in turn reinforced the

specifically, phases of a childâ&#x20AC;&#x2122;s

concept of health associated with

development. Colour coding the

this colour.

progressing age of the child aligned

choosing green was that pregnant

with the vaccinations of that In Indonesia a preference towards

phase, was preferred over assigning

green was also observed as the

colours to vaccines.

colour was culturally relevant to the context. They were also open

Mothers believed they would know

to using other bright colours for

what phase of the vaccination cycle

the purpose of identification and

their child was in and based on the

reminder creation.

age, they could report the same to nurses, who could look at her

In Kenya, bright colors are mostly

associated with health. Since the color of the existing vaccination

In Indonesia, color coding in the

card is purple, it was preferred by

card was very well received by users

many health workers.

as the country uses colour coding systems for different purposes. They

White color with red cross is also

had public transport system color

associated with health. Many users

coded based on locations, so the

Healthcard entries in various, strong colors.

Colors aligned with specific vaccine doses.

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Color aligned with time in phases of the Routine Immunization (RI) cycle

123 It can be very overwhelming to

it is actually used for right now

translate and analyse data from

and it can be harnessed through

three different locations and come

addition of various new categories.

up with a concrete step forward to

The information design of the

making design recommendations so

record is an aspect which has to be

a brainstorming session on making

handled at two levels ~ through

connections between common

understanding of needs and the way

and different data points from all

people access this information.

locations needed to be conducted. As often at NID this process is

REFLECTIONS

AHEAD

AND THE WAY

6.1. Making connections from data

~ Unmet information needs:

The current health record is not

carried out, a similar process was

able to address all the needs of the

suggested where all the insights

beneficiaries. Parents perpetually

from the field research were labelled

seek additional information about

in categories called thematics.

immunizations and its process

They were broad headers which

through the health workers.

encapsulated smaller, minute insights and helped formulate

In India, while many beneficiaries

a strategic way forward for

did not consider the card to be

drafting the guidelines for design

important, the nurses relied heavily

recommendations. A brain-

on their registers to keep a track

mapping chart shows how these

of immunizations. Thus making

connections were made.

the health record lose its potential

Information Design:

as an information artefact to relay information in a responsive

The record is a personal artefact

manner. Low literacy levels; high

that disseminates as well as acts as

dependency on verbal information

a bank for collecting and storing

and reminders (ASHAs); low

information of the child for the

health care awareness and mistrust

future. The potential value of the

on public health system also

record is more vast than what

contributed to low value of the card.

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Data from field Improved interaction and engagement Sorting the data

Increased validation, accountability, commitment Space for localization and personalisation

Looking at the larger picture

Making connections Physical form and format Information design Unmet information needs

Representation and visual cognition

Where is the date? Continuity of data

Different users Who writes on the card?

Visual literacy ~ understanding tables v/s graphs v/s numbers

Context in which information is read Flow and sequencing

Dependency on verbal v/s written information

Different users, different information needs, different expectations:

Abstraction v/s realism ~ illustrations or iconography

Cultures: colloquial language, media and format

Reading the information Too much information

brain-map OF CONNECTORS

125

To redeem this situation, few ideas

childâ&#x20AC;&#x2122;s health if they are not given

that were discussed which might

vaccinations on time.

help ~ Enhancing the record with self explanatory data to ensure self

As observed in the field, parents

reliance amongst beneficiaries and

want a measure of the height and

accuracy of information. The record

weight of the child to keep a track

could address the need of additional

of the childâ&#x20AC;&#x2122;s health. The parents

information fields such as danger

would want an indicator of standard

signs, missed vaccinations, allergy

growth curve and compare it with

information etc. The record could

the actual growth of their own

also allow for localisation. A

child. This mechanism would make

dedicated space could be allotted so

them self dependent in monitoring

that any kind of information which

the growth of their child.

the parents think was important could be added.

The record could also have the potential to answer different

The current card has no space

questions with respect to the

for additional information. The

immunization schedule esp.

mothers are often unaware of

regarding various vaccinations,

allergies or other vaccinations that

their details and benefits i.e What

a child needs. Having an additional

is being given? What is it protecting

space for vital information like

from? What is the vaccine full form

allergies and phone numbers might

and the side effects?

give mothers a reference point and also would not add confusion to the

In the immunization schedule,

existing data.

critical areas of information in the record could also be linked,

Some kind of negative

for e.g. the due date, information

reinforcement would also help

on the vaccine and height and

in getting the parents take

weight of the child. This suggested

consideration to the fact that

data, however, would need to be

there could be bad effects to the

adequately detailed with a mix

of comprehensiveness and a gist such that it would suit all users who might come from diverse

Snippets from the brainstorming board (Post field work),

educational levels and backgrounds.

