Keywords

1 Introduction

A multitude of definitions and views exist within design practitioners on what constitutes Design [1]. Traditionally the profession which was centered around Industrial production has moved into an approach which is applied to fields like software engineering, services, policymaking amongst others. Participatory design (PD) originated in the Nordic countries as a political approach to shaping democratic workplace [2]. Since then it has found its place in the design and business community as an approach for knowledge building and user empowerment [3]. PD has its roots in the developed countries and has been anecdotally practiced there. On the other hand, PD with marginalized users has been under investigated.

Due to the increase in ICT accessibility in India, there will be a significant ICTD intervention in India. On the other hand, these interventions will seemingly lack the practice of PD due to probable low awareness and challenges faced. Hence from a design perspective we would like to investigate the phenomenon. We would like to situate this context within the domain of healthcare.

The Constitution of India places emphasis on improving Public health as a duty of the State [4]. Vaccination is one of the most cost-effective child survival interventions [5]. Universal Immunization Program (UIP) for children, which includes 6 vaccines: BCG (Bacillus Calmette–Guérin), DPT (Diphtheria, Tetanus toxoids and Pertussis), polio, measles, DT and TT (diphtheria and tetanus toxoids) is provided free of cost through the Indian Government Healthcare. In India, vaccination has a national coverage of 61% [6]. WHO aims a national coverage of 90% for its member states by 2020 [5]. We feel the compliance rates can further improve if there is co-creation of services with PD.

2 Literature Study

PD is used to model users’ intrinsic knowledge and empower them in decision-making [2, 7]. Several challenges have been identified while designing with PD like contextual constraints [7] and literacy level of the participants [8]. Engaging participants with a meaningful PD problem statement and building relationship with the participants [9] are explored in PD literature. To conduct PD, it is advised to ensure participant’s access to relevant information [10]. Bowen et al. [11], identifies how users in PD find it easier to find solutions to problems which are visible than finding lateral solutions to non-obvious problems. Participant’s ability for decision-making [9] is also a factor, which affects PD. Yet PD does not have an established way of evaluating the output and there are conflicting views on debated the output of PD [3]. PD is used as a tool to find solutions to the problem or as an approach to understand the problem itself [7]. For the purpose of this study we have followed Sanders’ [12] framework of PD tools and techniques of Priming, Probing and recording experiences using Making – making tangible things, Telling – tools and techniques that support verbally oriented activities, and Enacting – acting and playing.

3 Method

3.1 Objective

The aim of the study was to explore the phenomenon of PD with ICTD users. We have situated our context in healthcare service design. The PD sessions were conducted to co-create Customer Journey Maps of vaccination services with users.

3.2 Participants and Setting

Our team in the field comprised of two Designers and a student of Public Health Policy who is also a qualified Dentist. The Designer was expected to bring in the perspective of PD, while the public healthcare student was expected to bring in the perspective of public healthcare. In addition to the participants, the sessions were observed by an Industrial Designer who remained as a passive observer. The focus of the Industrial Designer’s work is not within the scope of this paper, but we would like to mention his presence.

We recruited users who were migrants to the city, less-literate [13], and had a child within the past 18 months from the urban poor wards of Chembur and Govandi, Mumbai. We arrived at the criteria of 18 months as vaccination which is part of UIP [6] is done frequently within this. We assumed an operational definition of less-literate as not more than standard 8 education in India [13]. Users were chosen through door-to-door convenient sampling. Prior to the PD sessions, a Contextual Inquiry was conducted with 11 users to gather insights about user’s experience with vaccination. Based on the insights from CI, we decided to attempt PD with users who met our research criteria (Table 1). We arrived two types of users—User type A was compliant to the National Immunization Schedule and User type B had home births and was not fully compliant to the national Immunization Schedule through Contextual Inquiry (CI). We conducted PD sessions with both the user types. As part of the PD session, we situated the context in their recent past consumption of the vaccination service and triggered their participation into co-creation of such a service.

Table 1. List of users
Full size table

3.3 Participatory Design Session

The participants included a Designer, Public Health Policy student and the User. The PD session was planned and executed within a timespan of two weeks. The session duration varied between thirty minutes to ninety minutes. Sessions were held at user homes and were scheduled based on user convenience. There was a constraint of space within most homes, so sessions were conducted on the available space like bed or floor, amidst the household activities. We would like to make a fair disclosure that we anticipated our users to have difficulties in expressing themselves creatively and critically. Hence, PD was held with individual users and we dressed down to suit the users environment. The only exception to this was a session where a houseguest met our user criteria and was our user’s sister-in-law. We could not exclude her from the session due to the power structure within the family.

