Alex Little

Today Mums for Mums launched their new website, they are a local charity in Mekelle – see their new website for more info about what they do! Just before I left my VSO placement I was helping them update their website to make it easier for them to post up news stories and keep it up to date, but we didn’t get chance to make the new WordPress-powered site live. However, over the last few months, Kat (from the UK) has been volunteering with Mums for Mums in Mekelle and has got the new site updated, re-designed and given training for the staff on how to post up news stories and maintain the site. It’s really great to have the new site finally up and running!

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.

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.

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:

We’ve just set up a demonstration site of our analytics and mobile site for the patient management tools. Previously if someone wanted to test out the tool for themselves, we could really only give them the mobile application and the protocols to look at, but we didn’t have a demo area for the server side. The only demo was on my laptop, and we can’t give access to the live site as it has real patient cases. I took this opportunity to look at using Amazon Web Services (EC2) for setting up the demo server – it all worked out really well and very easy to use.

You can log into the analytics/scorecard site at:

http://odk-demo.digital-campus.org/scorecard/ (username/password is demo/demo)

and the mobile version is at:

http://odk-demo.digital-campus.org/scorecard/mobile (same username/password)

The demo user has supervisor privileges, so is able to see all the data entered, usually health workers logging in would only get to see the data directly related to their patients.

If you would like to see the whole process, from entering the protocols on the smartphone, all the way through to seeing the cases on the analytics scorecard and mobile site, I also set up a demo ODK Aggregate server for submitting protocols. To set this up:

1. Download and install on your phone our version of ODK
2. start the app and enter the following settings (go to menu > change settings):
   • Server: http://odk-demo.digital-campus.org/ODKAggregate (note that this is case sensitive)
   • Username: demo
   • Password: demo
3. Go to ‘get blank form’ – this should connect to the server and show all the available protocol forms – select and download the ones you would like to try out
4. Enter and submit a few protocols from your phone
5. You will then be able to see the forms you have entered on the analytics scorecard, and the mobile version – note that the forms don’t appear instantly on the scorecard or mobile site, it may take a couple of hours, as we have some caching running, to make the site run more quickly

Please let us know how you get on – especially if I need to add some more info to the instructions above.

Araya, one of the PhD students from Ethiopia we have been working with for the last few years, has just this week had his first journal article published: “The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study”. More details on BioMed Central or PubMed. Abstract:

Background

Community health workers are widely used to provide care for a broad range of health issues. Since 2003 the government of Ethiopia has been deploying specially trained new cadres of community based health workers named health extension workers (HEWs). This initiative has been called the health extension program. Very few studies have investigated the role of these community health workers in improving utilization of maternal health services.

Methods

A cross sectional survey of 725 randomly selected women with under-five children from three districts in Northern Ethiopia. We investigated women’s utilization of family planning, antenatal care, birth assistance, postnatal care, HIV testing and use of iodized salt and compared our results to findings of a previous national survey from 2005. In addition, we investigated the association between several variables and utilization of maternal health services using logistic regression analysis.

Results

HEWs have contributed substantially to the improvement in women’s utilization of family planning, antenatal care and HIV testing. However, their contribution to the improvement in health facility delivery, postnatal check up and use of iodized salt seem insignificant. Women who were literate (OR, 1.85), listened to the radio (OR, 1.45), had income generating activities (OR, 1.43) and had been working towards graduation or graduated as model family (OR, 2.13) were more likely to demonstrate good utilization of maternal health services. A model family is by definition a family which has fulfilled all the packages of the HEP.

Conclusions

The HEWs seem to have substantial contribution in several aspects of utilization of maternal health services but their insignificant contribution in improving health facility delivery and skilled birth attendance remains an important problem. More effort is needed to improve the effectiveness of HEWs in these regards. For example, strengthening HEWs’ support for pregnant women for birth planning and preparedness and referral from HEWs to midwives at health centers should be strengthened. In addition, women’s participation in income generating activities, access to radio and education could be targets for future interventions.

VSO currently has many placements available in Ethiopia, especially in the Technology/Engineering departments of large universities. The placements listed below are just those available in Mekelle (there are more available in Addis, Jimma and Bahir Dar):

• Mechanical engineering MSc thesis advisor and lecturer
• Librarian
• Industrial engineering MSc thesis advisor and lecturer
• Facility management expert
• Electrical engineering thesis advisor and lecturer
• Computer science and information systems thesis advisor and lecturer
• Civil engineering thesis advisor and lecturer
• Chemical engineering thesis advisor and lecturer
• Architecture and urban planning teaching and thesis advisor and lecturer

The full list of placements can be found at: http://www.vso.org.uk/volunteer/current-roles/ (see the Education section)

Whilst back in Ethiopia I tested out the GPRS speed – previously we’d only really tested that a connection was available, not the actual speed of this connection. The results were:

I used the SpeedTest.net app for Android for this testing, and it’s just to give an idea about what the speeds are, I can make no promises that these are the same speeds you’ll experience!

I’ve just come back from a 10 day visit back to Ethiopia, spending a week back in Mekelle visiting our phd students’ projects and a few days in Addis following up some contacts there for future project development.