CKS office, New Delhi

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ANM filling in her register, Parsa Bazaar PHC, Patna, Bihar

this association of user information

or a wall clock which could tell the

over due course of time becomes

beneficiaries about the next date

redundant, leading to varied levels

of vaccination or the ways which

of engagement between the user,

could describe how they may take

information provided and the

care of the child. It could also build

record as a whole.

on emergency cases which could be leveraged as a help mechanism at

For increasing the efficiency of

the time of crisis.

the information in the record, it is essential to break down the

The other portion of the record

needs and the interactions. It

could carry important information

could take place with regard to

about the immunizations and

the users. Splitting the record into

healthcare (to be entered by

two sections is an approach which

the health workers). This would

The milieu of the record changes

could help achieve the needful.

maintain the medical history of

every time the users engage with

One portion of the record could

the child which could be accessed

it. The different user and different

be ingrained in something that

whenever the need was paramount.

interaction scenario leads to

the beneficiaries use every day

It could be kept away with care

creation of diverse situations which

and is a part of their daily life in a

and accessed on the next due

can be leveraged to create context.

non-intrusive way. This portion of

date of the immunization. This

the card could work as a reminder

segment of the record would also

The record as an information

mechanism which could be read

provide information to be read at

artifact has certain drawbacks

by users while doing their daily

a glance without involving longer

which are caused by accessing

activities. The artifact could have

engagement for the users.

of data at different times and

the ability to merge into everyday

contexts. The relevance of the

objects and only get noticed when

Adopting this method of separation

information keeps changing as the

ever needed. Daily interactions

of the record into portions of

recorded information becomes

with the artifact could reinstate the

application inclination might draw

old and irrelevant after a period of

message in a more affirmative way.

beneficial outcomes as they might

~ Context in which the information is read:

suffice the requirements of the

time. Also the static information provided in the record has a time

The reminder mechanism could be

bound significance for the users and

translated into a due date calendar

different users.

Snippets from the brainstorming board (Post field work), CKS office, New Delhi

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~ Flow and Sequencing:

respondents not reading the entire

immunization schedule was found

Flow and sequentiality are

card and not being able to make

to be more helpful for beneficiaries.

important driving factors for

links between the information in

higher readability and recall

various sections.

of information as information placement or sequencing in the card

(a). Where is the Due Date?

Prominency of the information that is sought by the beneficiary, like the next visit data, can help in

Insights from the field analysis

reinstating the importance to be

will be noticed, read, and repeatedly

revealed nurses and beneficiaries

associated with the health record.

reinforced by beneficiaries or not.

having contrasting views on where

A more efficient system is likely

The immunization table is the

the next due-date should be placed

to be created with the ‘next-due

most important information piece

in the card due to difference in their

date’ reinforcement if the needs

in the design of the record and

relation with this information.

of these two user sets can be

has a direct relation with whether it

successfully reconciled i.e. Nurses

its placement will define the way people navigate. So it’s placement

From the nurses’ perspective, their

and beneficiaries. For instance, a

is significant to the intake of

preference of the date to be placed

card with a separate section clearly

information that people can have

in tandem with the immunization

marking the next due date in the

while going through the records

schedule was for two reasons - They

immunization schedule along with

would be able to calculate the due

its reinforcement as a sticker or a

of information for reading and

Where flow of information looks

date with ease seeing the last date

blurb preferably towards the end

connecting various sections of

at a logical a step by step data

of immunization given, it would be

of the card would address both

information in the card by the

segregation method, factoring

the last thing that they see while

information flow and sequencing

users, primarily beneficiaries.

on the time frame that the users

filling the immunization schedule

without compromising on the

get to interact with the card in,

and therefore they would not forget

access and ease of data reading,

The field insights showed that

sequencing looks at a more focussed

it and secondly, they felt that the

filling or comprehension.

linking the age of the child and

approach of data chunking of only

due date being mentioned anywhere

health care information along

those critical information fields

before the immunization schedule

with the immunization schedule

which are most relative to the users.

would dissuade mothers from going

strengthened the idea of growth

Despite being separate entities

through the entire card. Visibility

and progress especially amongst

in themselves, both need to be

and recollection of the next due

the beneficiaries.

strongly linked with each other

date and its strategic placement

to help address the problem of

in the card other than the

One of the final entries with a sticker as recall system.

(b). Continuity of Data:

Continuity of data is an important driver for flow and sequencing

It was analysed that breaking the card into separate sections for

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immunization schedule, growth charts and health care information with a similar timeline tended to skew the idea of health care in the beneficiariesâ&#x20AC;&#x2122; minds. It would best serve the card if the immunization schedule was linked to other critical information fields like information on the vaccination, its importance and protection value; the height/weight of the child with progressing age and important health care information that corresponds with each phase in the vaccination schedule. In this way the metaphor that the card uses, for correlating health and progress of the child with routine immunizations and appropriate health care, is stronger in the minds of the beneficiaries.

A mother in an FGD checking one of the entries for flow of information, Kisumu, Kenya

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Representation and visual Cognition:

Visual cognition is a vital aspect of data and picture inter relation and its interpretation in the card. It depends on changing

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

to graphs or numbers as cross referencing was a complication. ~ Abstraction v/s realism -

Illustrations or iconography:

Any bare bone visuals, iconography,

representations of visual

line-drawings, abstraction or

information i.e. shapes, form, color,

simplification of visual imagery was

style, illustrations etc.

not understood.

