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KOL-­‐Health  Application:  Building  a  Foundation  for  mHealth  in  iKure      Overview Community health workers are considered the “bridges” between communities in low-resource settings and the formal Indian health system. Witmer et al. defines these health workers as essential to health care delivery, because they not only come from the communities they serve, but also play a vital role in “translating innovative solutions into practice to address local needs” (1995). Within rural Kolkata, where iKure (a health-focused social enterprise) conducts a large portion of their health delivery operations, the extensive roles community health workers play become extremely important—for health data collection, primary prevention, and medical treatment in these regions. These health workers work in extremely remote environments, providing care to communities that are often geographically isolated from health facilities and services. Through an extensive goal-setting process with our partners at iKure, the University of Michigan graduate student team sought to build a technology solution that could support the variety of tasks that health workers perform in their communities, despite their localities’ remoteness. To better understand how to create this tool, our project design process focused on the following questions:

1) What is the current workflow process of health workers in the field?

2) What is the health workers’ current understanding of technology, and what value do they see a technology tool adding to their fieldwork?

3) What level of buy-in do health workers have in their communities, and how can a technology tool best support that relationship?

CHWs and ASHAs: Health Workers in Context What Does the Literature Say?

Extensive literature on Indian CHWs and ASHAs indicates that these health workers are predominantly female, and generally have no more than a 10th grade education—a detail emphasized within iKure’s own pool of CHWs, who can be as young as 18 years old. Despite the absence a higher education degree, these health workers are extremely intelligent and motivated to “serve the community, increase their knowledge [of health care] and become more associated with the formal health system” (Bajpai & Dholakia, 2011). As one CHW mentioned during our visit to the Jamdargur community in Godapiasal, she was eager to get more training from iKure to understand “the proper medicines to give to people, and how to better interact with community members to build trust.” The wide-ranging roles of health workers—from preventive care, to maternal-child health, to treatment and service delivery—requires that these individuals become fast learners in public health and medical terminology; information that then must be conveyed accurately and in plain language to their patients in the field.

 

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Health and English-script Literacy The training of health workers is highly varied, and dependent upon the institutions or agencies that are conducting the training procedures. Reviews on health worker—especially ASHA worker—training depict these sessions as being “overcrowded” or linguistically inappropriate, because the material and concepts are complex and usually written for an English-speaking audience (Bajpai & Dholakia, 2011). From our interviews with a handful of CHWs and ASHA workers across Kolkata, we gained an understanding of the variations in health and traditional “English-script” literacy (being able to read and comprehend English) at an individual level. We noticed during our first field visit to the Bhovanipur community in Balichak that the ASHA and CHW each had large paper forms for recording maternal-child health information—written completely in Bengali script. In our second field visit to the Bhai Nagar community of Balichak, the two ASHAs we interviewed had patient records stored in notebooks, for their own personal use. These too were written in Bengali script, aside from numerical values such as dates and immunization records. Our third field visit to Jamdargur, Godapiasal took our team even further into the nuances of health and English-script literacy with the ASHA worker program. The ASHA we interviewed showed us a large reference handbook, which contained charts, diagrams and descriptions about maternal, newborn and child healthcare—all written in their local dialect. The few pages written in English contained a list of medical acronyms that were deemed important for the ASHAs to recognize on survey forms in the field. All ASHAs and CHWs we interacted with over the last month told us that, although they could not read complete English text, they were able to recognize key English words and phrases through rote memorization; a skill taught to them during their training sessions. Incorporating Technology Alongside the repertoire of skills the health workers receive for their fieldwork, iKure has sought to add technology use into the existing body of knowledge that health workers have, to improve data collection activities and patient monitoring in remote settings. Our team’s proposed design solution, the KOL-Health Application, is a mobile patient record that can be implemented on tablet devices and smartphones and store health data under zero-bandwidth settings—a major problem that iKure expressed about doing fieldwork in these low-resource communities. When asked about the application’s value, many of the health workers we interviewed felt that it could: 1) Expedite their data collection activities, and 2) Safely store the patient records that they currently keep in paper formats. Although iKure views the KOL-Health App as a tool that can be implemented across regions of India, our team focused on designing to the communities of rural Kolkata where we conducted field visits. The software that was used to build the tool is flexible, simple and open-source, to allow for this scaling-up to occur in the future, should iKure choose to pursue this option. For now, the user interface, form flow and survey content are based on the feedback we received from CHWs and ASHAs in the communities of Bhovanipur, Bhai Nagar, and Jamdargur around Kolkata, India.

