UX Research and Design | Rural Healthcare 

Team Members: Shashwat Sanghavi, Rahul Patel, Anmol Anubhai

Role: Founder, UX Researcher & Designer. Used a combination of qualitative research methods such as contextual inquiry, ethnographic study sessions, culture probe kits, semi - structured interviews and focus groups. Worked with local folk artists to design content and prototypes. Worked on using machine learning (polynomial regression) to build the epidemic predictor system (an extension of this project).

Mentors: Mr. Ravin Sanghvi, Prof. Mehul Raval

Distinguished Client: Barakat Bundle (http://barakatbundle.org/)

Duration: Dec. 2015 - May 2015

This startup was incubated at Venture Studio, Ahmedabad

Website: http://kahinee.in/

We first began by making a chart of all our stakeholders in this space of rural healthcare in India. You can see a complete list of all our stakeholders below.

Expert Interviews

Next, we made a list of distinguished surgeons, cancer specialists and general physicians who were offering their services then in Gujarat, India. We conducted expert interviews with them. Below listed are some of our expert interview findings.

How do they decide what kind of machines to invest in?

• They generally decide on their own
  
• At times it is difficult. During such times they seek advice from consultants who suggest the type of machines that will suit their needs the best

Do patients have to wait in long queues?

• Prior appointment is required at her hospital
  
• Small waiting queues since it is a private hospital 

What kind of patients does she come across? 

• She comes across two types of patients. Some are very well read while some are unable to comprehend medical terms because of being illiterate
  

How does she explain the treatment needed to a patient who is unable to comprehend?

• She uses a variety of tools such as pictures and short videos to explain the problem
  

Do hospitals/clinics need to earn any certificates/follow a set of regulations?

• There are certain regulations framed by the National Accreditation Board for Hospitals & Healthcare Provider (NABH). All hospitals are expected to obey the same.
  

Are there any regular cleanliness checks at her hospital?

•  There are regular hygiene checks that are carried out by the manager 
  

Do patients often need a second opinion? Why?

• Some cases are fragile and require a second opinion. 
  
• Since the diagnosis process for certain cases can be complex in nature, it may often require a team of experts to diagnose the medical problem successfully  

What types of diagnosis tests does her hospital offer? How long does it take for the patient to get his reports?

• Her hospital offers tests such as sonography, mammography, elastography and biopsy 
  
• The turnaround time of some of these tests is between 12 - 24 hours while for some tests that require studying the patient's tissue it may take upto 5 -6 days

• Public Health Centers (PHC) cannot diagnose cancer. PHC can only do limited tests.
  
• PHCs send patients to Civil Hospitals in the cities after which they are often referred to the MP Shah Specialized Hospital
  
• Doctors are afraid of breaking bad news to patients
• Medical camps are organized by NGOs, Corporates, individuals and government colleges or hospitals
  
• Educated individuals often exploit the illiterate by asking them to pay extra money in medical camps
  
• Anxiety, Depression and Dementia are the major problems faced by our elderly currently
  
• There is a dire need of instruments that can detect various psychological disorders 
  
• No psychiatric treatment is available at the PHC level
  
• Standard guidelines for psychiatric treatment (APA) need to be followed
  
• Helplines aren’t functional 24x7

We conducted interviews with multiple doctors, microbiologists, PHC and CHC doctors. In the next section, I give you a quick glimpse of some of our interviews

Interviews and Contextual Inquiry | Local Village Doctors 

Next, we went to remote villages of Gujarat and conducted contextual inquiry as well as semi structured interviews with a number of medical professionals who practice there. Below listed are some of our findings

• They refuse to give up tobacco because of not being fully aware of tobacco's negative effects on their health
  
• All doctors in the village are well educated and try their best to offer best services. However, patients refuse to come to the clinic because of community pressure
  
• Refused to comment on child marriages and problems that young mothers face. He told us that the women are not allowed to take their own health related decisions. Their husbands and in-laws decide what is best for them. This causes issues such as being anemic because of multiple pregnancies at a young age 

• 1 Or 2 cases of mouth cancer whom he had referred to the Civil Hospital
  
• Multiple child marriage cases and mothers who are as young as age 15
  
• Young girls are not explained the importance of family planning and taking contraceptive pills
  
• He owns a variety of latest tools and gadgets
  
• He owns a no touch thermometer, ECG machine, glucometer and a variety of other instruments
  
• He owns a personal computer which he uses to look up treatments of new ailments
• He is on plexus MD (doctors' online network) 
  
• Showed interest in using a device to detect oral cancer

Ethnographic Study Sessions & Contextual Inquiry

We sat in government hospital lobbies and conducted multiple ethnographic study sessions there. We also talked to a few patients who had come to the city from their villages in order to receive their treatment. In the next section, I would like to share our team's ethnographic study session findings.