Currently the health cards employ

Cross locational insights showcased

a rather fragmented and restrictive

a high degree of preference for

approach to data visualisation

detail and realism in illustration

which is perceived to be confusing

styles. A realistic approach to

and non informative to the either of

visual imagery was more valuable

the user sets.

and well received by all users. This

~ Visual literacy - Understanding tables v/s Graphs v/s Numbers:

also proved to be beneficial for users with low literacy levels or places where verbal information

Looking at the diversity in the user

is primary as reinforcement of

demographic, a strong problem

information through step by step

identified on field was reading

iterations makes understanding

and comprehension of graphs for

better and simpler.

growth charts. Certain insights revealed nurses to be comfortable

A realistic yet simple approach to

with graphs while the others

data or visual representation would

preferred either a number based

suit best. Visual styles of a relatable

progression or a tabular format.

nature with human forms and daily objects drawn as the users actually

Areas with very low visual literacy

see in their everyday lives would be

preferred data in tables as opposed

most valued and understood.

(On top ) An entry with the growth chart as a graph supported by a table compared to the current card of Bihar (the picture underneath) with the growth chart as a graph.

131

Physical Form and Format:

The physical form of the record should have the quality of being functional under duress. During field work there was a preference seen towards familiar and existing forms of the records as the form selected needed to convey seriousness, ownership and state recognition. For example a bi-fold or a booklet form was preferred by most people. This behaviour showed that the beneficiaries were looking for the record being compact with less number of folds which made the card manageable, easy to maintain, portable, handy and cost effective.

Entries of varying formats during an FGD in Patna, Patna guest house, Patna, Bihar

132

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Brain storming board during post-field analysis, CKS office, New Delhi

6. REFLECTIONS AND THE WAY

AHEAD

Contd ...

6.2. Looking at the larger picture

133

Dependency on verbal v/s written information:

Simran Chopra on the brain storming board during post field analysis, CKS office, New Delhi

Currently the information dissemination for the card is fragmented between information written by health care workers, specifically Nurses and verbal information given by ASHAs. Beneficiaries have no role of data engagement with respect to the card for written information which links back to the challenge of user connect and engagement and inclusion of a customized space for users to write in the card. Hence, verbal information, (which is a poor source for authentication and recollection of data) becomes a primary source of information reliance for beneficiaries.

Low literacy levels give rise

the information given by nurses

medium if linked to the context of

to problems revolving around

or visuals on walls or places that

culture. Culture and technology

understanding information in

frequently inhabited by the users.

go hand in hand are determinant

current print based formats.

of each otherâ&#x20AC;&#x2122;s existence. The most Also dissemination of information

viable way of technology being

Fields insights showed a crucial

from people of importance

considered as a new medium to be

need for availability of varied media

like doctors, important figures

integrated with the cultural context

and formats for a higher degree

involved in the health care and

of the location.

of clarity, data reinforcement and

policy making process or looking

user involvement. This issue is

at a better platform for creating a

likely to be addressed with cards

citizen engagement forum.

designed to bridge the gap by supporting written data through

Despite varying insights around

audio messages as a reminder of

technology, it is as an advantageous

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Cultures - Colloquial Language,

shows how these responses can be

Different cultures have different

entry in the system.

Media and Format:

utilised into being useful for data

ways in which they communicate, comprehend, register or even trust

The first row shows that incase an

information. This may be dependent

ID number could be provided in

on who is giving them information

the form of or involving the birth

(source), what media and format is

number of the child, it would be

it being communicated in (face to

easier to identify the child.

face, mobile, audio, text, visual and so on), what is the manner or tone

The second scenario shows that

of communication (instructional,

instead of asking for the name of

positive motivational, reverse

the last vaccination given, if the

psychology and so on) and the

mother was asked the area where

techniques used to reinforce that

it was given and this was recorded

same information.

somewhere, the name of the vaccination could be back tracked

Information flow and data

from this.

management are likely to improve if leveraged on the knowledge of these

Lastly, another way of knowing

local cultures of information and

last vaccination given might be

communication and account for

to link the number of visits made

them while designing a new system.

by the mother to the number of vaccinations given i.e. it might

From the field work, it was observed

enable the health worker to

that how at various instances

know where the child was in the

information was asked for by the

vaccination cycle. However this

health worker and what information

would only work if it the child has

in turn would be provided by the

received a vaccination on every visit

beneficiary. The table shows this

made along with the mother.

disconnect in information. It also

The nurse would

Identifying the child

enquire about the

name of the child. The nurse would

Identifying the last vaccination given

Identifying where the child is in the

immunization cycle

enquire about the name of the last

vaccination given. The nurse would

enquire about the name of the last

vaccination given.

