News for the ‘Tuberculosis Management’ Category

Going global

all_colonies_blank_map1

A lot has happened in the last 6 months. Everyone involved with Mobiles in Malawi is excited by the SMS program’s impact on healthcare delivery at St. Gabriel’s Hospital. The medical staff and participating CHWs have taken ownership of the initiative, and what’s left of a public service grant will keep the program running for 10-15 years – at just $500 per year.

St. Gabriel’s is certainly not alone in the challenges it faces as a rural healthcare provider. After witnessing the effects of simple ideas and equally uncomplicated technology on medical care, one thing was clear – each day that a clinic goes without tools they want and need is a day with undue hardship.

To date, I am talking with healthcare organizations working in eleven countries (Burundi, Malawi, Uganda, Zambia, Mozambique, India, Kenya, Ghana, South Africa, Peru, and Haiti) about partnerships to expand the tools and strategies used at St. Gabriel’s to their respective sites. Details regarding these organizations and my role in supporting them will be expounded upon at jopsa.org in the coming weeks. In addition to healthcare providers, I’m honored to be collaborating with kiwanja.net, The kiwanja Foundation, the FrontlineSMS team, and MobilizeMRS.

After speaking with global health organizations and the clinics they’re linked to, it is clear that 2009 must be a year of action. Everything that happens will be posted here. I hope you’ll join me on this journey, and share your thoughts along the way.

Posted: January 21st, 2009
Categories: CHW Training, HIV/AIDS Care, Home-Based Care, Technology, Tuberculosis Management
Tags:
Comments: 3 Comments.

What’s everyone texting about?

A few, very committed individuals – my mother and sister – set out to answer that question. My mom, Casey Nesbit (DPT), receives every message that is sent to the hospital, via email (thanks to a simple forwarding command in FrontlineSMS). Those messages are in Chichewa. For four months, she translated every message to English.

My sister, Elizabeth Nesbit, decided to code and organize every SMS sent by the CHWs. She’s a sophomore at Rice University, making her way to medical school. She categorized messages by keywords and/or phrases (e.g. symptoms, supplies, patient updates/referrals, deaths, requests for help, requests for visits, meeting coordination).

Under this introduction is a list of all the symptoms found in messages communicated to the hospital. Elizabeth sorted these symptoms out into categories (body pains, digestive and urinary tract, respiratory tract, swelling, skin and sores, malaria and fever, weakness, heart problems, cancer, and other). She broke apart every incoming message this way.

Below the symptom list, you’ll find the fruit of their combined efforts – charts explaining the subject matter of texts to the hospital. Click on any of the charts to view a larger version. These messages fell between mid-August and early December. Shoot me an email if you want to see more of Elizabeth’s analysis.

Enjoy!