Some of our Ethnographic Study & Contextual Inquiry Session Notes

• 40 to 50 people in lobby 1 outside OPD 
  
• Majority of patients above 20 
  
• Patients are scared because of being unable to read their files and comprehend the medical terms
• Patients ask each other while waiting in the lobby if they knew how to comprehend the medical terms and if someone can help them with their files
• People do not know where they should go to get their reports and medicines 
  
• Each patient had on an average 2-3 accomplice 
  
• Only the cases files were being transferred and the patient was nowhere to be seen a couple of times 
  
• Highly effective cleaning - Every 15 to 20 minutes sweeping and mopping carried out 
  
• People discuss medicines, waiting time and the arrangements that they had made to be able to afford the treatment
  
• Many were quiet and looked perplexed 
  
• Improper ambient conditions. No natural light in lobby outside OPD 
  

Learnings and Insights

We learnt the following from our study:

• Women are pressurized to marry at the early age of 10 in these remote parts. They are pressurized to give birth to a son as soon as they hit puberty. This leads to frequent pregnancies that in turn causes excessive blood loss and deterioration of health. Many women start suffering from anaemia
  
• Doctors are concerned about addiction to substances such as tobacco. They stress the importance for increasing early awareness of addictive substances and their side effects
  
• Illiterate patients find it difficult to understand the doctor's diagnoses. They ask to be shown pictures or be given another explanation in simpler language in order to understand the doctor better
  
• People believe in superstitions that prevent them from seeking help from local clinics and doctors. They instead prefer to go to the 'witch doctor' (locally known as the 'Bhuva'). For example, they believe that a child suffering from measles is 'possessed' and cannot be taken to a hospital. They believe that only the 'witch doctor' can heal him. In such cases this causes further deterioration of the child's health because of doctors not being able to begin the treatment on time. 
  
• Women are not allowed to take decisions on matters concerning their own personal health. Their in-laws and husbands play a vital role in taking their decisions. 
  
• Internet accessibility is poor in rural India.
  
• Existing PHCs (Primary Healthcare Centers) have the necessary resources. However, they tend to run out of them easily. 
• There is a huge gap between hygiene, disease rates, health awareness, doctor expertise and treatment facilities between urban and rural populations
• The rural areas have high incidences of diseases arising from or related to poor hygiene, tobacco addiction, early marriages and child-births, lack of family planning, poor child-care and lack of timely treatment
• Due to illiteracy and lack of resources, rural people have resistance to formal methods of health education
• Lack of awareness often leads a larger number of rural people into psychological disorders arising out of some cirtical diseases

Ideation

As a part of our Ideation process, we sketched a variety of solutions in the beginning.

Solution Proposed and Initial Design

Kahinee intends to improve healthcare awareness by delivering audio content that does not require internet access. Audio is preferred as a mode for communication as it does not require the user to be literate in order to understand the content. The print mode on the other hand requires the person to be literate and leaves room for miscommunication. The content is designed keeping in mind the rural citizens, their needs, likes and dislikes. The content is designed in their local language. The content's key focus is to educate the citizens about maternal healthcare issues such as family planning, taking iron tablets to battle anaemia etc. 

We invited local folk artists and with their help composed short skits as well as folk music on these topics. We made sure that we use relatable characters and simple language. We could also effectively highlight the disadvantages of not following certain healthcare guidelines through this simple story telling approach. We designed content on a variety of topics using the help of local artists, community health workers and doctors. We then went back to the villages and conducted multiple test iterations in order to gauge understandability as well as effectiveness of the content. We conducted interviews, surveys and focus groups in order to understand their take on the system. We used the 'Wizard of Oz' technique in the beginning when we simulated the idea of the mobile system playing content on the health topic a user chose using his simple mobile phone. 

Pilot Test with Barakat Bundle

Inspired by the Finnish Baby Box,  the startup (incubated at Harvard University) - Barakat Bundle provides a curated bundle of life-saving solutions paired with desired maternal and baby care items to support expectant mothers during delivery and infant care. Barakat Bundle wanted to incorporate audio functionality to supplement their existing pictorial informational pamphlets which provide instructions on correct usage of provided items and general maternal and child health issues. 

Barakat Bundle worked in collaboration with the Indian Institute of Public Health (IIPH) and Society for Education Welfare and Action (SEWA) Rural. Barakat Bundle decided to incorporate simple push-button audio technology into its pictorial information pamphlets. When pressed, the buttons play a pre-recorded content that guides the user through the pictorial content in order to provide them with the Kahinee phone number using which they can connect to the Kahinee CDM for additional information. Kahinee CDM is a menu based helpline. It asks the user to enter a digit related to the content which they desire to listen. 

The motivational reason to incorporate audio technology into the pictorial pamphlets was to increase comprehension of the low-literacy rural citizens and reduce the likelihood of miscommunication as well as confusion. Kahinee assisted Barakat Bundle to procure press button based audio modules, record the content and embed audio content in those modules. Kahinee also played a critical role in adapting the direct health information into audio dramas. The rationale for this two-pronged approach was to assess comprehension, acceptance, and recall of direct information versus entertainment approach.The Kahinee CDM was used to impart these audio based content.

During baseline assessment, Barakat Bundle, Kahinee, and IIPH conducted in-depth interviews to pretest the pictorial information pamphlets and focus groups which included feedback on the pictorial information pamphlets as well as the audio content and the Kahinee CDM experience. A detailed questionnaire focusing on a variety of crucial points was prepared.