We returned to Uganda in 2011 with
the revised design and met with the same
ethnic groups with whom we had originally
visited. We held 15 additional FGDs with
the same stakeholder groups (the individuals differed) and interviewed over 30 leaders in circumcision policies and practices.
These interactions were used to gauge
community interest in the revised design
among TMC practitioners and establish the
extent to which Ministry of Health officials
and clinical surgeons supported the design
and associated procedure. To evaluate the
preferences among stakeholders, we asked
FGD participants to compare the original
and revised prototype designs using a
We found that 80 percent of cutters
and their assistants and 97 percent of clan
leaders chose the revised device over our
original design for its simplicity, ease of
use, and perceived increased protection.
When asked if they would use and/or
support the revised device if public health
officials supported its usage and the TMC
cutters were properly trained, 74 percent
of cutters and assistant cutters and 88
percent of clan leaders strongly agreed
that they would do so.
We are currently conducting a study in
Uganda to collect anthropometric data on
penile sizes and evaluate the ability
of the device to grip the penile glans.
UNDERS TANDING S TAKEHOLDER
The design ethnography techniques we
used in our design process provided many
critical insights. The techniques were key to
establishing and confirming the need, which
had a significant cultural load associated
with it. They also helped us understand the
stakeholders’ viewpoints and concerns, and
provided data used to generate justifiable
user requirements and associated engineer-
Indeed, there were no publicly accessible
data available about TMC practices in
Uganda and sub-Saharan Africa—at least
not specifically detailed data necessary to
base design decisions on. Therefore we, as
engineers, needed to take the initiative to
collect the data. This involved the use of
both qualitative and quantitative techniques
inspired by tools used by ethnographers.
The data garnered through this work
would have been impossible to obtain in
a conventional laboratory setting. For
example, we learned that while the ethnic
group participants had general knowledge
about the effectiveness of AMC against
HIV transmission, they preferred TMC due
to cultural reasons. We found out about the
potential role of churches and mosques with
respect to the promotion of safe TMC and
their religious leaders' interest in supporting
the development of an intervention, as well
as the recent formation of a “cutters union”
among the Bagisu to preserve TMC’s cultural
significance. These data were directly used
to inform the establishment of stakeholder-
driven user requirements.
Our experience demonstrates the
value of an iterative, process-focused,
design ethnography approach that
actively engages stakeholders to confirm
needs, drive the establishment of user
requirements and engineering specifications
based on rigorous studies that generate
quantitative outcomes rather than
anecdotal evidence, and provide continuous
feedback on early stage design iterations.
Design ethnography is an enabling
methodology that can be can be used in
product design when limited information
is available. The methodology is especially
useful when designing for low-resource
settings, where financial, social, and cultural
constraints impose challenges on designers
developing affordable, accessible, available,
and culturally appropriate devices.
We would like to acknowledge the
intellectual contributions of all individuals
and organizations that assisted in this
project. We also acknowledge the financial
contributions of the Bill & Melinda Gates
Foundation and the National Collegiate
Inventors and Innovators Alliance. •
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Design ethnography is an enabling methodology that
can be can be used in product design when limited
information is available.