Symptoms:
scabs, TB, sores on lungs, swollen leg, swelling, weakness, bowel problems, begun to be sick, vomiting, hypertension, disease of the blood pressure, coughing, weak stomach, bowels, rash, malaria fever, HIV positive, coughing, weakness on ARVs, porridge coming out of nose, diarrhea, headache, weakness, swollen legs, delayed reactions, sick, swollen eyes, headache, weakness, loss of appetite, painful scar, unable to walk, leg and joint pain, cannot take medicine, itching stopped, trouble with teeth, sores, swelling in the legs, stomach, swelling, joint pain, trouble straightening leg, congestive heart failure, chest pain, headaches, pain in the joints, paralysis from knees up to waist, asthma, two patients ill, swollen leg, TB, high blood pressure, arm and leg, sores in mouth, mouth sores,TB patient with swollen legs, high blood pressure, stomach swelling, HIV, cough for three weeks, out of breath, swollen, sores, diarrhea, difficulty with legs, patients with diarrhea, stomach twisting, cramping, coughing, TB, HIV, trouble breathing, TB, pain in legs, legs not swollen, can walk, diarrhea, malaria, TB, can’t eat, cancer, not eating, vomiting, burning feet, swollen hand, back pain, severe headache, pain in middle of stomach, sick on ARVs, chest cold, frequent pain, lost voice, chest cold, coughing, chest cold, TB, asthma, trouble walking, boil, swelling, passing blood, TB patient feeling itchy, passing blood, swollen legs, itchiness, shaky because of food, head fever, or malaria, TB, shortness of breath, swelling in armpit, rash, eye, headache, malaria, drinking, convulsions, swollen stomach, elderly, needed food, diarrhea, ear problems, blood oozing out, body wounds, vomiting, swollen, fever, swelling of neck, swelling of stomach—head chief, cough, swelling in legs, stomach problems, out of breath, legs and stomach pain, wound, leg numbness, body aches, diarrhea, difficulty after stomach operation, HIV, crying, hot feet, coughing, malaria, vomiting, sick, trouble with legs, bursting sores, swollen feet, swelling, urine with blood, stomach pain, fever, congestive heart failure, unable to eat, head, fever, general body weakness, demented, swelling, chest cold from TB, body wasting, can’t walk, weak legs, trouble breathing, TB, malaria, body weakness, fever, chest cold, diarrhea, shortness of breath, back ache, leg pain, coughing, sick—malaria, vomiting, loss of appetite, headache, vomiting, malaria, feet pain, fever, back ache, arm pain, body aches, swelling, puss, pregnancy trouble, leg pain, not eating, difficulty breathing, oozing wound, swelling, legs, fever, leg swelling, legs, fever, swollen stomach, slight headache, swelling of legs, face, chronic heart failure, oozing, difficulty with legs, chest cold, stomach pain, diarrhea, leg pain, wound breaking out, leg pain, HIV positive, shingles, leg difficulty, body ache, coughing, cancer—passing urine, yellow body, malaria, convulsions, body aches, body aches, foot pain, swelling of feet, passing urine, soft voice, sleeping for many days, abdominal pain, diarrhea, malaria, cough, weakness, paralysis in feet/toes, illness of head, swollen stomach.

Message Summary

______________________________________________________

Symptoms and Illnesses


____________________________________________________

Supplies

____________________________________________________
Patient Updates and Referrals

___________________________________________________
Requests for Help
____________________________________________________

“Other”

Many, many thanks to my mother and sister for all their work.

Posted: January 11th, 2009
Categories: HIV/AIDS Care, Home-Based Care, Other posts, Technology, Tuberculosis Management
Tags: , , , ,
Comments: 19 Comments.

Tuberculosis, Meet FrontlineSMS

On Christmas morning, Silia stopped by the guest house to talk about the SMS program. He’s responsible for testing, drug provision, and follow-ups for TB patients. He described how he’s using FrontlineSMS and the network of cellphone-wielding CHWs. Almost all of what follows developed in my absence.


Some sputum-positive patients don’t turn up to receive their medication. It’s Silia’s job to track these patients and get them back on their drug regimens. Before the SMS program, he was visiting an average of 17 patients per week – this took him three trips on his motorbike. Each trip would take ~9 hours. That’s 27 hours per week spent tracking patients in various villages.

The SMS network has allowed Silia to share his workload with the CHWs. He now tracks an average of 20 patients per week via SMS. He simply texts CHWs nearby patients that haven’t turned up. As Silia says, the CHWs provide “immediate feedback.”

The program has been running for roughly 26 weeks. With the shift to SMS-based patient tracking, Silia had an additional 700 hours to utilize. Not surprisingly, he’s been using FrontlineSMS to supplement other areas of his work.

He now visits an average of 4 patients per week, for different reasons. Some messages from the CHWs tell of patients who are too ill to travel to the hospital. Silia will respond by bringing a new supply of drugs. Other messages relay symptoms of community members – e.g. “A man has a chronic cough, and we suspect TB.” Silia will visit the patients, and collect a sputum sample. He’ll return to the hospital to do testing and send the results, by SMS, back to the CHW.

Finally, when patients at the hospital test positive for TB, they’re told which CHWs near their home have cell phones.

Some numbers from the TB program for the last 6 months:

700 hours of follow-up time saved
450 follow-ups via SMS
(At least) $2000 in motorbike fuel saved
100 new patients enrolled in TB treatment program

Coming up: Impact on Home-Based Care, PMTCT, Public Health, and HIV/AIDS programs

Posted: December 25th, 2008
Categories: Technology, Tuberculosis Management
Tags: , , , , , ,
Comments: 4 Comments.

