News for the ‘Home-Based Care’ Category

Why I blog about (and work in) Africa

jopsa-farmer

With this post, I am responding to kiwanja’s tag, and following in the footsteps of very impressive voices. Here are my $.02.

If someone asked me why I blog about Africa, I would give a straight response, “Because I work there.” A question might follow – “Well, why do you work there?” I think I can tackle that query with a quick story.

I was at St. Gabriel’s Hospital in the summer of 2007, volunteering with the mobile HIV testing unit, helping with immunizations, and counting pills in the pharmacy. When I wasn’t occupied, I spent time in the wards with my Mother, a physical therapist. It was my first time on the continent.

I was told that the hospital serves over 1/4 million people, spread 100 miles in every direction. There were two doctors on staff, assisted by a small group of clinical officers. The staff told  me they had recruited over 400 volunteers to act as community health workers (CHWs).

In four weeks at the hospital, I met only one CHW, who came in every week or so. I’d learn his name was Dickson Mtanga.

One day, Dickson was watching my Mother as she worked with a stroke patient, keeping track of the different exercises. As always, he carried a small notebook, wrapped in newspaper. I had seen him with the notebook, before. This time, curiosity got the best of me, and I asked him what was inside. He turned to me with a smile, scooted my way, and proudly opened the journal – revealing impeccable drug adherence charts for over 20 HIV-positive patients he was tracking. He’d walk 15 miles to check in with the patients, then another 25 miles to the hospital – just to have the ART clinician sign off on his volunteer work, and look over the statuses of his patients.

The thought that there were, potentially, 400+ ‘Dicksons’ within the hospital’s catchment area stunned me. The staff admitted that these CHWs were as disconnected from the hospital as the patients, and Mobiles in Malawi was born. I write about Africa and Malawi because I work there, and the people I work for are there.

Posted: February 10th, 2009
Categories: HIV/AIDS Care, Home-Based Care
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Comments: 6 Comments.

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
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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
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Comments: 19 Comments.

SMS for Patient Care, in its Truest Form


I sat down with Alex today, to discuss the FrontlineSMS and its impact on the Home-Based Care (HBC) program at St. Gabriel’s. Essentially, he’s a one-man, mobile care unit – focusing on chronically ill patients and those who simply cannot travel to the hospital. The backpack, pictured above, is full of medical supplies.

The SMS network has brought Alex to the homes of 130 patients who would not have otherwise received care. That’s about five responses, per week, to requests for remote medical attention.

Before the SMS program, Alex was visiting around thirty patients a week, rotating through the HBC roster. He now follows up on five patients per week, usually checking in on those who have been recently discharged from the hospital. The CHWs take care of the rest – since the program started, approximately 520 HBC patient updates have reached the hospital via SMS.

The difference in Alex’s HBC activities amounts to about 500 hours and over $1,000 in fuel saved. He has responded to ~40 requests for healthcare supplies (usually dressing materials for wounds and cervical cancer patients). With FrontlineSMS blasting automated responses to drug inquiries and Alex responding to questions regarding basic care, the central SMS hub truly serves the CHWs and their patients.

Alex, who is a highly capable nurse, also holds full shifts in the male ward at the hospital, and is one of two staff members coordinating antiretroviral treatment (ART) for the catchment area. His multitude of responsibilities make time saved in managing the Home-Based Care program extremely valuable.

The first batch of solar panels from G24 Innovations (www.g24i.com) arrived today – I tested one of the products and it quickly charged my phone, to completion, amidst a thunderstorm. More on this later – we are gearing up for training and distribution on Monday.

Posted: December 27th, 2008
Categories: HIV/AIDS Care, Home-Based Care
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Comments: 17 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
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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
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Comments: 1 Comment.

Need-Stressing Couched in Gratefulness*

I promise I’ll explain the title – in a bit. First, here’s a re-cap of some of the week’s developments:

Above, I’ve provided a snapshot of today’s activities in the Home-Based Care (HBC) office, the new home of FrontlineSMS and the CHW maps. From left to right – Neggie, a nurse in labor ward; Grace, the hospital’s ART coordinator; Alex, the HBC nurse. Neggie showed up at the office with a list of mothers – they were enrolled in the hospital’s PMTCT program, but they’ve failed to report for their 6-week follow up (when blood samples are taken in order to determine the child’s HIV status by DNA PCR). Alex is locating the mothers’ villages, and reading off the ID numbers of CHWs in their vicinity.

These days, the majority of the patient visits made by the mobile team are responses to SMS requests for immediate medical attention. Still, certain visits are scheduled follow-ups after patients have been discharged. Traveling with Alex, I realized that, at least half the time, the patient is nowhere to be found. Alex now sends a few quick messages to the CHWs overseeing the patients he’s planning on visiting, letting them know he’ll be stopping by. While he’s out in the field, any response from the CHWs is forwarded to his cell phone. This assures that he sees patients who are available – and avoids 40-mile journeys to discover a patient is away, selling maize in Mozambique.

A CD4 outreach initiative funded by the World Bank starts up later this week. They will use the CHW communications network to inform villagers of testing sites and dates – aiming to increase client turnout, thereby bolstering access to the free testing services.

This past Saturday, we gathered the first 30 CHWs for a refresher course – explaining the automatic unit top-ups and the drug keywords (we’ve already had BB Paint, TEO, Panadol, and Multivitamin info requests). After the session, I video-interviewed four of the CHWs, in English.

I’m leaving Malawi this coming Friday, and when I’m back at Stanford I will be uploading the videos. I’m planning to embed them in individual posts – so you can hear the stories of care from those who have lived them. Their general attitude might be described as thankful, yet realistic about the pressing needs of their families and friends – hence, the title of this post. Malawians are said to spend roughly 10 percent of their waking hours at funerals. The statistic does reflect troubling times – but it also demonstrates the blurred boundaries between family and fellowship. Villages are full of brothers, sisters, and mothers – some share heredity, but all share circumstances. Every text message sent by the CHWs has invited me to appreciate the true meaning and function of community.

*title credit: Maggie Chen

Posted: August 4th, 2008
Categories: HIV/AIDS Care, Home-Based Care
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Comments: 6 Comments.