1.
1
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.

2.
2
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.

3.
3
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

4.
4
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