Back on the (Wet) Ground


I’m back in my old room at the hospital’s guest house, and it’s pouring rain. I arrived just in time for the last Home-Based Care course – 21 new, volunteer CHWs were reviewing referral procedures, patient rights, the contents of their drug kits, etc. The group, seen above, is copying acronyms into their notebooks. Here’s a snapshot of what they’re writing:

At the end of the session, the CHWs were asked to turn in a piece of paper describing the location of their home. Most of their responses were paragraphs long – some included extensive maps.

Joanna, who is running PointCare’s CD4-count outreach program, relayed an interesting conversation with one of the CHWs a week ago. She traveled to their farthest site – a good 100 mile drive – and ran into Zakeyo, who said, “You know, Josh is coming on the 19th.” I checked FrontlineSMS, and Alex hadn’t warned him. It’s exciting to know that the next time I see him, I’ll pass along a solar panel accompanied by a solar-powered light.

Tomorrow, I’m going to spend some quality time with FrontlineSMS – working through the communication over the last four months.

Please comment freely, or shoot me an e-mail, with any questions. I have just two weeks before I return to Stanford, and I’m trying to make the most of it! As always, thanks for reading.

Posted: December 20th, 2008
Categories: CHW Training, HIV/AIDS Care, Home-Based Care, Tuberculosis Management
Tags: , , , ,
Comments: 6 Comments.

CNN – “Texting to save lives”

That’s the headline the CNN Technology site is using to pull visitors to a story covering the project. Here’s the link:

Text service provides more than a Band-Aid for rural health service by Steve Mollman

It’s amazing to see Alex and Grace on the site, and I think Steve wrote a wonderful article. I’m headed back to the hospital for Christmas break, and I’ll be updating the blog regularly – starting now. Here’s a (very) quick 30-second video, as a re-introduction to the project and a few of the people involved.

In Writing – What’s Happened


Healthcare challenges

In 2008, FrontlineSMS was implemented as a central SMS hub for a rural hospital in Namitete, Malawi. Located 60 km from Lilongwe, St. Gabriel’s Hospital serves 250,000 Malawians spread over a catchment area 100 miles in radius. The vast majority of the people the hospital serves are subsistence farmers, living on under $1 a day.

• The catchment area has an HIV prevalence rate of 15% combined with widespread malnutrition, diarrhea, Multi-Drug-Resistant Tuberculosis (MDR TB), Pneumocystis pneumonia (PCP) and other opportunistic infections. Three medical officers are employed at St. Gabriel’s – creating a physician-to-patient ratio of 1:80,000.

• The hospital has enrolled over 600 volunteers to act as community health workers (CHWs) in their respective villages. Many of the volunteers are active members of the HIV-positive community, and were recruited through the hospital’s antiretroviral therapy (ART) program.

• When one ART monitor, Benedict Mgabe, was asked why he started volunteering, he replied, “I began when I saw my relatives and friends who were suffering from HIV and AIDS. I took it very personally; I knew I must get involved in curbing this epidemic.”

A need for a true community health network

Distance presents an often-insurmountable obstacle for patients seeking care at St. Gabriel’s. Many patients walk up to 100 miles to the hospital; those with more resources ride bicycles or oxcarts. In order to report patient adherence, ask for medical advice, or request medical care for remote clients, CHWs had to travel similar distances to the hospital’s doors.

The most motivated of the CHWs kept their own patient records, and journeyed to the hospital every few months. Their activities effectively isolated by distance, the impact of the volunteers’ work was restricted to their communities and disconnected from the centralized medical resources at the hospital – their potential role delivering healthcare stifled by disjunction.

Implementing the project

During the summer of 2008, I traveled to St. Gabriel’s with 100 recycled cell phones and a copy of FrontlineSMS – a free program developed by Ken Banks to act as a central text-message hub. My plan was to implement a text-based communications network for the hospital and the CHWs.

In groups of 10-15, CHWs were brought to the hospital, given cell phones, and trained in text messaging. The volunteers’ locations were mapped, and the phones were disseminated throughout the catchment area.

Stationed at the hospital, a laptop running FrontlineSMS coordinates the health network’s activities. The day-to-day program operations were handed over to hospital staff within two weeks. FrontlineSMS is operated by Alexander Ngalande, a nurse who heads the hospital’s Home-Based Care program.