The mother will remember

the birth order of the child i.e.

whether the child is her 1st born, 2nd born, 3rd born

However the mother would only remember the site on the body where the

vaccination had been given.

However, the mother would remember the number of

visits the mother has made.

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Different Users, Different

information in the record must

Expectations:

Information Needs, Different

echo what they tell mothers,

~ Reading the Information:

Nurses would like to be able to

this will enable better recall and

track the childâ&#x20AC;&#x2122;s immunization

The card has a critical role to play

improve the level of trust mothers

status and missed opportunities,

in improving interaction and

have on the nurses and the

and the growth trajectory at a

information flow between the

information itself. The difference

glance, engaging in quick filling

health providers and beneficiaries.

of necessities is also highlighted

of the information in the record.

This interaction is dependent on the

in the countries of the FGD.

Mothers would like information on

fact that the record is accessed

Health workers in Indonesia felt

next due date, what the vaccination

at different periods of time by

cards should have self explanatory

protects against, detailed child

different people being the health

information, not â&#x20AC;&#x153;too much

rearing, growth and danger signs

workers or the beneficiaries.

informationâ&#x20AC;? which may encourage

and role of the father so it involves

a lot of questions from parents.

reading at ease.

~ Different Users:

There are primary, secondary and tertiary users involved in the interactions with the record. The primary being the beneficiaries who engage with the record the most and utilize critical information

In Kenya and India, Nurses felt there was a need for the card to be a reference to enable them to do better health care counselling. ~ Who writes on the card?

The act of writing on the card is

from it. The secondary being the

always restricted to the health

health workers which are the nurses

workers giving the immunization.

and the mobilizers who fill the

This interaction is relevant to the

card, interpret the information and

beneficiaries as well, if they would

disseminate it to the beneficiaries

want to generate some information

involved. The tertiary are the people

or use the record as a reminder

that access the card momentarily

mechanism for themselves. But

for example teachers, relatives etc.

the health workers perceive it as a

The need of the each user is very

threat to the record as they think it

different and the card has to be an

can hamper the information.

answer to most of the questions involved. Nurses feel that the

~ Too much information: The beneficiaries look for

self explanatory visuals, with detailed information so that they can interpret the information themselves. Nurses are of the opinion this will encourage more questions which they would like to avoid because of limited time. Also the beneficiaries perceive growth as increase in weight and height, therefore they just look for that information progressing over months in the card.

Users from all locations during the FGDs; Bandung, Indonesia; Kisumu, Kenya and Patna, Bihar, India

136

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

~ Increased Validation,

Accountability, Commitment:

A challenge that the health cards are currently facing is validation and accountability of data. Field research indicated that the one of the primary failures of the card was the beneficiariesâ&#x20AC;&#x2122; lack of motivation/inspiration to retain or refer to the card as they were not able to either relate to or depend on the card emotionally or functionally. Reinforcement of data from higher authorities esp. for beneficiaries is another factor that the card failed to accomplish. Health workers facing data fudging/ manipulation, tracking missed vaccinations and validating the same with beneficiaries are areas which have yet to be addressed

Nurse during an FGD, Kisumu, Kenya

Improved interaction and

in the card which also lead to

Engagement with the record can be

system rather than just an artefact.

engagement:

enhanced through increasing and ingraining the interactions with the card. The same can be done through various methods employed within the system and the design of the record itself.

breakdowns in the card working as

Specifically in India, migration of mothers to deliver their babies in their native village results in creating complications for mothers in keeping a track of the childâ&#x20AC;&#x2122;s

137

It was seen that, without

major impact on how a health card

Emotional attachment to the

reinforcement of validation or

is viewed or retained in terms of

artifact owing to the sensitive

accountability for either user

its significance and potential for

nature of the record will lead to

sets, motivation or commitment

future use.

personal incentives. The parents

to not just preserve the card but

health trajectory with respect to the Nurse during an FGD, Kisumu, Kenya

health workers involved in his/her

will be motivated in the process

towards completion of a routine

Engagement of the record can be

to take care for the health record

immunization cycle is a challenge.

monitored and increased through

as there will be a suggestion of a

building an ecosystem that

target and an achievement. Thus

Cards with signatures, stamps

supports the interactions within the

instigating a sense of commitment

and stickers of the nurse giving

card through different times and

towards the record and the health

a particular vaccination are

circumstances. These interactions

care system.

more likely to address issues

can be built in the record through

around ensuring validation or

elaborately thought activities which

This is a step wise process that has

accountability. It also tackled

will have to be sequenced and

to built into the record to have an

the challenge of information

placed to increase the relationship

effective ecosystem to increase

being validated from a higher

of the parents with the card. Also

engagement with the card. If there

authority for the beneficiaries.

leading to a higher dependency

is an ecosystem to support the

Cards with pledges, photographs

on the card to gather health care

interactions effectively it will lead to

or information on vaccine

information rather than depending

a proficient health care system.

benefits are likely to generate

on the health care professionals.

