FONEASTRA
A low-cost system to safely pasteurize breast milk designed for resource-constrained environments
Saving lives through collaboration
My team and I collaborated with PATH, an international global health NGO, as part of an HCI class on designing technologies for resource-constrained developing regions.
Babies in these regions are vulnerable to severe malnutrition, illness, and fatality due to premature birth, low birth weight, HIV, or being orphaned. Breast milk has the capabilities to nurse the infant back to health, and contains a higher nutritional value than formula — which is harsh on his digestive system, risks exposing him to pathogens in water, is expensive, and inaccessible.
These babies need the nutritional and immunological properties that breast milk provides.
In South Africa, 40% of mother-to-child HIV transmission is through breast milk. HIV can be eliminated from breast milk through pasteurization. But currently, pasteurization is a process that requires an expensive ($2000-$12,000) and large machine that needs to process large batches of breast milk at a time. All of this makes it difficult to scale in terms of cost, real-estate, and donated milk in resource constrained environments.
In an effort to mitigate the constraints that pasteurization machines pose, PATH developed a low-cost technique to pasteurize breast milk called Flash Heat Pasteurization (FHP). FHP is as simple as heating up breast milk to 72℃, in a pot of water, for at least 15 seconds.
Flash heat pasteurization makes safe breast milk accessible to anyone with a jar, a pot, and a heating source.
PATH wanted to drive adoption of FHP in order to increase the number of human milk banks and eventually provide access to this technology in homes and communities. In order to do so, they would need to ensure the safety, reliability, and record keeping of every FHP session.
The challenge
PATH challenged us to design a low-cost system that could monitor temperature, give feedback, and provide quality assurance for nurses and volunteers conducting FHP in South Africa. The long term goal would extend use to mothers and caretakers in homes and communities.
The technology to make it happen
The FoneAstra is a networked sensing system that was built by Computer Science Phd candidate Rohit Chaudhri. PATH previously worked with Rohit to use the FoneAstra platform to monitor temperature in vaccine cold-chains and had the ability to notify the necessary people via SMS if a temperature went out of range.
It had two of the things we needed — a way to monitor temperature and transmit the data — and it was low-cost. But it did not afford direct user interaction.
We talked about the additions that would be possible to implement with the FoneAstra that Rohit would work on: a water proof, food-grade temperature sensor; beeps, LEDs, and a 16-character, 2-line LCD display to provide audio and visual feedback; and the phone to send data to and from a QA analyst. We then simultaneously worked on research, design, and development.
The deep dive
Our team was challenged not only by a problem space that was unfamiliar, but we also had limited access to the people that would be using the system and the environment of use — both would require a flight to South Africa.
What we did:
We started with a literature review that covered a wide variety of topics. We explored:
- The use and experience of other products and methods used to make breast milk safe
- PATH’s literature, use cases they developed, and interviews with users
- The possibilities and limitations of the FoneAstra technology platform
- The experience and effectiveness of the FHP method developed by PATH compared with other pasteurization methods
- The stigma around the HIV virus and cultural acceptance of products to combat HIV transmission
- The safety and storage of breast milk after pasteurization
- Other organizations and companies doing work in the area
- The operations and processes within milk banks
This prepared us with an initial set of questions to dive deeper in our interviews. I conducted in-depth interviews, over Skype and in-person, with subject-matter experts that worked at PATH. From these interviews we got a better understanding of the people conducting the FHP process and about the environment.
We then conducted in-house experiments administering FHP, so that we could immerse ourselves in the process and get a better understanding of the steps and what the user would be going through. We also observed the effects of using different materials and heating intensities on FHP, as this would be a factor that differed within homes and communities.
What we learned:
Consolidating our research gave us a couple things to consider while designing:
- We would need to design a system that gave clear, simple instructions that took into account an audience with varying levels of medical knowledge and literacy.