Case Management Tools for HEWs
We spent a couple of days with the Health Extension Workers and midwives who are using the maternal care protocols and scorecard:

• We introduced them to the HEAT mobile application we have been working on recently. Their feedback this was really positive. They liked being able to access the videos directly on their mobiles.
• One of our concerns was that they’d have trouble with the content and quizzes all being in English, but actually what the HEWs told us was that they liked it being in English, since the entrance exam for the HEAT programme will be in English, so having the self assessment questions in English is actually good practice for them. Although the real test will be if we see them continuing to use use it.
• They seemed to like the changes that we’ve recently introduced to the protocol forms and appreciate that the changes we are making are based on their suggestions for improvements. They seem keen to see us using the same system for other aspects of their work, for example IMCI (Integrated Management of Childhood Illnesses), tuberculosis, immunisations and others.
• The HEWs really like the mobiles and seem to have very few problems using them. In fact several have managed to create their own facebook accounts, even though we have never mentioned anything about this, plus other general internet access.
• Something we noticed was that many HEWs were not using the rubber protective covers for the phones, or the bags we provided. Apparently the rubber covers make it difficult to fit the phone in their pockets, and the bags are too small to hold the other items they need to carry for work. So we need to rethink what we provide them to help protect the phones. We’re thinking about getting the TVET college in Wukro to make some leather bags for us. They made the tables for our elearning labs at Mekelle Uni, so we just need to find a good bag design for them to create a sample for us.
• Solar lamps/chargers – originally we had given the HEWs a d.light to use to recharge the phones and for lighting. As a trial, we also bought one ST2 solar lamp/charger from the Solar Energy Foundation office in Addis. It seems only a few HEWs use the solar chargers for recharging their phones, most, even though they don’t have electricity supply at their Health Posts, charge their phones at home or elsewhere in the local town. For those who are using the solar lamps/chargers, they felt the one from ST2 was better as the battery lasted longer, and fully charged the phone. This works well for us since these devices are available in-country whereas the d.lights we would need to import. The cost for each type of device is roughly similar.

A couple of other observations/notes:

• Phone reliability. So far, after almost a year of usage, we have had a much lower level of phone breakage or loss that we originally expected. Our initial expectation was that we may need to replace around 25% of the phones per year. However, so far we have had no phones lost or stolen. The only hardware issue we’ve had so far is with some phones having insensitive touch screens. 3 of the 20 phones we initially bought have got insensitive screens, although 2 of these had insensitive screens when we initially bought them. We have some replacement screen kits, so we’ll try to fix these. We’re very pleased with this low level of breakage/loss, especially since we are using second-hand phones bought on eBay.
• We also need to start looking at which phone models may be a good replacement for the HTC Hero phones. Although the HTC Hero phones have been working well for us so far, they are a relatively old phone model, and their availability is likely to decrease, so soon we’ll start to look at which phones may make a good replacement model, based on cost/performance and availability. The only Android phones which seem to locally available are high end Samsung Phones, priced at almost 14,000 birr (approx 640 Euros) they are a little expensive!
• We heard that one of the local phone manufacturers may start to produce Android phones, so these could be a good alternative option to importing phones.
• I made few measurements of the GPRS speed, using the SpeedTest.net Android app. I’ve put this information in a separate blog post (and will post a link here).
• Henock, one of the research assistants, has been doing a really good job of following up and training the HEWs. I think it also helps a lot that he is from the local area where the HEWs are based.

Another local mHealth project
Whilst in Adigudem, we visited the health centre where they are running another mHealth project – funded by the Clinton Foundation. It’s a very different system to ours, as it’s SMS based, any newly pregnant mothers are registered on the system (by a technician in the Health Centre), with basic information, such as name, location, LMP & EDD. Then when the EDD approaches the HEW receives an SMS to remind the woman to go to the Health Centre for delivery. The HEW needs to respond, using a code to inform the health centre that she has received the message and whether she has been able to contact the mother.

Elearning Thin Client Labs
We visited the elearning lab at Ayder campus, but unfortunately it seems neither of the 2 labs we set up are currently functioning. The main issue is that with both of the servers the disks are full, so no-one can save any of their files, and no new user accounts can be created. Fixing this should be straightforward with help from the university ICT team.

EMRS System at Ayder
Ayder Referral Hospital, where the Health Sciences College is based has recently implemented an electronic medical records system, using the SmartCare system, which is also being used in Zambia. It has been implemented throughout the hospital, with over 100 medical staff having access to use the system. There is some more info regarding the SmartCare system on their website, although it’s a little unclear to me whether this system is open source or not, or how any new modules can be developed (maybe only the original developers can create new modules?). If anyone has more info on this, then please let me know and I can update this posting.

HEW Training
We visited the Nurse and HEW training college in Mekelle and met with the College Dean, and in Addis we met with Tedla from AMREF, who has been working with the HEAT programme for the last few years. Both these meetings have given us a lot more insight into how the HEAT upgrade programme for HEWs is now working, since it has recently changed from a blended/distance based course to centre-based. A couple of the HEWs who were working with us have now joined the college in Mekelle, where they’ll be for the next year for their HEAT training. So we’re interested to see if we can run a short talk to the rest of the classmates about the case management tools they were using.

In all the visit went very well, we’re really pleased with the progress being made and how much everyone seems to like the HEAT on mobile application.

Just posted on the Digital Campus blog:

Video demo of the patient management tools currently being used by Health Extension Workers on our project. This video shows the mobile protocols (using ODK), the mobile scorecard and analytics dashboard.

Since my camera broke the other day (I’m waiting for a new one to arrive), I used a flip camera for filming this, unfortunately it doesn’t focus well in close up, so the images of the mobile screen don’t show up well on this video, once my new camera arrives, I’ll refilm the video, to better capture the mobile screen.