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 project’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:
COPYRIGHT STATEMENT
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 Institute’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 Š 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 Š 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 ‘labour’ - 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 I’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
22
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
29
3.8. Cue card stimulus for focus group discussions 3.10. Process constraints
38
CONTENTS: VOL. I
61
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
7
9. CONCEPTUALISATION
8
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
21
10.1. Content Categories
10.2. Content Architecture
11. FINAL PROPOSED HEALTHCARD FRAMEWORK
37
12. CONCLUSION
65
13. REFERENCES
68
14. ANNEXURE
69
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 winners’ certificate 14.5. Stakeholders and Key players
15. CREDITS
96
A rickshaw ride along the Boring Road, Patna, Bihar
Brainstorming sessions at CKS office, New Delhi
22
1.
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 patients’ 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 child’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
24
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 ‘Health Record
from a traditional, paper-based
Redesign’ 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 –
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
1.
contest’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
26
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 team’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)
30
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 country’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.
31
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 country’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
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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 – 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, Bihar’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 Bihar’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).
34
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
37
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 Indonesia’s third largest city
~ Tuberculosis (TB)
is divided into 26 sub districts, 139
Most of Bandung’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
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Anupriya Arvind | PGDPD Graphic Design | Diploma Project | Records for Life | 2014
3.
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.
01
Secondary Research 4 weeks | 6 expert interviews, Literature review and detailed location selection process
02
Design Entries Technical Evaluation 1.5 weeks | Creating an online evaluation form for designers and health experts for first level of entries evaluation.
03
Evaluation Process Evaluation Process 2 weeks | Evaluating entries and downselection, Developing cue cards
04
Research Design Creating protocol guides, User Profiling
05
Focus Group Testing of Prototypes 1.5 weeks | FGDs, Testing, Validation
06
Data Synthesis and Analysis 2 weeks | Field Insights, Analysis, Data linkages, Theme creation
07
Expert Evaluation Jury 2 weeks | Compilation of Data, Workshop guide, Judging & evaluation criterias
08
Strategic Design Recommendations 3 weeks | Report writing, Drafting recommendations
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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 20’s to late 40’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:
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
years
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
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
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
Family
years
Graduate
Joint/
Nuclear Family
protected as part of the consent form signed by them to particpiate in the discussion.
Children
Children
years
years
above
3 and
above
3 and
2-5
1-3
2-4
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
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
45
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
46
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.
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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
50
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
52
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
53
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.
54
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.
3.
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
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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
57
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
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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,
3.
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
63
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
64
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
71
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
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.
5.
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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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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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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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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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
register to that time-period.
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
6.
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
140
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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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
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