Archive for November 2012

New research paper: Knowledge and performance of the Ethiopian health extension workers

Araya has just had his second paper published: “Knowledge and performance of the Ethiopian health extension workers on antenatal and delivery care: a cross-sectional study”. The full paper is available from Human Resources for Health, provisional abstract:

Background

In recognition of the critical shortage of human resources within health services, community health workers have been trained and deployed to provide primary health care in developing countries. However, very few studies have investigated whether these health workers can provide good quality of care. This study investigated the knowledge and performance of health extension workers (HEWs) on antenatal and delivery care. The study also explored the barriers and facilitators for HEWs in the provision of maternal health care.

Methods

In conducting this research, a cross-sectional study was performed. A total of 50 HEWs working in 39 health posts, covering a population of approximately 195,000 people, were interviewed. Descriptive statistics was used and a composite score of knowledge of HEWs was made and interpreted based on the Ethiopian education scoring system.

Results

Almost half of the respondents had at least 5 years of work experience as a HEW. More than half (27 (54%)) of the HEWs had poor knowledge on contents of antenatal care counseling, and the majority (44 (88%)) had poor knowledge on danger symptoms, danger signs, and complications in pregnancy. Health posts, which are the operational units for HEWs, did not have basic infrastructures like water supply, electricity, and waiting rooms for women in labor. On average within 6 months, a HEW assisted in 5.8 births. Only a few births (10%) were assisted at the health posts, the majority (82%) were assisted at home and only 20% of HEWs received professional assistance from midwives.

Conclusion

Considering the poor knowledge of HEWs, poorly equipped health posts, and poor referral systems, it is difficult for HEWs to play a key role in improving health facility deliveries, skilled birth attendance, and on-time referral through early identification of danger signs. Hence, there is an urgent need to design appropriate strategies to improve the performance of HEWs by enhancing their knowledge and competencies, while creating appropriate working conditions.

mHealth: Patient Identification Issues

Patient identification is still proving to be quite an issue with the records that Health Workers are submitting, making it difficult to be sure that a record for a follow up visit is attached to the right patient.

As not everyone has an id number we can use, originally we asked health workers to identify patients by the id number they enter in their log book. This, we thought, had the advantage that we could easily then match up the database records to the paper records. The combination of this and the health post name (selected from a text list in the form, but stored as code number in the database) should have given us a unique identification for each patient. Only the first registration form contains the full name, on the other visit forms, we just ask for the health post name and the id number, plus the year of birth and age to use as checks for the data.

Using the year of birth and age checks we can identify where patient ids may have been entered incorrectly, but we are seeing quite a lot of errors. In theory rectifying these errors shouldn’t be very time consuming or difficult, assuming that follow up calls to the HEWs are made soon after the error is made. Unfortunately, delays to following up these errors, mean that now it will be quite difficult to fix all the errors.

On each patient visit form, we recently also added the patient first name, as an aid to matching errors back to their correct registration forms.

Some of the problems we have come across include:

  • Two (or more) patients being registered with the same ID number
  • Patient visit forms being entered with the wrong ID – and so getting matched to the wrong patient registration record
  • Patients being re-registered with a new id number, especially when they may attend a visit at a different health post, or in a health centre. HEWs issue a registration card to each patient when they are first registered. If the patient later visits a different facility, the health post name and id from the card should be used, but seems this is not always happening and patients are getting re-registered. This makes it very difficult to track whether patients are following up on referral advice.
  • Some health post have restarted the numbering in their log books (the new year in the Ethiopian calendar started in September), so we are starting to see the same id number being re-used for new patients (although this wasn’t meant to happen)

Given the lack of reliable identification numbers, it was probably inevitable that we would have experienced some errors with correctly matching records up. I would have hoped that with quick follow up to rectify errors, the health workers would have soon got used to taking extra care when entering patient id information.

There are other options we could have taken for patient identification, but these may have also had their own drawbacks. For example:

  1. pre-registering all patients in a given area – though this seems like substantial work; or
  2. providing a set of pre-generated bar codes or numbers (with check digits), which the HEWs can issue when the see a new patient. A check digit mechanism, would have really helped ensure mistakes in entering id numbers were minimised – though it may not have avoided the same numbers being reused for different patients. In retrospect I think this is the approach we should have taken.