 

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Iterative and Community-Centered Design: Our Process The KOL-Health Application was designed with a few key functions in mind. We wanted to ensure that the application could support health workers’ regular data collection activities, allow them to view and store patients in the system, and foster communication with doctors. Prior to our first field visit, our team was able to model certain App features after iKure’s Kiosk model, which was originally intended for health workers’ use and had some of the frameworks already built. The objectives for App development focused on:

-­‐ Patient registration (for basic demographic information) -­‐ Case entry (where symptoms and vitals could be entered) -­‐ Public health survey forms (we focused primarily on maternal health) -­‐ Messaging (for health worker-doctor communication) -­‐ Syncing (to enable rapid data transfer between the mobile devices and iKure’s main

patient record site, WHIMS) -­‐ Prescriptions (allowing health workers to select which medicine a patient needs, and

having a referral notice sent to a doctor) Rather than attempt to build the entire application at once, we decided an agile framework would work best for this setting, allowing us the flexibility to gather information from the field and tailor the application features accordingly. Our field-testing process is shown in Table 1 below. Table 1: KOL-Health App Field Testing Process

Within our field visits, we divided our time between information gathering and application testing activities, to ensure that the features in the KOL-Health App reflected the health workers’ opinions and perspectives on their current workflow. For each field visit, we spent approximately an hour and a half interviewing the health workers—who were selected by iKure prior to our arrival—and approximately one hour testing their abilities to perform different tasks in the device itself. In total, each field visit took approximately 3-4 hours to complete the interview and testing process with two health workers. Key Findings Below (Tables 2 and 3) is a list of key findings from both the interviews and the application testing process that emerged from all three of our field visits. Although each health worker’s literacy level and ability to use the application varied, we discovered some important patterns in both their perspectives on their current work, and their navigability of the KOL-Health App.

Field Test Date Location Users Application Design Probes 1) June 1, 2015 Bhovanipur,

Balichak 1 CHW, 1 ASHA

1. Paper survey vs. electronic survey (MCH) 2. Patient registration process 3. Vitals and symptoms recording process

2) June 12, 2015 Bhai Nagar, Balichak

2 ASHAs 1. Categorizing health information into “forms” 2. “Symptoms” and “vitals” as “case” sub-forms and “antenatal care” as

Maternal Health Survey sub-form 3. “Cancel,” Save” and “Next” button logic

3) June 18, 2015 Jamdargur, Godapiasal

1 ASHA, 1 CHW

1. End-to-end test with patient registration and case entry workflow 2. “MD referral” logic 3. CHW-MD messaging features

 

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Table 2 Key Interview Findings

1. Building a relationship with the community is essential. 2. Tracking patients requires extensive and careful record keeping. Health workers carry large notebooks

detailing the information of each household they visit. 3. Tracking women and children is an extensive process that begins once a woman is “married or moves

into the community.” 4. Health workers feel the training they receive is too short and inconveniently timed; it takes them away

from their patients. 5. Electronic records would be useful, because it would help the health workers enter data quickly, and

would “securely store” patients’ information Table 3

Key App Testing Findings 1. Certain terminology in the forms—such as “antenatal care” and “gestational age”—while familiar to

one ASHA was not familiar to the other ASHAs or CHWs we interviewed. 2. Messaging a doctor was not an intuitive process; the health workers currently only call doctors on the

phone in emergencies and do not want to “disturb them.” 3. Most health workers were hesitant to click on various buttons, out of fear of “messing something up”

or breaking the tablets. 4. Literacy was a major issue: every health worker needed the content read out loud to her, because it

was all written in English and not Bengali script. Summary and Implications

Although our team was able to glean some of this information about literacy and health worker roles from the literature searches, it was only by being in the field interacting with various health workers that we understood a more comprehensive picture of their work, and the real-time challenges they face in being health workers. We are now more aware than ever that the health workers are highly invested in the wellbeing of people in their communities, and are willing to learn any technology necessary to conduct their work more

smoothly. However, to ensure on our end that technology tools are meeting the needs and contexts of the health workers, iKure should always consider:

1) Literacy issues with using English forms, and how to tailor the content to the local language

2) The amount of technology training needed to make all health workers comfortable with using electronic tools in the field

3) The training that currently exists for health workers, and what opportunities exist to improve upon health literacy and standardize knowledge across the health worker spectrum