Mr. Ngalande, on setting up and running FrontlineSMS:

“It was very quick. And, people didn’t know that this thing could work here – because, it’s our first time to have this kind of system whereby people can directly communicate with the hospital using FrontlineSMS. It’s simple and straightforward.”

Impact on patient care and hospital operations

The SMS network has enabled the following:

• Requests for remote patient care

  • CHWs text the hospital staff when immediate care is needed, and the patient is subsequently visited by the Home-Based Care mobile unit. Patient location and health status are communicated, allowing the mobile team to bring needed drug supplies. According to Dickson Mtanga, a CHW in the pilot program, “When I have a problem with my patient, I just send a message to the hospital, at once. If they are helped and assisted, I feel so much better.”

• Patient tracking

  • The hospital is now able to track patients in their distant communities. According to Mr. Ngalande, “Each and every department is free to use FrontlineSMS. We have ART, Home-Based Care, TB, PMTCT (Prevention of Mother to Child Transmission). For example, TB patients who are not coming for their appointments, we use FrontlineSMS to text volunteers close to the patient’s village. It’s easy to get feedback from the community.”

• Checking drug dosages

  • CHWs in the field have been given basic drug supplies (e.g. Panadol, Ferrous Sulfate, eye ointments) for primary care. The CHWs now check drug dosages and uses within seconds. When FrontlineSMS receives an SMS with a drug name, it automatically responds to the health worker with that drug’s information.

• Patient updates

  • CHWs regularly update the hospital staff with regards to patient status, including reporting patient deaths. These messages have created a post-discharge connection to patients’ well being.

• Coordinating Home-Based Care visits

  • In addition to responding to medical emergencies in the communities, the Home-Based Care (HBC) unit also follows a schedule of home visits – sometimes checking on patients have been discharged recently. Other patients are enrolled in the hospital’s palliative care program. Before traveling to the patients’ villages, the mobile unit text messages CHWs in close proximity to the clients they plan to visit. Any response by the CHW (e.g. “Patient is not at home.”) is forwarded to the mobile team’s phone, allowing medical staff to maximize their productivity by visiting available patients.

• CHW-to-CHW communication and group mobilization

  • CHWs are now communicating and collaborating. All texts are shuttled through the hospital, and FrontlineSMS commonly relays messages and requests between CHWs. This has been an important function in setting meeting dates for Village AIDS Committees and linking HIV/AIDS support groups. Hospital activities throughout the catchment area (including microfinance and Positive Living programming) are organized using the SMS network. Baxter Lupiya, a CHW in TA Kalolo, notes, “We used to travel a long distance. Now, we have easy communication with others. The program must be continued, because it is so good!”

• Integrating connectivity into HIV counseling

  • HIV Counseling and Testing (HCT) at the hospital has been augmented because of the SMS network. If a client tests positive, he or she is paired with to an HIV-positive CHW with a phone – these volunteers act as models for Positive Living and provide comfortable, relatable links to the hospital.

Other benefits:

• CHW status

  • The connection to hospital services has solidified the CHWs’ role as legitimate healthcare representatives in their villages. The patients and their communities, according to the program’s participants, have noticed the phones, each one clearly marked with the hospital’s logo.

• Incentives and accountability

  • The phones provided very concrete incentives for the volunteer work done by the CHWs. The SMS network created, for the first time, a way to track the CHWs’ activities, paving the way for more informed decisions regarding allocation of resources (e.g. which CHWs should receive bicycle ambulances).

A whole-hearted thanks goes out to everyone who has been reading these posts. I’d be thrilled to hear from you. In the next few days, I’ll put up a post that will (attempt to) cover the various, exciting ways this project is moving forward. In the next week or so, I’ll also be developing a DIY guide, based on a series of FAQs – much more on this later.

Verona Kapagawani; Community AIDS Committee Chair

As promised, here is an interview with one of the Community Health Workers involved with the pilot in Malawi. Verona speaks on why she started volunteering, how the SMS program has changed her ability to care for patients, and what it means to be a healthcare volunteer.

Here are a few of the messages sent to the hospital by Verona, in the first weeks of the pilot:

AK has a problem of CCF; his medicine is finished, and he is getting a bit better.

AJ is on TB treatment, he is taking the drugs following instructions. He is improving. AM had swollen thighs but she is improving. She is taking drugs following instructions – the guardian is strict.

Adherence: TN is alright. He is taking the drugs following the instructions, he did not miss any day.

PT is very fine, working hard in the garden. He did not miss any day.

Straight from the User

After a few days of traveling, I’m back at Stanford. It was difficult to leave Namitete, but there’s plenty to be done in the US.

Below, I’ve uploaded an interview with Alexander Ngalande, the hospital’s Home-Based Care nurse, regarding his experience with FrontlineSMS. Please excuse the poor quality – my equipment was limited to a small, digital camera.

Posted: August 14th, 2008
Categories: CHW Training, HIV/AIDS Care, Home-Based Care, Technology, Tuberculosis Management
Tags: , ,
Comments: 1 Comment.

Caught Smoking


A baker’s dozen left St. Gabriel’s Hospital on Thursday with cell phones, trained and ready to communicate. Below, a CHW practices texting “Malawi.” He’s the Home-Based Care provider in his village, and runs an orphan care center.

Text messages are notorious for being concise, hence the Short Message Service (SMS) protocol and its 160 character/message cap. Most of the messages to and from the hospital are brief, and to the point. Some CHWs, however, send stories – sometimes, five messages in length. A few examples (translated from Chichewa):

PF is refusing to use the condoms in his family which has made his wife to be pregnant of three months and he also drinks alcohol much, and also likes women. In so doing I advised him not to stop using condoms and also to stop drinking because they are putting his life in danger. And his wife should start going to her doctor visits, like at St. Gabriel’s.

I found TJ smoking, and he is on TB medication. He failed his first treatment in 2006, and this is his second treatment. AJ is on TB treatment, he is taking the drugs following instructions. He is improving. AM had swollen thighs but she is improving. She is taking drugs following instructions – the guardian is strict.

Both of these CHWs texted for the first time a little over a week ago.

I’m planning to video-interview a few of the CHWs this Tuesday and Wednesday. Any questions for them?

Posted: July 27th, 2008
Categories: Home-Based Care, Tuberculosis Management
Tags: , , , ,
Comments: 5 Comments.

Virtues of FrontlineSMS


Over the last week, there’s been a cascade of communication. A few examples, of many:

- A man missed his appointment with a TB officer. A CHW was texted, who reported the man had gone to Zambia for a funeral. The hospital will be notified upon his return.

- An HIV support group met, and decided on new member guidelines. Via SMS, the group leader asked the hospital to print copies for the lot.

- A CHW asked about ferrous sulfate dosages, so he could administer the proper amount to an anemic child.

I’m at the halfway point of my trip, and after five weeks on the ground, a discussion of the tools is in order. Ken Banks, the creator of FrontlineSMS, recently wrote an article about the emerging social power of mobiles for BBC News:

http://news.bbc.co.uk/2/hi/technology/7502474.stm

Ken is building a community of implementers. Interested parties should visit two of the group’s sites: www.kiwanja.net and www.frontlinesms.com.

It is precisely due to FrontlineSMS’s smart simplicity that the project has developed organically – first and foremost, to meet the hospital’s needs as it serves its catchment area. The quick uptake of the project was fueled, in no small part, by how user-friendly FrontlineSMS is, as a central communications hub.

It also has provided solutions to some potentially tricky questions. A quick example:

Text messages cost 10 cents. Units can be sent from one phone to another via Celtel’s Me2U service, but managing the units of 100+ phones manually is near impossible. So, I had to find a way to both monitor each phone’s unit level and top up (replenish depleted reserves) automatically.

Before leaving Stanford, I engraved each phone’s faceplate with a two-digit ID number. Using FrontlineSMS’s auto-forward function, I’ve set up a system to automatically top CHWs up. When they are running low on units, CHWs can text “(ID number) Units” to FrontlineSMS. Subsequently, a message is sent to Celtel, with instructions to top up that particular CHW. System abuse is unlikely and avoidable – the volunteers know that FrontlineSMS records every message received, sandwiched by unit requests.

We’re starting to explore additional functionalities of FrontlineSMS. Each CHW is given a kit of basic medications – a portion of the questions we’re fielding involve those drugs. We’ll set up an auto-reply system so that any message containing a given drug name returns a summary – function, dosages, etc. – for that drug.