A Tattooed Bracelet for Child Vaccination Records in a Developing World Context

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1 Work in Progress/Late Breaking A Tattooed Bracelet for Child Vaccination Records in a Developing World Context Bongkeum Jeong Madeira-ITI University of Madeira Funchal, Madeira 9020 Portugal bongkeum.jeong@m-iti.org Jesús Ibáñez Madeira-ITI Funchal, Madeira 9020 Portugal Jesus.ibanez@m-iti.org EMAiD School of Art and Design Barcelona, Spain jibanez@vilanova.cat Nuno Nunes Madeira-ITI Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for third-party components of this work must be honored. For all other uses, contact the Owner/Author. IDC 17, June 27-30, 2017, Stanford, CA, USA 2017 Copyright is held by the owner/authors ACM ISBN /17/06 Funchal, Madeira 9020 Portugal nuno.nunes@m-iti.org Institution Superior Técnico Lisbon, Portugal nuno.nunes@tecnico.ulisboa.pt Monchu Chen Hewlett Packard Labs Hewlett Packard Enterprise Palo Alto, Los Angeles, CA, USA monchu.chen@hpe.com Abstract This paper proposes technical solutions to collect, record, and track health vaccination records for children in a developing world context. The problem we address in this paper is very important, and often underappreciated. Our solution consists of two elements: bracelets containing NFC tags (intended to be worn by the children), and NFC enabled Android smartphones (intended to be used by the doctors) in order to manage the vaccine information contained within the bracelets. We use a tattoo design inspired by ethnography for our prototype of the NFC enabled bracelet. The visual representation of the tattoo is printed on the bracelet surface. It conveys an overall picture of the current vaccination status. Furthermore, the tattoo is the central element of the user interface of the Android App that allows the doctors to access, read, and update more detailed information about the child s vaccination status. Author Keywords Tattooed Bracelet; Vaccination Visualization; Child Vaccination Records; Ethnography Design; Functional Tattoos; Developing World Context 637

2 Work in Progress/Late Breaking Discover: Loss and Inaccuracy ACM Classification Keywords H.5.m. Information interfaces and presentation (e.g. HCI): Miscellaneous. H.5.2 [User Interfaces]: Theory and methods, User-centered design, Graphical user interfaces Introduction Figure 1: Families never receive child health record, or lose it. Also they are not accurately filled out. Figure 2: The health worker thinks the child had the vaccine. Figure 3: The surveyor gets less correct information [10]. Images above Figure 1, 2, 3 are by Jeong B. on HCIK 16 [6]. In the traditional sense, ethnography is complete only when the researcher is assimilated into the target culture or social community [8]; on the other hand, from the modern perspective, any type of research that includes cultural factors is recognized as ethnographic research [4], [6]. Ethnography strengthens design by exposing the user s surrounding environment and drawing out the understanding of cultural implications and primary users [9]. It can be effectively used particularly when it is analyzed in a broad sense related to overall strategy rather than direct feedback [1], [4], [6]. Whereas ethnography has been highly utilized in interaction design and industrial design, its application has been less prevalent in visual communication design. However, ethnography can be useful in helping designers find the communication strategy or insight required for a plan, method, or composition that allows for the most effective and natural communication under any given circumstances [4], [6]. In this sense, we present a design that fuels both the tattoo visualization and the prototype that are described in the precedent and present paper. Tattooing in Africa dates back thousands of years. It holds a fixed place in Africa s history. Evidence of painful tattooing was also found on the bodies of pregnant women and little children, which is said to have originated from a strong belief that such tattoos will chase away evil spirits and provide protection [8, 9]. Our research proposes technical solutions to collect, record, and track health vaccination records for children in rural parts of Africa. We used a tattoo design inspired by ethnography for our prototype NFC enabled bracelet. The problem addressed by the study (Figure 1, 2, 3) is very important, and often underappreciated. This research will spark lots of discussion about current and emerging problems in developing countries in areas that concern children. Related Work Our earlier studies described a specific context that we have been working on [4, 5, 6], followed by case studies conducted with child health records, along with the ethnography design method we applied [8, 9]. The purpose of the study [6] was to provide communication design recommendations that can solve problems with child health record systems in Africa. Additionally, the research aimed to test an ethnographic method in a broad way, in order to find a design solution within African culture. We conducted literature reviews and stakeholder interviews on the topics of child health and vaccination status, as well as on African tattoos. When the core users are child who have unclear communicative expressions, the environment of the child (Figure 4) has a dominant influence [6, 7]. Figure 4: This triangle user structure shows the definition of users (Family, Health worker, and Surveyor) 638

