Thank you Anjuli Dasika, Jackie Wolf, and Nick Reid for sharing your story.
Prior to arriving in India for the University of Michigan’s Global Information Engagement Program, our team – a UX designer, public health specialist, and technical developer – had spent four months building a relationship with a health technology firm in Kolkata. Our goal was to develop a mobile tool for Community Health Workers (CHWs) in West Bengal to support communication and problem-solving during medical home visits. During conversations with our Indian partners, our team’s objective was to work with the CHWs and design something that was useful, easy-to-use, and could be well-integrated into their normal workflow within community settings. To prepare for extensive fieldwork, we conducted literature searches on Indian CHWs while in Ann Arbor, to better understand the context and the workflow gaps for these health workers.
It was one thing to dream up designs in Ann Arbor using our research on CHWs as a foundation for these designs and quite another to be on the ground in India, learning about the CHWs’ context in West Bengal as we proceeded with our project.
Our project partners in Kolkata who oversaw the operations of these CHWs and strongly favored a technology implementation for healthcare delivery had tried to provide us with descriptions of the CHWs, their locations, and their roles in providing health services to low-resource communities in rural areas. Although this information gave us a starting point, we believed that our design process would benefit from some ethnographic field research where we could observe the CHWs’ work and speak to them in person. We felt that this, combined with some lightweight usability testing of our tool, would be the focal point of our time in India.
Literature versus the Real-World
In those two months, we recognized that CHWs are not all the same, in either the work they do or the challenges they face in their communities. Much of the existing literature on health workers elucidates that experience, education level, and training are “highly variable” based on the community and region of India. However, through our interviews with CHWs in West Bengal, we were able to explore that variability even further and get a richer perspective on what those differences actually meant for their workflow.
Drawing on our field findings, we took three key aspects into consideration for the CHWs’ mobile tool, calling them the “Three Literacies”:
- Our project partners suggested that most of their CHWs understood English. However, the women frequently told our team (via a translator) that they felt most comfortable reading and speaking Bengali. One CHW specifically mentioned that she would prefer that the electronic forms (in the mobile device) were in both English and Bengali, because “all of [their] papers forms were that way.”
- Our project partners remained torn on whether to spend money on sleek dependable Android touch screen phones or to purchase the less expensive (and less reliable) i-Ball tablets for the CHWs. As we discovered through usability tests and interviews, this decision was irrelevant, as the women were equally uncomfortable with both. Most CHWs were unaccustomed to typing on a computer, let alone using touchscreen devices. It was clear just by the way they handled the devices that the CHWs were afraid something would break, despite our reassurances. Making users comfortable enough to interact with the device, in addition to understanding the content itself, is critical in a mobile health program implementation.
- Something our team had already gleaned from our literature review in Ann Arbor was the immense variation in CHWs’ experience levels and health knowledge. This information was reinforced in our interviews: the amount of experience CHWs had in their communities ranged from 2 months to 8 years. A number of them could recognize medical acronyms such as “ANC,” but then could not identify this word in our electronic survey when it was written as “antenatal care.” This knowledge of medical terminology also varied greatly among the CHWs we interviewed.
Understanding the Context
Throughout our field experience, the assumptions we brought into the project were challenged and refined. We learned that the significant time, resource, and staff constraints within our partner organization made arranging field visits with the CHWs difficult. However, as our team navigated these obstacles, we saw the enormous opportunity we had to fill a gap in existing research on Indian CHWs.
To better understand how to tailor a mobile tool to their realities, we focused on the individual narratives that the CHWs had about their frustrations in managing situations they were not trained to address and the physical and political obstacles that prevented them from assuring timely healthcare to patients. Beyond taking note of the small difficulties that the CHWs had in navigating through the mobile application’s workflow, we noted each screen glare issue, each question about specific words, each button press as factors that would further hinder the CHWs in working with community members.
What we needed to do, beyond relying on literature, was to apply the CHWs’ experiences and take their feedback into consideration in order to design a mobile tool that would enhance the work that they do, even given the obstacles they face in their environments. Prior to this experience the three of us were already advocates for how important embedded work is for creating useful tools, but the time we spent in West Bengal working and listening to the CHWs reinforced that there is no substitute for first-hand contextual inquiry and ethnographic research.
Anjuli, Jackie, and Nick are currently graduate students at the University of Michigan.