Findings from the Field: Second Field Test in Balichak

For our field visit on June 12, 2015, our team went to the Bhai Nagar community to interview and conduct second-round field-testing of the KOL-Health App with two ASHA workers. We had a few major objectives for testing this week, including:

  • Understanding health workers’ current door-to-door activities in communities through a series of interview questions.
  • Assessing health workers’ current level of health and technology literacy through interview questions and KOL-Health App testing scenarios
  • Evaluating the health workers’ competence and self-efficacy in navigating different features of the KOL-Health App
  • Determining improvements that need to be made to the App, to better support health workers’ roles and standardize health data collection activities in the field

Our testing approach included a combination of key informant interviews with two ASHA workers from the Bhai Nagar community, followed by a run-through of a few specific tasks within the KOL-Health App to determine how the health workers interacted with the application, and where they ran into difficulties with using it.

Learning about the ASHAs

ASHA workers from Bhai Nagar fill out the Pregnant Mother Survey in the KOL-Health App

Caring for women, children and infants has become the primary responsibility of health workers, ASHA workers in particular, throughout India. For the ASHAs working in Bhai Nagar, they described that the maternal-child health work they do is not only for the pregnant woman’s knowledge, but “for her entire family as well.” Although the first 30 minutes of one of these visits is spent taking vitals of the pregnant woman, the ASHA worker takes the rest of the 2.5 hour period to raise the household’s awareness around: pregnancy complications the mother may have, proper nutrition for the mother and children, vitamin and nutritional supplementation the woman needs, and immunizations the children need once they are born.

In addition to these specific points of advice, the ASHA also ensures that pregnant women are being cared for regularly during the antenatal and postnatal periods, by conducting regular house visits, taking the woman to the closest health facility for antenatal care, and arranging transportation to a hospital for delivery.

Addressing emergencies, unlike the process of conducting house visits to pregnant women, is a less structured and significantly more complicated responsibility that the ASHA workers face. When discovering a pregnant woman or child with a serious problem or health condition, the ASHAs must immediately try to flag down a vehicle–a difficult task in such a remote location. Until a form of transportation arrives, if it ever does, the ASHA workers must try to find some temporary solution to the problem at hand. Whether these guidelines are detailed in their handbooks or if the ASHAs are trained on addressing these situations is unclear.

Technology Exposure

Both ASHAs  told us that they did not have an extensive knowledge of technology tools; however their use of technology in their everyday lives was vastly different. One said that she had a laptop, which she used to access her bank account and type, but she was not too familiar with mobile apps or smartphone technology. The other ASHA said she was “not very comfortable” with using technology, although she said she owned a touch phone. Whether this was a smartphone or not was unclear from our interview. She told us that she only uses her phone to do basic messaging and make phone calls–she too did not discuss any familiarity with mobile applications.

Overall Technical Findings

IMG_5742We noticed that there were patterns in issues that both ASHAs experienced with the application interface overall. Firstly, navigating to a specific form was difficult for both ASHAs, and they seemed extremely hesitant to click the “wrong buttons” or perform something incorrectly. In addition to being afraid of clicking buttons on the application overall, both ASHA workers did not seem to recognize the functionality of the “cancel” buttons we put on all the forms, nor did the circle icon at the top page make sense as a “save” button.

Making the application as straightforward and simple as possible for the health workers is the best solution, and that might involve placing actual “save” buttons on all the forms (not the circle icon), and “edit” buttons for every question, to allow health workers the flexibility to make changes if they do not feel comfortable cancelling out of a form.

Two major improvements that will need to be made to the KOL-Health App for our next field test are: increasing the font size on all the forms, and changing heading colors to make them distinct from the buttons. These were places where our team noticed the greatest user issues, and can easily fix for the upcoming week.

Recommendations and Improvements

As with our first field visit, this trip to Bhai Nagar was definitely focused on gathering more information from health workers, and garnering their feedback on the KOL-Health Application, as pertaining to their current activities in the field. Although this application was tested among ASHA workers and not iKure CHWs, we hope that this application will provide both sets of health workers with the ability to make data entry more efficient, and a central device in which they can gather and store patient information safely and securely.

After this visit to Bhai Nagar and after interacting with the ASHA workers , we now understand a few important points that need to be considered for further development of the KOL-Health App:

1. An immense amount of what the ASHAs do in their communities is establish relationships with the people and directly interact with them to raise awareness around health promotion and disease prevention.

Where KOL-Health fits in: The mobile tool that we are building for health workers should work alongside this existing workflow, which is highly interactive and embedded in social contexts of the community. The application’s interface should be simple and straightforward enough, so as not to detract from this existing relationship-building process that is central to the health workers’ roles.

2. The ASHA workers in this particular community view communication with a doctor as being useful. However, they are reluctant about this interaction currently, because they do not want to “disturb” the doctors in their work by calling them with a problem from the field.

Where KOL-Health fits in: Building a messaging feature is the next phase in our team’s development timeline for the application. This messaging component is ideally linked with a patient’s case information (vitals, symptoms, or a health survey), which can then be sent to a doctor in the closest health facility via a “referral” button or some other action. The doctor will essentially be able to view these messages whenever they log into the application site, which would forego the issue of health workers calling the doctors at inconvenient times.

3. Important initial reactions the ASHAs had to the application included: having a difficult time seeing the text due to small text size and screen glare, and being afraid or hesitant to click any buttons without extensive prompting.

Where KOL-Health fits in: Both increasing the font size of the text and altering color contrasts to lessen issues with screen glare are simple improvements to make in the application for the next iteration of our team’s design process. To address the health workers’ hesitation towards using the application—and any technology tool in general for their fieldwork—this comes with not only proper, context-appropriate development of the interface, given the health workers’ feedback, but also implementation guidelines that iKure can follow to better tailor and sustain this technology within the rural communities their health workers are a part of.