We learned from our interviews that the people conducting FHP in each of the hospitals that PATH was working with, could either be a nurse or a volunteer. Nurses typically had about 2 years of medical experience and had many other duties along with FHP. Volunteers were typically mothers that came in and were trained by the nurses specifically on how to run the FHP. The levels of literacy varied amongst the volunteers. - To design a system that could preserve as many nutrients as possible, we would need optimize when feedback was triggered to best match the temperature curve required for pasteurization.
Currently, the nurses and volunteers were using the visual indicator of water coming to a rolling boil as the indicator to remove the milk from the heat. This works in a controlled environment. But as we saw in our in-house experiments, there were instances where the milk would reach its optimal temperature either before or after the water was boiling. Reaching the optimal temperature of 72℃ for 15 seconds kills HIV, but anything past that starts killing more and more of the nutrients babies need. - Our system should prioritize successful pasteurization over optimization.
From my interview with a PATH nutritionist in South Africa we learned that one of the implications our system would be introducing is the possibility to disapprove a batch of milk (the current method ensured that the milk was at least heated enough to eliminate HIV). She expressed the importance of donor breast milk and that they try to make sure that it’s safe and does not go wasted. It’s important that any design puts successful pasteurization first.
I gathered photos of the milk bank unit in one of the hospitals so we could better understand the environment where the system would be used.
We then mapped out the FHP process and identified points at which the user would need feedback from the system to successfully pasteurize a batch of milk. I then designed a set of light, sound and text combinations to guide the user through the process.
Wizard-of-Oz, the flames and all
We started by creating a lo-fi prototype of the system with cardboard, LEDs, and strips of paper to simulate text on LCD display. Using the Wizard-of-Oz method, we acted as the “computer” by monitoring the temperature on a laptop, and triggered the feedback accordingly while the participant went through the FHP process.
The Wizard-of-Oz method allowed us to quickly test the design for a low-cost before a fully functional prototype could be developed.
From our lo-fi testing, we observed the following:
- Audio feedback is a must
In this phase we only tested the visual feedback via LEDs and text because there was trouble incorporating audio feedback on the development end. It raised questions as to whether it was necessary. Though we believed audio feedback would be important, we tested our assumptions through paper prototyping. We found that it was hard for participants to keep their attention on the system while they waited for the next step — it made them nervous and feel like they would miss a step. - Acknowledgement is needed
In the feedback we tested, there was a discrepancy between what the participant considered a step and expected feedback, and what the system acknowledged as a step. There were times during the process where we observed hesitation and uncertainty from participants after completing a step. They felt like they should visually see some feedback or information that confirmed that they were on the right track. - Textual feedback needs to be more informative and actionable
We saw during our study that textual feedback such as “Analyzing”, when participants should be waiting for QA approval made it unclear what they were supposed to be doing at that time. The text prompts needed to inform the users of what was going on and also what action they needed to be taking.
Testing the real thing
We refined our design to include:
- Temperature data so that users could visually quantify what was happening during the process
- More “call-to-action” prompts so participants were aware of what they needed to be doing at each step
- Intermediary feedback that acknowledged actions and also primed participants for actions that were coming up
We tested with with users that were both familiar and unfamiliar with the process because the people that would need to use the system had varying levels of knowledge. To simulate the training they would receive at the milk bank, we designed the study to include an introductory training portion about the FHP process prior to conducting the test of the system.
All participants successfully completed FHP of the milk. Our post study questionnaire showed that participants thought the system was easy to use. One of our participants stated:
“Intuitive, impressive…easy to understand. The device walked me through all the steps so I really didn’t have to think things through…”
The Success Story
Path pilot tested the FoneAstra pasteurization system at multiple locations in South Africa following our design iterations. The system received positive feedback and 100% of test batches returned HIV-free.
PATH received the Gates Grand Challenges Explorations award of $100,000 to continue research and development after the pilot test.
The project is still under development and received a second round of funding from the Bill and Melinda Gates Foundation of $1 million. The latest version of the FoneAstra pasteurization system has a smart phone and bluetooth printer integration.