3 Work in Progress/Late Breaking Challenges and Opportunities Figure 5: This photo in our interview shows Carlton, a journalist from Germany. His tattoo is a reminder of his infant son. He said he wanted to have an ugly tattoo, not a beautiful one to remember his son. The research subjects are children, parents (Figure 1), health workers (Figure 2), and surveyors (Figure 3). We tried to develop a design that satisfies all of these subjects needs (Figure 4). We also intend to include characteristics of African culture in a health service process where tattoos as a design element are reborn as a symbol of children s lives being saved The tattooed bracelet for baby vaccination records in Africa addresses an important issue: identification and maintenance of vaccination records for children with both families and health care workers. Health records and data are considered as sensitive private information, which may be a big challenge. However, we believe that it will give us many opportunities. Carlton, a journalist from Germany, his tattoo is a reminder of his infant son (Figure 5), and Tika s tattoo is a reminder of the birth of her son. She wanted to have all information, birthdate, time of birth, place of birth, weight, and height in her tattoo as a baby guidebook (Figure 6). Tattoo Design as human-readable data These are examples of vaccination data encoded in variations of the base tattoo design. The evolution from left to right that follows age, with the tattoo increasing in size and complexity for the additional vaccinations required immunizations (Figure 7). Design Approach The design is applied to two artifacts: a baby guidebook and a baby bracelet. Our concept is to test combining technology with the tattoo by adding an NFC readable bracelet with a matching tattoo design on it. The tattoo design is for human readable, and the NFC component provides a machine-readable version. Figure 6: In this image, a German woman who lives in Madeira, Tika s tattoo is also a reminder of the birth of her son, but encodes multiple pieces of relevant data in the tattoo design. The tattoo contains the date and time, the location, and her son s weight and height at birth. User centered research in-depth interviews User centered research has to evolve along with new studies and technologies. The basic principles of such a methodology and the basic research that yields design paradigms exist at one end [7]. To assess user needs from 13 parents and 2 health workers, in depth interviews were conducted in Madeira. From the interviews we discovered that tattoos were usually meaningful reminders of specific events, such as an engagement or child s birth. We found very interesting parents who have tattoos relating to their child s birth. Figure 7: Vaccination data encoded within tattoo design The Tattooed Bracelet as machine-readable data We have designed a system for recording and accessing the information regarding a child s vaccinations. The central element is a bracelet, which contains the abovedescribed tattoo in two different (and complementary) ways. First, the visual representation of the tattoo is printed on the bracelet surface. Second, the bracelet encloses an NFC tag that stores the information encoded by the tattoo in a more extended manner. Thus, we intend our bracelet to be useful at two levels. 639

4 Work in Progress/Late Breaking Figure 8: It shows the initial tattoo a child would receive at birth, together with the encoded information about which of the vaccinations required at birth the child actually received. This tattoo shows, the three vaccinations required at birth, but only one was received and 2 missed. Figure 9: All 4 required vaccines received at 6 weeks old, plus the two additional ones that were missing at birth. After that time, at 10 weeks old the child received two of the three vaccines required. On one level, the physical visual representation of the tattoo can be read and interpreted without requiring any kind of technology (Figure 8, 9, 10, 11, 12). We hope that once the designed tattoo becomes popular, the users (doctors and parents) will be able to understand the symbol and the information it conveys (the vaccines that have already been administered to the child wearing the bracelet). On the other level, the users can employ NFC enabled devices (Figure 13, 14) in order to access, read, and update more detailed information about the child s vaccination status (such as the vaccination dates). Prototype This section describes the system we have prototyped so far. The prototype consists of two elements: bracelets containing NFC tags (intended to be worn by the children), and NFC-enabled Android smartphones (intended to be used by the doctors) in order to manage the vaccine information contained within the bracelets. NFC stands for Near Field Communication. It is a set of communication protocols that enables two electronic devices to establish communication by bringing them within 4 cm of each other. Usually, one of the two devices is a portable device such as a smartphone, while the other one is an NFC tag. NFC tags are basically passive data containers. They can be written to and read by an NFC enabled device. More concretely, the tags are electrical circuits that function thanks to the inductance of a nearby device. A smartphone located near a NFC tag supplies the power that the tag needs to fire up. The use of NFC tags has two remarkable advantages. Firstly, the tags are very cheap. For example, we found waterproof NFC bracelets for US $0.18 available from Alibaba. Secondly, there is no cost related with maintaining the NFC tags, since they do not require batteries (they are unpowered circuits.) Nowadays many current models of Android smart phones can be employed to manage the information contained in the NFC tags inside the bracelets, since those phones incorporate an NFC controller able to read and write data to an NFC tag. We are aware that smartphones are not cheap. Thus, we recommend minimizing the cost of our approach by reusing secondhand smartphones. Every time we buy a smartphone, we could donate the previous one so that, it can be used by doctors in a developing world context. If we could induce that behavior, we would obtain many useful devices, because the current rate of phone replacement is very high and raising. There are various types of NFC tag with different memory sizes, normally between 96 bytes and 8KB. For our prototype, we have used 1Kb tags. The material we used to craft the bracelet is EVA foam. We used this material because it is easy to manipulate, and is therefore appropriate for rapid prototyping at this stage of our research. However, we anticipate that silicone will be employed for the final prototype instead of EVA foam. With respect to the NFC-enabled device, we employed a Google Nexus 5 smartphone to test every functionality and option we implemented in the App. Once the prototype was stable, we also tested the App on various different phones. We have prototyped two slightly different versions of the App. One is for medical staff and the other is for 640