3.4 Procedure

Prior to the sessions the team developed an outline for conducting the sessions. This was based on Sanders et al. [12] framework of PD tools and techniques such as visual triggers (making), verbal triggers (telling) and roleplaying (acting).

The artifacts we used for PD were A4 size colour prints of (1) set of emoticons for empathy mapping, (2) photographs of vaccination process in India, (3) sketches with animals hidden in a forest (4) photographs of making tea. We collected images from the Internet due to shorter time window to create our own. The photographs of vaccination were chosen based on visual similarity to vaccination service in Mumbai. We also carried ruled notebooks and sketch pen sets. All of the stationery was purchased from the user’s neighborhood to ensure they would be commonplace to the user.

The sessions contained different phases meant to understand user’s experience and generate alternatives to the existing scenario. The introductory activity was based on verbal triggers and it captured users’ daily life, vaccination experience and difficulties they face with vaccination process. In the subsequent activity discussion took place around customization with an example of customizing food to their children’s liking. Our aim was to establish how experiences could improve when it is tailor-made for the user. The next phase user was primed for the generative phase through lateral thinking activities. The activities include identifying circular objects by shifting point of views and spotting the hidden animals from the image provided. While the former activity proved ineffective, the later became an icebreaking session user gained confidence from. At this phase we introduced pen and paper to the user. The subsequent activity was intended as process mapping using collage making. User had to map the process by which she prepares tea. Due to the environmental constraints, the activity was altered into a story telling exercise by making use of the photographs we provided. The next phase was generative which started with an activity to elicit users happy experiences and brainstormed to layer their qualities [14] on vaccination service. Subsequently, a process map of the vaccination service was captured through verbal triggers, sketches and artifacts like sketch pens. Further, we captured stakeholder maps by charting all the stakeholders mentioned in the process map. Assigning hierarchies to the stakeholder maps followed this activity. Further, we used photo elicitation to capture emotions user experienced during the vaccination service. We used emoticons to initiate discussions on emotions experienced by the user through the vaccination journey. Final activity was roleplaying where the user enacted how service providers are at points of service breakdown. User then generated alternatives scenarios to these scenarios.

4 Discussion

4.1 Need for Flexibility

Despite planning PD sessions in advance, researchers need to accommodate user context by altering the activities on the fly. Since users were also engaged with work we altered our methods and tools to suit their context. We could not photograph and sketch frequently, and engage with her in ways other than verbal and gestural due to the contextual constraints (lack of physical space available and as it affected their natural participation). So we used images to elicit responses on the existing process and to generate ideal processes. Personalizing the stakeholder maps helped increase user’s enthusiasm levels. For example, in the illustrated stakeholder map we always referred to the baby by user’s child’s name. This often made the user smile and become visibly enthusiastic to contribute. During session 1, we illustrated the service providers and processes using simple illustrations that user spoke of. These sketches became a starting point for discussions in the further activities. During another session we provided the user with colored sticks to build process maps and stakeholder maps. Even though it provided an opportunity for user to record experiences, it was ineffective in furthering discussions. We eventually discovered that it is easier to build the process map and build stakeholders map and elicit users emotions using it as a foundation. But the interdependency of these activities also meant lesser opportunities to discover radically new information. Mapping emotions to the stages of vaccination journey was initially difficult. Users did not know how to describe in detail how they were feeling through various stages of the vaccination journey. To overcome this, we let the user assess the emoticons provided and interpret what emotions they represent. At times our users enacted the expression of the emoticon without us prompting. Users then matched the emoticons to the process map and elaborated on what it felt like to be at various stages of the vaccination journey.

During photo elicitation, users pointed out inconsistencies in the photograph with their experiences. For example, during the process mapping activity for preparing tea, users would point out inaccuracies in the photographs we showed and described their process in detail. Users often corrected us without hesitating, but the real challenge was to get in-depth descriptions. We constantly had to reassure the users since initially they doubted PD to be like a school examination. Such doubts were often expressed during the ‘making’ activities. The photographs of vaccination process during photo elicitation depicted service provider and user seemingly happy. Upon seeing them, the users mentioned how the depiction is inaccurate. They proceeded to tell us how they expect the service providers to be more empathetic towards children.