Another factor which may have contributed to this problem is that we’re forcing ODK to do something that it probably wasn’t really designed for. ODK is a general data collection tool, each form is an independent entity, not necessarily designed to link up records entered from different forms. Some other recent mHealth tools, have a front-end so the user needs to click on a particular patient to enter the a visit record. But this requires some form of synchronization of the data between the phone and the main database, to ensure that all the patients a health worker may visit have their records already stored on the phone, otherwise it may lead (again) to patients being re-registered.

In Ethiopia, there seem to be some efforts to resolve this identification issue, for example the national Health Management Information System (HMIS) or Family Folder system, but these aren’t fully rolled out to all the health posts we’re working in, so we wouldn’t be able to take advantage of these. It seems to me that for these types of mHealth tools to work well and generate good quality reliable data, then a reliable and consistent system for patient identification is required, but hopefully this will be coming soon in Ethiopia.

Update on Ethiopia Visit

Have just returned from another visit back to Ethiopia, a week in Mekelle to see how the Health Workers are getting on, followed by a few days in Addis, mainly in meetings and catching up with friends.

The new batch of Health Workers who started with us in the last 3 months are doing really well, and we updated their phones with the latest version of the mobile learning app, along with the video content. The research program is due to run until April next year, and we’re looking at ways in which Health Workers can transition over to the new national mHealth program. This national program has started recently and the pilot area in Tigray (there are other pilot areas in other regions) overlaps with where we’ve been working and the HEWs are already familiar with the phones.

Although the national pilot is focused on maternal care, so the forms/protocols and technology used should be very similar, I think there are some differences in the implementation. I’m not sure the details have been finalised, but the information I currently have is that there will be one phone per health post (so 1 per 2 HEWs) and the phones will have some restrictions on which apps can be accessed. I’m not sure how the HEWs who have been working on our research program will react to this, as is more restrictive than what they have become used to. I think one of the reasons that our project has been relatively successful is because we tried to encourage the HEWs to take real ownership of the phones, they have one each and we allow them to use any of the apps on the phone (or even install apps themselves). I think this ownership explains why we’ve had such a low level of loss/breakage (only one phone was stolen, but then later recovered) and we’ve had very few technical issues (accidentally deleting apps/files etc). There will be much more information on all this once we get the feasibility and technical papers finalised and published in the coming months.

Whilst in Mekelle I also visited the Health Sciences campus and the lab we set up there over 3 years ago now. The lab is still (just about) running, surprising given the very low level of maintenance it has had for the last couple of years. The Health Sciences college has been investing a huge amount in improving student computer access. They’ve recently purchased over 300 Macs, most people don’t believe me, until they see the photo, so here it is:

Mac lab at Ayder campus

Although it wasn’t quite up and running when I visited, they’re just waiting for the wireless network to be set up, the lab looks really impressive and is almost certainly the most number of Macs in one room in Ethiopia! I should also mention that these Macs weren’t from a donor, but purchased directly by the college. I hope the students can make really full and effective use of this resource. I believe the college also has plans to buy large numbers of Galaxy Notes, for students to be able to loan from the library in the same way they loan books. These new Macs are in addition to a smaller Mac lab (approx 50 machines) which has been established for a while now.

Back in Addis in the last week, we’ve had lots of meeting with various NGOs and technology companies here, as there is now a lot of interest here in mHealth, specifically around using smartphones. So hope our research project in Tigray can provide a lot of information and lessons learned to contribute to the success of any new projects. But I still get the feeling that mHealth is seen as the silver bullet rather than just the tool. I think mHealth by itself is unlikely to solve many underlying problems of low level of training, lack of motivation etc.

I also met up with Ahmed, a masters student from Addis Uni, who recently contacted me about porting our mobile learning application to run on J2ME phones. He has made excellent progress and it looks really good, but still a few areas to get finished off. I’d originally thought he was doing this as part of his masters project, but seems not, he’s just doing this because he’s interested and wants to move into programming/computing after he finishes his masters.

Here are the rest of the photos I took: