Healthcare Platform: Understanding and Contrasting Participatory Design – DHIS2

With DHIS2 (District Health Information System v2) originating in Oslo, Norway, and shaped by users of the software from around the world, a traditional approach of Norwegian design processes is that they are participatory. Participatory Design, or Co-creation as it’s often called, requires actively including all the actors in the design process in some manner such as a workshop – both the business and design personnel along with a representation of the end-users.

It can spark a reminder of the feared experience of “design by committee”.

When first hearing the term “Participatory Design” it can spark a reminder of the old and feared adage of “design by committee”. Design by committee is a grimace motivating occurrence in a design process where users contribute to the creation of what one might call “sidelines” on any number of detailed issues, without having been provided with a clear rationale for providing input at an appropriate stage and in context. However, the dreaded design by committee is not at all reminiscent of Participatory Design. For the latter, in whatever is the most appropriate setting, participatory session participants use the tools at hand to convey their understanding of how the end product should work in a guided and complementary way with design, development and other stakeholders. These sessions give the design and development team an up-close-and-personal opportunity to encounter perspectives only understandable by being in-situ with representative users. To be clear, users do not design the final solution in a participatory design session, but instead, they inform it, for the design and development team.

Participatory Design brings the users to the design team – although, in the case of the District Health Information System platform, DHIS2, it was necessary to travel to Uttar Pradesh, India for a more contextual enquiry and a sense of “ethnography-lite” to see and meet the using teams in their environments.

Being in situ with end-users and stakeholders is an opportunity to first-hand absorb the context and nuances that the updated system will operate in post-deployment, that can then throw out completely the paradigm that a designer from outside that context takes as gospel. For example, the average touch-screen mobile phone that suits everyday home and office use are unlikely to have the same design considerations for satellite phones for Arctic explorers. Likewise, a designer from a particular context may find that the rules of visual composition he or she has familiarity with are not the norm in another context. Even more so, when considering the context can comprise of layers of meaning affected by language and nuances of culture, that is itself formed through history, politics and mass-media, ethnicity and so on. With this in mind, we may find that our designer’s honest but blinkered perspective adds to the target user’s cognitive load rather than manifesting the efficiency the visual composition would illicit in his or her originating context.

If this seems like an overemphasis on the affecting human-factors consider the remarketing of good ole Betty Crockers Instant Cake Mix, a product in the US. Initially, although customers reputedly requested the product it had limited sales with housewives who wouldn’t use it. Baffled by the failure of what seemed like a dream product, Edward Bernays the credited “father of Public Relations”, a psychologist and nephew to Sigmund Freud was recruited to consult on behalf of the manufacturer to research the reasons behind the product’s failure. Berneys uncovered that for housewives, using the product undermined their social currency – they felt they were cheating or short-changing their families by not making the mixture themselves. Berney instructed the manufacturer to remove one of the product ingredients – egg powder – and concocted a marketing message – “Just add your own eggs!” that gave housewives the sense of security and creativity they were concerned about losing and using the phrase’s tautology to infer a personal biological (ovarian) contribution. Changing the message to overlap with unconscious audience motivations, however, is not always the appropriate solution. There are times when a product must be adapted to respect and be compatible with the context of use, regardless of external perceptions of there being better approaches – better often spelt “our”. Again, looking for similitudes, some of us remember when a system was successful if it was accurate from a data-capture perspective without consideration of the end-users.

As well as the participatory sessions in India, there is also plan to interview users in-person.

For the health information platform DHIS2, the approach has been to first assess the different aspects of the design against a set of well-established heuristics. Following this, the intention is to interview the various stakeholders by phone, and to carry out user testing as part of a contextual enquiry – something planned while Doctoral Fellow Magnus Li will be on-site in the target healthcare district.

As well as the participatory sessions in India, there is also plan to interview users in-person and to user test the system remotely, and moderated in person, where possible. Following that, we would correlate the qualitative research with the changes required, by the healthcare team presenting updated requirements – the reason for the project and the result of compounded feedback. The initial change requirements supplied by the local Uttar Pradesh team using DHIS2 have been worked through by Professor Sundeep Sahay, at the Department of Informatics, University of Oslo. My first stop has been to carry out the Expert Review, that is now already well underway and, to capitalise on time, beginning to assemble primary assets as part of the low-level prototype for a later organisation in line with the research outcomes. The one thing we can firmly count on is that the data indicators about the population health currently collected will continue to be required as they are relevant for population health. Constructing the prototype, that might initially seem redundant, also serves well as a more granular basis for identifying usability issues in the existing system, granted by my Western standards. DHIS2 has not undergone any accessibility adaptation – something I am keen to do as the Web Content Accessibility Guidelines (WCAG) provide internationally adopted accessibility conformance criteria and improve user experience with both disabled and non-disabled user alike.

The Uttar Pradesh installation of DHIS2 is in a state with a population of some 200 million people. Changes made to the product in the context of Uttar Pradesh will then inform modifications made to the product in other regions in India as well as the other countries across the globe using DHIS2. Undoubtedly, time and effort it will take. But what little an effort when considered against the wholesale good to public health management.

The entirely reasonable but often unwelcome question of “How can you design without meeting the users?” will always be relevant. Participatory design is a valuable investment for any project that can accommodate it, and especially useful to projects of general public concern.


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