4.2 Communicating Intangible Concepts

Preparing a strategy to communicate common PD terminology to less-literate, non English speaking user could increase time spent on PD activities. It was relatively easy to probe for experiences, emotions and to generate alternatives for very specific problems within the service. PD was ineffective in generating suggestions for a holistic system design. We often found it difficult to communicate what a service is and where it begins and ends. User considered vaccination service to be only about the point where she walks into the ASHA workers station and gets the injection done. Whereas we believed information dissemination, preparation for the upcoming vaccination, post vaccination care also to be part of the service. Sketching the user stories provided an easier means of capturing intangible aspects of a service and initiate discussions. Users assumed sole responsibility for getting their child immunized. Yet they never considered themselves to be important enough to have opinions about the service. Often there was difficulty in explaining technical terms. Even a translation to Hindi was not effective for words like ‘involvement’ or ‘process’. Concept behind each word had to be explained in-depth.

4.3 Creating a Meaningful Experience for the User

The commute, weather and the intensive sessions were exhausting. It was difficult to keep the user focused on the activities due to the physical constraints and the constant interruptions. We constantly adapted the activities and the narrative to keeping the user interested. Our Users and the Designer were non-native Hindi speakers. These lead to fragmented transitions between activities. We spend a significant part of the time to explain concepts to users. In order to improvise on the activities the Team needed to communicate within us. Users indicated discomfort as we switching from Hindi to English to speak to each other. Since our users initially expressed doubts that they were being tested, we had to minimize discussions within the team. Communicating within the team while putting the user at ease was especially hard in sessions where distractions like dependent members were not present. Vaccinations are not a daily affair and this could have contributed to our users not participating in PD with seriousness.

At times during the probing for experiences activity users described experiences of discrimination, abuse and of being deceived during the vaccination process. This combined with our time constraints, often created an ethical dilemma on whether to proceed with PD sessions. As a result, sometimes we cut short activities and spend more time listening to the user speak. It was especially hard with Users who had non-institutional delivery and partly immunized children.

4.4 Creative and Critical Opinions

We could barely convince the user that her opinions and ideas matter. Users believed they were powerless to influence the process. For example, when asked to generate solutions for service breakdowns a user responded by saying that she just follows what the doctor says for the benefit of her child.

User was introduced to pen and paper during ‘spot the hidden animals’ activity. Upon seeing the pen and paper one user responded that she does not know how to write. Even though the activity did not require her to write, it still intimidated her. During the process mapping, the Designer and the Student sketched to record the users story. User hesitated to even hold the pen later and required a lot of coaxing.

4.5 Insights About Vaccination

PD indicated a preference for woman as a service provider in vaccination. Women were more empathetic, gentle and playful to the child according to the users. Users expressed a lot of concern on a crying child being injected. They feared the child would faint from exhaustion. Users also suggested a need for Doctor’s presence at the point of Immunization. This was because of experiences where the users were denied immunization service after the health worker felt the child could be sick. Users would then be asked to get of certificate from doctor. There was comparison between Hospitals or Camps being Immunization center. Users mentioned familiarity, ease of access and lower indirect cost in favor of camps. But they believed hospitals provided better care and service providers at hospital attempted to build better rapport with the child. Certain users who had partially or unimmunized children were under the belief that the child was fully immunized. They were not aware of immunization as a process, which involves multiple doses at intervals. Their experience with the vaccination process was limited to one or two events. Another User was under the impression that the mother-child protection card [15] needs to be completely filled for enrolling the child in school. To her, immunization was only a way to enroll her child in school. In such cases, PD activities we had designed for the sessions had little relevance to the user scenario. It was interesting to note that all of the suggestions were centered around the child and the user never considered her difficulties worthy of solving. Our users faced economic difficulties and did not have refrigerators in their homes. They buy Rupee 1 Frozen Cola sachets for cold compression.

5 Challenges and Limitations

Two weeks were a shorter time window to build relationship with our users. Sessions were often interrupted by external factors. We did not provide any monetary compensation to the users; instead we gifted the children with stationery and candy as a token of appreciation for participation. It was also our first experience conducting PD.

Since the users had several social commitments, it was difficult to conduct the sessions despite taking prior appointment. Many a times sessions happened while the user was cooking lunch, amidst crying children or houseguests. At times, users could not keep the appointment because of last minute interventions from older members of the family. We observed that users participated better in the absence of older dependent members, mother in law for example. We observed our users being comfortable with telling and enacting methods. We suggest caution during ‘making’ activities to minimize connotations of schooling. During PD with a single user within user setting, it is challenging to convince the user to participate formally. Transitioning between activities has to be planned carefully such that the user stay focused and finds PD meaningful. Further research is required to situate PD activities and terminologies within ICTD context when there is a constraint of physical space and users with little exposure to former schooling.