The final Firefly phototherapy device (left) and its predecessor, the Bilibed phototherapy prototype (right) at Da Nang Women and Children's Hospital in Vietnam.

Design that Matters uses the power of human-centered design (HCD) to solve problems for and with the poor in developing countries. In a partnership with the East Meets West Foundation (EMW) and Vietnamese manufacturer Medical Technology Transfer and Services (MTTS), we developed the Firefly Phototherapy device to address the health crisis of untreated newborn jaundice in low-resource settings.  Our goal was to build on MTTS's novel Bilibed phototherapy prototype, which they had already piloted in several Vietnamese hospitals.

The Firefly project involved the work of hundreds of volunteers and input from countless medical experts in the US and potential users in a dozen countries overseas.  To maintain our focus throughout the Firefly design process, we defined four design principles: effective, comforting, maintainable, and user-friendly.

These four simple principles lead to Firefly's high-tech aesthetic, comforting bird's-nest environment, wipeable surfaces, and hard-to-use-wrong design. These features directly led to end user adoption and the extensive impact Firefly has seen since its introduction.

This is the story of how we interpreted those design principles for Firefly, and how user feedback gave us confidence that we were on the right track.

Left: The Bilibed prototype was not well trusted due to its outdated aesthetic. Right: Firefly is designed to look like a modern medical device.

1. Effective

A high tech aesthetic drives perceived efficacy and user adoption.

Everyone knows what an effective piece of medical equipment looks like; everyone has seen them on TV, and nearly every hospital has received donations of high-end western medical equipment. Unfortunately, the materials and manufacturing techniques available in Vietnam constrained EMW's and MTTS' equipment to a utilitarian, but outdated "Soviet" aesthetic. Though their equipment works incredibly well and is designed to be much more suited to the rugged context, people didn't trust the equipment on first impression. From Bilibed to Firefly, we updated the aesthetic with a shift to rounded corners, modern materials and manufacturing processes, for a modern medical aesthetic healthcare providers and parents could trust.

Feedback about Bilibed:

"We don't use the bilibed alone because we don't feel it illuminates enough of the baby."

- Dang Van Tai, Head Nurse, Moc Chau District Hospital, Vietnam

"The sex appeal of the bilibed is low. When I was visiting Vietnam to provide training, some parents insisted the doctors use the overhead phototherapy instead of bilibed because they looked more modern."

- Dr. Steven Ringer, Chief of Neonatology, Brigham and Women's Hospital

First impressions of Firefly:

"My first impression when I saw Firefly was that it was very modern and probably very good."

- Vu Thi Huong, Nurse, National OBGYN Hospital, Vietnam

Left: The Bilibed prototype didn't look safe and comfortable to many caregivers. Right: The Firefly device better secures the infant and surrounds them in soft curves.

2. Comforting

Better engaging caregivers with the High Tech Bird's Nest.

A surprising finding from our field research was that Bilibed's overall design was not only outdated, but it also did not set parents or healthcare providers at ease. Adults, whether parents or healthcare providers, have natural instincts when it comes to caring for babies. We saw healthcare providers showing preference for closed incubators over open beds due to the all-encompassing, womb-like environment. We frequently observed naked newborns receiving phototherapy while lying on rolled-up cloths wrapped around the newborns like nests.

The Bilibed's aesthetic with sharp corners and low sides made caregivers hesitate to use it for newborns. Dr. Binh of Moc Chau District Hospital asked DtM to, "the bed should look like a bird's nest." The result is a rounded bassinet just the right size for a newborn and clear sides just high enough to keep the baby safe, but enable caregivers to keep close watch on the newborn. Additional features include the ability to remove the bassinet to keep baby comfortable during a quick check-up and a rounded top light to prevent bumps and bruises when being taken in and out of the device.

Feedback about Bilibed

"It is important for the device to be comfortable, providing enough space for the infant. Once the baby feels comfortable, he will not cry, and his family will feel more confident about the treatment."

– Dr. Nguyen Van Loc, Doctor, Ninh Giang District Hospital

Feedback about Firefly

"Firefly creates a safe condition for the patient. The shape is like a bird's nest wrapping the infant and comforting him. With overhead phototherapy, the baby just feels like they are out in space and the light is hanging over them. In Firefly, the baby feels very safe and families and doctors feel comfortable."

– Dr. Khuat Thanh Binh, NICU Director, Moc Chau District Hospital

Left: The Bilibed prototype was difficult to clean. Right: Firefly incorporated smooth curves and removable baby bed for easy wipe-down.

3. Maintainable

Easy to clean means wipeable to reduce infection.