more commitment, a sense of

The interaction with the artifact

accomplishment and motivation

can be initiated through various

for preservation for beneficiaries

associations and activities.

immunization cycle.

and act as a strong driver for them to understand their responsibility

These can help build validation and

Insights revealed the need of the

towards routine immunizations.

accountability into the information

Health workers signing and fill their names in the immunization schedule which held them accountable by mothers in case of doubts and questions or something going wrong.

artifact. The act of holding the Integrating and augmentation

parent and the health worker

of motivation for preservation,

accountable for the childâ&#x20AC;&#x2122;s health

accomplishment, accountability

through the record will increase

and validation in the card for both

attachment towards the record.

users sets is most likely to have a

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

~ Space for localization and personalisation:

The interactions involving personalization are really necessary in the process of bonding with the beneficiaries. They are the primary caregivers and need to be able to relate to the record. If you allow them to take ownership of the contents of the record, they can be better associated with the immunization process as a whole. The record can be created to offer different interactions and opportunities to the beneficiaries to form personal connections. Interactions like signatures or putting down notes in the records itself will offer a higher level of ownership, thus leading to better a richer engagement. Interlinking the importance of the immunization process to that of a personal responsibility will generate newer responses and probabilities. The space provided in the card for localization can even help the health care professionals in retaining information in the card

even though they do not have a

strong personal connect it forms

relevant section for the same. The

with the beneficiaries.

practice of localization will also help retain the emotional bond with

The records can also bring about

parents as suggested earlier.

a change in how the beneficiaries interact with the record as of now

The essence of customization and

by bringing an element of Do -It-

localization can also be enhanced

Yourself (DIY). There is already a

by giving the beneficiaries the

need projected by the beneficiaries

ability to incorporate the things of

to become self reliant in

their liking in the record for e.g.

understanding the growth of their

religious symbols, and stickers can

child. The component of DIY can

be incorporated by them. Religious

facilitate such a scenario increasing

symbology can help retain the card

use and engagement with the card.

for longer as the artifact increases in importance and can avail the

(Picture on the left) FGD in Kisumu with nurses, Kenya; (Picture on the right) FGD in Bandung, Indonesia

FGD with mothers, Kisumu, Kenya

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

identity and health status tracking,

radically impact coverage.

health-care and nutrition related

Here are a few questions which

counselling and behaviour change

focus on what the card has a

communication (BCC).

potential to do or factors it could address ~ What kind of a record can

7. RECOMMENDATIONS FOR

DESIGN 7.1. Concerns for validation

7.1.1 The record as a system and in a system The current definition of the ‘health record’ challenge may be restrictive and we are likely to come up with incremental solutions if we repeatedly define the problem as it has always been defined. It is possible to redefine the problem and craft a more appropriate scoping of the challenge. For now this nebulous challenge can be placed at the intersection of issues affecting different user sets such as beneficiaries, front-line health-workers and the backend health system. These issues are largely related to data entry and retrieval, patient

It is also interesting to note that the

facilitate an improved rapport and

record is the only tangible artifact

engagement between beneficiaries

that is retained with the beneficiary

and the routine immunizations?

and therefore possibly the only ‘identifier of the service’ that is in

~ Can the record become strongly

closest proximity of the beneficiary

synonymous with or an icon of sorts

family. It is therefore even more

of the child’s health and growth

critical for it to signify the essence

such that beneficiary communities

of the service i.e. child protection,

invariably associate the record with

health and growth and act as a

child’s health?

bridge between the beneficiary and the health provider.

~ Can the record instill in the beneficiary the desire and behaviour

Furthermore the proximity it

that prioritizes the long term goal of

occupies with the beneficiary makes

the health of the child, within which

it a key vehicle for behavioural

the immunization process is viewed

change communication.

as being only an aspect of, rather than the sole objective?

Re-designing the health record provides us with an opportunity to,

~ Does this artefact have the

step back and, radically re-imagine

potential to enable the introduction

the role it ‘can’ play in the public

of a feedback loop, from the

health system. In response to the

beneficiaries and health-worker to

loosely framed challenge (above),

the health system, such that there is

it would be important to develop a

smoother flow of health data as well

series of different hypotheses on the

as feedback on the service?

‘kinds’ of health record that could

141

~ Can this record link with other

an interplay of aural, visual and

identity and public service artefacts

textual media.

that the beneficiary communities retain and value; such that it

Additionally user engagement

becomes a more critical identifier of

with the record can be increased

the individual and the family?

by designing a multi-modal format that enable a series of interactions

~ Can the record serve as the

through different times and

anchor for all exchange of health

circumstances in the information

information between the health

environment of beneficiaries. These

provider and the beneficiary?

interactions can be built in the record through elaborately thought

From an information design

activities which will have to be

perspective, the health record

sequenced and aimed at increasing

has the potential to occupy a

the relationship of the parents with

more critical role in enabling the

the record.