5 Work in Progress/Late Breaking Figure 10: At 14 weeks old the three required vaccines have been given, along with the additional one that was missed at 10 weeks. Figure 11: At months old the child received both required vaccinations, along with the missing one from 6-12 months. Figure 12: The guidebook provides instruction on how to interpret the tattoo. parents. The version for parents allows the users to query information. The version for medical staff also allows the users to update information. The user interface of the App is primarily visual. Note that there are between 1,250 and 2,100 different languages spoken natively in Africa [3]. Some authors even talk about 3,000 languages [2]. Ironically, English is the most widely spoken language in Africa [11]. Many African countries also have a very low literacy level. Thus, we make the user interfaces as visual as possible, to overcome the language and literacy barriers. Specifically, we employ the tattoo design as a catalyst for both visualization and interaction. In cases where written language is needed, we use English, the most universal language in Africa nowadays. The overall functioning of the App is easy and intuitive. The App was designed in order to simplify the interaction of both medical staff and parents with the information contained in the NFC bracelet. (Internally stored as a text string that encodes vaccines identifiers along with the dates when the vaccinations were made). Whenever an NFC bracelet is located very near (a few centimeters) a smartphone with the App installed, the App is automatically triggered. The main screen (Figure 13) is presented to the user, including the whole tattoo symbol. The areas of the tattoo related to vaccines still not administered appear in a light color. Conversely, the areas corresponding to vaccines already administered are represented in a dark color. Thus, the main screen conveys an overall picture of the current vaccination status. The version of the App intended for parents allows the users to query the information in an intuitive way. By touching any region of the tattoo symbol, the App visualizes the information pertinent to the corresponding vaccine (Figure 14). The information includes the vaccine name, whether it has been administered or not, and the date it was administered or the date it is supposed to be administered. Moreover, when a vaccination date approaches, the app warns and notifies the users about it. The version of the App intended for medical staff additionally incorporates the ability to update information related to each concrete vaccination. Thus, the doctors can update both the date a vaccine has been administered and the expected date of the next vaccination. Beyond the design and technologies described in this document, there are other aspects that must be taken into account for our system to be used in the real world. We are aware that health records and health date are considered as sensitive private information. They are subject to security and privacy regulations. Even though the use of NFC technologies for very sensitive actions, such as payment systems, is increasing, we think that having sensitive information in wearable NFC tags presents some risks. Therefore, we will take these concerns into account and will work to minimize these security and privacy risks in our design. Conclusion In this paper, we have described our technical proposal for collecting, recording, and tracking health vaccination records for children in a developing world context. Our solution comprises both bracelets containing NFC tags (that store information regarding 641

6 Work in Progress/Late Breaking the child s vaccination status) and NFC-enabled Android smartphones (that allow the doctors to access, read, and update that information). The bracelets also have the vaccination status recorded visually as a tattoo design printed on their surface, allowing both human readable and machine readable access to the information they contain. The tattoo design combines traditional ethnographic elements with easily interpreted variations to encode basic vaccination data in a form, which is aesthetically and culturally acceptable while still recording the important data. Figure 13: The App is automatically triggered whenever an NFC bracelet is located. Our future work includes conducting user research in real settings, in collaboration with NGOs. Furthermore, since we are dealing with sensitive private information, we will also devote effort to minimize the security and privacy risks inherent to this kind of technology. 2. Epstein, Edmund L The Language of African Literature. Africa World Press. 3. Heine, Bernd; Heine, Bernd, eds African Languages: an Introduction. Cambridge University Press. 4. Jeong B., Ibáñez J., Nunes N., Chen M Mobile App to Assist with Tattoo-encoded Baby Immunization Records in Africa. In proceedings of the 5th International Conference on Advanced Technology & Science (ICAT 17), Istanbul, Turkey. 5. Jeong B On-Skin Technologies: Aesthetic, Expressive, and Functional Tattoos for Child Health Records. ACM International Joint Conference on Pervasive and Ubiquitous Computing (Ubicomp/SWC 16) Heidelberg, Germany DOI: 6. Jeong B., Chen M., and Ibanez J A Tattooing for the Child Health Records Design that can Save Lives. In Proceedings of HCI Korea (HCIK 16), ACM Digital Library, Seoul, Korea, Jeong B., and Chen M The New Understanding of User-centered Design through the Extension of User Definition and Goal. In Proceedings of HCI Korea (HCIK 15) ACM Digital Library, Seoul, Korea, Jeong B An Ethnography Design for Cultural Implications in Africa. In Proceedings of 2015 KSDS Spring International Conference, Seoul, Korea, Jeong B Study on Ethnography Methods for Design Strategy. Proceedings of 2014 KSDS Spring International Conference, Seoul, Korea, Acknowledgements We would like to thank the anonymous reviewers who provided helpful and wise comments on the previous version of this document. The LARSyS has been funding this project, UID/EEA/ 50009/2013. Acknowledgement to ARDITI - Regional Agency for Development and Technology for the financial support through their grants in the scope of the Project with reference M References 1. Figure 14: The App visualizes the information pertinent to the corresponding vaccine. Dreyfuss, Henry Designing for People. Third Ed. New York: Allworth Press