Cleaning is a long-standing challenge in low resource settings, with few personnel to treat the newborns, cleaning often falls by the wayside. EMW and MTTS knew the key to cleanability was wipability. The most common available cleaner in Vietnam is rubbing alcohol. With the Bilibed, MTTS made an attempt at wipability, but found the quilted vinyl cover provided plenty of nooks and crannies where germs could hide. Cross infection is a serious concern with neonates, with sepsis as a leading killer. The resulting Firefly bassinet is perfectly smooth with no sharp corners making dirt visible and wipeable. The bassinet is also removable to enable occasional deep cleaning in a sink.

"Firefly is easier to clean than the Bilibed because it's plastic, while the Bilibed has crevasses and is made of leather, so it never quite feels clean. We use a wet cloth to wipe down the overheads while we use a chloramine disinfectant to clean the Bilibed and Firefly because we don't have enough alcohol."

- Cam, Head Nurse, St. Paul General Hospital, Vietnam

Left: Healthcare providers didn't trust Moms to be alone with the Bilibed prototype. Right: Healthcare providers ask to put the more durable and easy to use Firefly in the room with mom.

4. User Friendly

Bringing phototherapy into mom's room by going beyond "User-Friendly" to "Hard to Use Wrong".

As the Bilibed phototherapy is only lit from the bottom, we observed a number of people felt the need to turn the baby from back to stomach. With Firefly, the top and bottom configuration provides light on both sides of the baby, saving precious time for misguided staff who would otherwise turn the baby.

In addition, some healthcare providers in rural hospitals reported the vinyl surface of the Bilibed did not seem comfortable enough for babies. As a result, many healthcare providers would lay down a blanket that also blocked the light.

Firefly also has a cleanable plastic bed surface, so we added a top light that can provide effective phototherapy on its own. With Firefly, any hospital should be able to provide effective treatment, even if someone unknowingly blocks the bottom light with a blanket.

Feedback about Bilibed

"We'd like to put the Bilibed in bed with mom, but we're afraid she'll break it by spilling water or getting baby's milk or urine on it."

- Dang Van Tai, Head Nurse, Moc Chau District Hospital, Vietnam

First Impressions of Firefly:

"Firefly has only one button. You turn it on and it can't go wrong. No one needs to think about the brightness. It is very easy to use with one button."

- Nguyen Ngoc Loi, NICU Director, National OBGYN Hospital

After Firefly use:

"For use in the mother's room, I prefer Firefly. This is because it can be right next to the mother so she can better take care of the baby and it takes up less space."

- Trung Thi Nhu Huen, Doctor, Da Nang Women and Children's Hospital, Vietnam

"During these past months, I have noticed that with Firefly, moms never make a mistake in using it. With the Bilibed, the head is often where the feet should be which blocks more of the light."

– Dang Van Tai, Head Nurse, Moc Chau District Hospital

"I am very happy! This is the first time I have been able to be with him since he was born"

- Nguyen Thu Tuyet, Mother, Da Nang Hospital for Women & Children, Vietnam

Human-centered design was critical in uncovering these insights that transformed the Bilibed into what we know today as Firefly. Our close partnership with EMW and MTTS and the HCD process enabled us to connect with more than 200 doctors, nurses, administrators, technicians, parents, (and newborns) in Vietnam, the Philippines, Cambodia, Nepal, Bangladesh, Indonesia, and India. As a result, Firefly phototherapy has become EMW's flagship product enabling their newborn healthcare program to expand rapidly to rural hospitals throughout Southeast Asia and Africa.

Summary

In order to design Firefly phototherapy, Design that Matters used human-centered design to collect feedback about the Bilibed phototherapy prototype developed by partners East Meets West Foundation (an affiliate of Thrive Networks) and manufacturer MTTS. The resulting four design principles led directly to Firefly's successful adoption by healthcare providers in nine developing countries.

* Effective: A high-tech medical aesthetic drives perceived efficacy and user adoption.

* Comforting: Better engaging caregivers with the "high-tech bird's nest".

* Maintainable: Easy to clean means wipeable to reduce infection.

* User-Friendly: Bringing phototherapy into mom's room by going beyond easy to use to make it hard to use wrong.

We've discovered that with a little modification, these Firefly design principles serve as excellent guidelines for just about any medical device.

The collaboration between DtM, EMW and MTTS from 2011-2013 was made possible with visionary support from the van Otterloo family, the Lemelson Foundation and many other donors.  Firefly has gone on to win loads of design awards, including the Edison Award Gold, the top Spark! design award and IDSA IDEA Silver.  Even better, Firefly devices have now reached 23 countries from Afghantistan to Zimbabwe, and as of May 2017 they have treated more than 100,000 newborns.  Go design!

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This "Design Experience that Matters" series is provided courtesy of Timothy Prestero and the team at Design that Matters (DtM). As a nonprofit, DtM collaborates with leading social entrepreneurs and hundreds of volunteers to design new medical technologies for the poor in developing countries. DtM's Firefly infant phototherapy device is treating thousands of newborns in 21 counties from Afghanistan to Zimbabwe. In 2012, DtM was named the winner of the National Design Award.