nurse to link the baby with the card, thus reducing judgment based decision making, whereas with respect to providing critical health care information the health record is expected to play a dual role: assisting and verbal, since the beneficiary is more reliant on and trusting of verbal counselling. With respect to dissemination of vital health care information, there is an opportunity to align it with local knowledge sharing cultures. Key information can then be rendered in a multi-modal format;

After a discussion with Divya, a sketch of the nexus with health information (the card) at the centre, with multiple axes of healthcare, diagnosis, decision making and patient identity crossing it, CKS office, New Delhi

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

An ANM filling in details from the card into her register, Parsa Bazaar, Patna, Bihar

143

information or a due date stamp

For instance with respect to the

as designed to be functional

given by a person of authority can

Unique ID, the card could attempt

even in the face of limiting field

provide the needed push to the

to capture information that can

challenges. This will help bridge the

beneficiaries to routinely adhere

function as secondary or passive

gap between desired protocols and

to the vaccination cycle. Similarly

identifiers, either in the form

actual execution on field.

visually arresting reminder

of a unique identification code,

methods can be designed into the

additional backup data field or

record. Thus fulfilling a broader

through the provision of a blank

perspective than just using the

space for localized information.

record as a passive artefact. Safety Checks within the Card:

Similarly the due-date data field could be designed in way that

The health record as a system

ensures visibility at any given

needs to incorporate information

time that the user is reading the

redundancies through overlaps

record, regardless of the manner in

in order to eliminate information

which the record has been folded

leakages. The presence of safety

or held. If such safety nets are built

Currently the record does not

checks within the health record as

into the fundamental logic of the

perform the function of serving as a

a system is a critical, considering

card, then it will be equipped to

mnemonic reminder of the service

the logistical pressure that the

operate effectively in a variety of

or the next due date. The record

system presently exerts upon the

field scenarios. It will also increase

must be able to remind beneficiaries

health worker. The sheer number

dependency on the record to gather

about the next due date, in advance

of beneficiaries that have to be

health care information rather than

and then reinforce on the day,

serviced within a short span of time

depending wholly on the health

alongside providing a sense of

give rise to the scope of process

care professionals.

where they are placed in the entire

errors or process deviations. In

vaccination cycle.

order to reduce this the health

In addition to this, introducing

record must seek to reinforce

additional security layers to the

The proposed reminder mechanism

critical health care information that

information collected in the

can be designed as being a bridge

is currently designated as falling

card can aid the health workers

between audio and visual. An

within the core responsibility of the

immensely since the system is

aural message as a reminder of the

health care provider.

then geared for efficiency as well

Reminder and Recall:

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Behavioural Change:

Without being restricted to only

better decision making. Having

immunization, the record can later

this continuous data flow into the

how human behaviors reinforce

transit into integrating information

district and state levels can facilitate

dissemination about health,

the system to create strategies

nutrition and sanitation.

around how better to respond to

The design can even leverage on responsibility. For instance, incorporating the signature or stamp of the health worker as well as the beneficiary after the act of vaccination, can encourage perceptions of accountability and accomplishment as well as reinforce the significance of vaccination. Features that can enable the parent to make the record their own, like a health log or photographs etc. can

Acquiring User Feedback:

specific health vulnerabilities of different patient sets or people

Once this is achieved, it makes it

across different regions. At an

even more imperative to acquire

even higher level it can inform the

user feedback continuously

creation of an ecosystem that can

from beneficiaries, in order

invite cross sectoral investments to

to incorporate incremental

serve specific health needs of

but dynamic improvements in

beneficiary populations.

health system processes. While the record in its current form

These and other hitherto

which is an incentive for retention.

may not be designed to capture

unimagined potentialities can help

beneficiary feedback, an appropriate

us re-think not only the critical

The parents may be motivated to

redesigning of the record and the

role of the card within the larger

information transaction protocol,

system but also envision the card as

may enable us to do so. This will

a system in itself. The record can be

enable even the front-line layer to

seen as acting as a self sustaining

initiate micro reforms and tweaks

entity, an icon of change or a service

within its manner of functioning to

identifier that can pave the way for

ensure optimized process efficiency.

upgrading the entire system.

aid in building emotional value;

preserve the health record due to the suggestive presence of a target and an achievement. Additionally, the act of holding the parent and the health worker accountable for the childâ&#x20AC;&#x2122;s health through the record could radically change perceptions and thereby practices around record retention and use. Once the record has gained mindspace and traction, it can then address a larger concern, that of the overall development of both the mother and the child.

Health Data Flow and Decision Making:

From a systemic perspective the card should have the potential to ease the collation of patient and child data and flow it back into the system, in order to enable

A used Bihar healthcard in a deplorable state of damage, showing basic flaws in the card. Phulwari Sharif, Patna, Bihar

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

A nurse in an FGD speaking of the importance of healthcare information, Kisumu, Kenya

147 implemented at a universal health

path and strategic directions.

and policy level.

