Variability in the capacity across the clinics
we partner with is also a challenge. The number of skilled prosthetists and technicians,
as well as the administrative capabilities,
differs from clinic to clinic. Some clinics are
permanent and some temporary. While field
trials require rigor and strict control, actual
data collection from people requires adaptability and flexibility, so that we can quickly
pivot on the ground to efficiently manage a
quality process and respond to hurdles.
The survey we developed requires that prosthetists spend at least an extra 30 minutes
interviewing each patient, that the clinic set
up an area for timed gait-testing, and that
clinic administrators add on an additional filing
system to maintain patient confidentiality. Our
experience is that any product, including user
surveys, that doesn’t fit with users’ existing
behavior and expectations, will not be adopted.
We’ve learned through experience that the
quality of the data collected may suffer if we
ask the subjects and clinicians to do too much
beyond their typical operations.
We worked closely with clinics to translate
the survey into local languages. Language,
in itself, is an interesting design challenge—
there aren’t always lingua franca equivalents
for technical medical terms. Our translators
worked to interpret appropriate colloquial-
isms, and we iterated with individual clinics
to best update the material to local norms
and phrasing. Most clinics asked that techni-
cal and medical jargon remain in English,
even if English was not the prosthetists’
first language, resulting in a series of hybrid
translations—a lesson consistent with previ-
ous experiences we’ve had with technical
language across a wide range of geographies.
We also adapted some of the contexts of the
questions to better fit our patient profile.
For example, we eliminated questions about
swinging a golf club, hitting a puck with a
hockey stick, and throwing a bowling ball.
Once a survey is designed with intention, fit to local context, tested, translated
into the appropriate language (or mix of
languages), it is a product, but it is still an
unused one. In any ethnographic study there
is an acute tension between drawing out
truth and paying respect to the user. How
do we understand a user’s very personal and
emotional experience and translate that
through a survey into a line on a spreadsheet
without diminishing his or her reality? This
question gets to a central tension in product
development; as personal stories can convey
what a gait test cannot.
One of the more emotionally challenging
amputees that we met during field trials
lost her leg about a year ago in Guatemala.
Her immobility made it impossible for her to
continue her job as a cook, and she has been
struggling with her inability to work ever
since. Like many patients, she was emotional
throughout the interview process, but when
we began to talk about her work history she
broke down into tears. One of the Guatemalan clinicians we were working with immediately put the paperwork aside and wrapped
her in a hug.
When asked to rate her satisfaction with
her current device on a scale of 1 to 10, she just
shook her head and said, “I’m devastated.”
The smiling and frowning faces on our Likert
scale just did not adequately capture the real
life they were designed to represent. The story
reminds us to acknowledge this tension and
ultimately prioritize patient care and respect.
Product integration is a key challenge to
achieving scale. Almost all of the clinics D-Rev
staff visited have reported problems with
consistent delivery of components. Issues
range from an inconsistent supply of donated
devices to a dizzying array of barriers for
importation and customs. In order to achieve
scale, we realize that we must remove as
many of these barriers as we can to make the
ordering and delivery of prosthetic components seamless. Devices need to work with a
variety of different prosthetic systems, as different clinics around the world have adopted
different systems to fit amputees.
We must also be aware of the different profiles of clinics operating in low-income regions,
from “parachute prosthetists” that visit a
clinic a few times a year, to large government-run facilities ensnared in red tape. We have
seen hospitals that will only order all of their
components, tools, and materials from a single
company because the approval process for
ordering new equipment is so complex. Even
if a new device provides better performance
at a lower cost, these large institutions will be
reluctant to change their entire systems.
Each stakeholder is part of the feedback loop in the design process