~ Able to critique the crowdsourcing approach and explore new

The two days involved reviewing

public information challenge areas

field responses on these new design

where such an approach could be

records, reviewing, evaluating,

thought of and applied

voting and discussing the different propositions designers have made, plotting them on parameters of

7. RECOMMENDATIONS for

DESIGN

Contd ...

7.2. Systems integration

Key drivers behind card choices:

Amongst the cards presented, the

emotional v/s functional value,

jury preferred cards that employed

retroactive data entry, transition

simplicity in the layout, provided

to digital technology followed

clarity of information and were

by extensive discussions on

concise in communicating critical

timeframes and feasibility of

information. Flexibility with respect

7.2.1. Insights from the London

implementation of the design

to the incorporation of additional

workshop

propositions. The day consisted of

information fields came across as a

An expert jury of designers, health

negative voting and positive voting

valuable criteria of evaluation.

professionals and policy makers from UNICEF, WHO, BMGF, GAVI, IxDA and CKS met to evaluate the record entries, at the last leg of the project. Representatives from

exercises, individual voting and collective voting, brainstorming

Many jury members also preferred

sessions, structured as well as

cards that had the ability in their

free-flowing conversations with the

design to adapt to progressive

entries as stimulus such that the

technology. Cards that clearly and

judges were:

effectively communicated the entire

were unable to attend.

~ Reviewing the same entries

vaccination cycle to the beneficiary,

The agenda of this jury was two

spending time improving their own

Grameen and Ministry of Sudan,

fold - evaluating and awarding the strongest design entries in various categories and discussing parameters for design recommendations that could be

through different lenses and judgement so they could identify the strongest records by the end of the session. ~ Able to reflect on the design stimulus for charting out the future

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

The jury evaluation in progress, London, United Kingdom

149

~ A list of critical data fields

production resources essential for

and responses to the vast range of

(minimum data-set) that the health

upgrading / redesigning a countryâ&#x20AC;&#x2122;s

systemic problems as identified

record must look at collecting, in

health record.

so far. However at a process level several suggestions were made

order to ensure that data collected is future ready with respect to

Additionally this online resource

with respect to engaging with the

introduction of newer health

can also be equipped with various

solutions to be crowdsourced.

service interventions.

graphic media material which can be crowd sourced through design

~ A strategic-value dimension on

competitions. The core significant

what the role and place of the card

feature of the resource will be a

should be within the system

library of health record designs that can be accessed online, thus

~ Digital compliance criteria

providing countries with the option to pick and choose the design that

~ (Record) media and format

is best suited to their context. This

decisioning based on the

online repository can first engage

communication and information

with the challenge of providing

cultures across societies

comprehensive support to the process of immunization, which

FGD with ANMs in progress, CKS Patna guest house, Patna, Bihar

~ Synergies with how WHO or

in the future can also be scaled up

Systems Integration:

UNICEF may envision a purely

to respond to larger questions that

digital future that does not involve

impact the public health ecology.

the discussion transitioned from

a hard-copy record and in the

Over the course of the workshop, the health records and its role in the system into a larger discussion of systemic reforms / processes that need to be established to facilitate more informed decision making in the future. Judges contemplated an architecture of different types of guidelines that should be developed for countries:

build up to that we create some

Another critical feature could

milestones along the way to a

be a repository of best practices/

complete eclipse to the record.

measures as have been observed as being successful with respect to

Consensus was also achieved with

health data to help countries make

respect to the idea of creating an

informed decision around health

integrated backend resource system

data management. Through the

for countries. This will consist of

online resource system, there is an

an aggregation of design and local

opportunity to elicit participation

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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

The Crowdsourcing Process:

are selected and the designers

There was consensus on having

are encouraged to refine and re-

inter disciplinary teams of

submit their entries in view of field

designers and public health experts

responses. Individual countries

to work together to conceptualize

can then consider contracting the

solutions. It was also recommended

winners, with the contest becoming

that a midway be sought between a

a vehicle that aligns national health

completely open ended process and

systems with local top design talent.

an invitations only approach as a

This talent can be deployed on

means of controlling quality.

other health and public information design challenges.

As a process suggestion the jury was of the view that a systematic, 2

It was also recommended that

tiered field research process should

pro-active decision makers from

be done. In the first visit a brief

ministries of health of different

ethnographic research is conducted

emerging economies be involved

across 3 to 5 countries to gather

in the final jury panel, so as to lend

context specific data that feeds into

contextual appropriateness. This

a better definition of the challenge

will ensure that solutions generated

itself. This design challenge is then

have been viewed through multi

opened up to the larger design and

disciplinary viewpoints and can

public health community along

be adapted to real-time country

with granular field data which

specific scenarios.

provides participants a clearer understanding of the nature of real time challenges. Design ideas are crowd-sourced, dynamically downselected and a smaller set of 35 concept ideas are taken back to field for testing. The set of top 10 design propositions

FGDs in progress with beneficiaries, Kisumu, Kenya

151 be easily recollected. Along with

tabular vertical format, without

that a photograph of the child with

cross referencing would be easier

family is also a good idea as it could

for parents to follow; to monitor

help the health worker in correct

height/weight of their child.

identification or if the card got lost. ~ The immunization schedule could

7. RECOMMENDATIONS for

DESIGN

~ It would be an interesting

be demarcated with drops/needles

thought to incorporate the card in

depending on the vaccination to be

something day to day of the usersâ&#x20AC;&#x2122;

given. Alongside basic information

lives, even if its a part of it. This

on certain vaccinations etc. could

leads to the idea of splitting the

be provided.

card, wherein one part is portable

Contd ...

7.3. Final design recommendations

and small, handy and can be carried

~ Healthcare information could be

to the PHC - something which can

in detail, with real-time yet simple

be replaced easily and has a small

illustrations, avoiding icons or

shelf life. The more detailed card

abstract forms of any kind.

with healthcare information is the The London workshop led to a revamp of looking at the design recommendations that the team had drafted. Also, the unofficial trip to interiors of Bihar made me understand the context of health better and indirectly fed into the second level of design recommendations that developed. ~ Some level of identifier other than the parentsâ&#x20AC;&#x2122; name could be developed; something that could

other half which can be kept at

~ The format of the card could be

home and even if the first part is

made compact, handy and easy to

lost, the parents can refer to this

maintain; something like a booklet

other part.

(as said by many usersâ&#x20AC;&#x2122; who wanted health cards like the private health

~ An extension of the card could

clinics and hospitals).

be an easy to digitise transfer format, so that data feeding for the

~ The card cover and back could be

operators becomes more fool proof.

protected with a plastic covering which would prevent spoilage.

~ As suggested several times, and on field, the immunization schedule

~ As a reminder and recall system,

and growth chart could be linked.

a safety net of a sticker system could

~ Also, in place of just a graph, a

be built into the card, which could

152

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

focus on the next due date being stamped somewhere towards the end of the card. ~ Colors was an ambiguous topic however, some sort of color coding in the immunization table might help. Also the background of the card could be something light or pale making it easier for people to read and write on it and with which they could associate health. ~ Additional categories of allergies, notes, blood group could be added to the card. ~ Maybe to increase the emotional connect, a certificate of authentication and praise could be added in the card which would be given (like a mastersâ&#x20AC;&#x2122; or graduate certificate) as an accomplishment to parents who have fully vaccinated their child. ~ To prevent data from being fudged, some stamping or signature mechanism of the Nurses/ANMs could be incorporated in the immunization schedule of the card.

An entry which had a creative imuunization schedule during an FGD, Patna, Bihar

153

7. RECOMMENDATIONS for

DESIGN 7.4. Design criteria

design CRITERIA Easy identification of child Contd ... Content Structuring Milestones

Based on discussions with team at CKS, drafting design recommendations with them,

Easy navigation Reminder/Recall System

insights from the London Workshop and feedback from my guide, these were the design criteria that seemed appropriate to act as a bridge to the next phase of the project ~ Designing the card.

Skeletal framework of the design crieria and how they connect with each other.

Manageable, Portable, & Handy format

Economical

Material sustainibility (for 3 years at least) Digital transfer made easy

Preservation of card > Preservation of data

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Design criteria on the brainstorming board, National Institute of Design (NID)

155 8. CONCLUSION FOR VOLUME ONE

and Introduction to Volume two

As stated earlier, volume one of this project dealt with design research. It was six months of intense field work, understanding the criticalities and technicalities of design research, the social context and user behaviour; conducting discussions, personal interviews, and visual mapping of a city were a few more attributes to research that opened my eyes to a whole new diaspora of things. The reason for me having taken this project was to delve into the realm of design research and see how it fits into the world of design. My learning from this experience has been great, not only as a designer but as a human being.

Moving onto the second phase, design, volume two will look at aspects of design and the ways in which the research would feed into my design sensibilities in terms of image making, systems thinking content generation and post production methodology; finally leading to the creation of a better, improved health card template. So to get a better understanding of the entire project, I would encourage the reader to go through the second volume as well.

Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014

Colophon: The document is set in A4 size (closed size); landscape format. This document uses: Warnock Pro Light and Warnock Pro Bold for the titles Warnock Pro Italic | Warnock Pro Bold | Din Bold | 8.5pt. | 13 pt. leading, for sub-headings Warnock Pro Regular | 8.5pt. | 13 pt. leading, for the body text Din Bold | 8 pt. for the photography credits. The Warnock font family has been designed by Robert Slimbach. The FF-DIN (DIN) font family is based on the original German Standards Organization font number DIN 1451, which was commissioned for use in German public administration and signage. FF-DIN, drawn by Albert-Jan Pool, took the original DIN 1451 design and revived it for digital typesetting. Adobe InDesign CS5 was used for typesetting and layout of this document while Adobe Photoshop CS5 and Adobe Lightroom CS5 were used to edit the photographs.

Records for Life: Re-evaluation and Re-design of a Healthcard Framework | Vol. I