SMP Health Links Forum 14th May 2015
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This document discusses the use of mobile health (mHealth) in Malawi. It provides examples of how mHealth can be used for health services and information through tools like PDAs and mobile phones. Some potential uses of mHealth mentioned include education and awareness, remote data collection, monitoring, communication and training for healthcare workers, and disease tracking. The document also discusses strengths like increased mobile coverage and affordability, as well as challenges such as security, app relevance, and costs. Specific mHealth tools used in Malawi are mentioned like Dial a Doc and emergency triage assessment. Barriers to healthcare at the primary level are summarized from a study. Next steps proposed for further developing mHealth in Malawi include optimizing emergency
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SMP Health Links Forum 14th May 2015
- 1. Tweet us @ScotlandMalawi #SMPhealthforum
- 2. mHealth in Malawi Tweet us @ScotlandMalawi #SMPhealthforum
- 3. mHealth: “using mobile communications- such as PDAs and mobile phones- for health services and information” Tweet us @ScotlandMalawi #SMPhealthforum
- 4. Tweet us @ScotlandMalawi #SMPhealthforum ■ Education and awareness ■ Remote data collection ■ Remote monitoring ■ Communication and training for healthcare workers ■ Disease and epidemic outbreak tracking ■ Diagnostic and treatment support
- 5. Tweet us @ScotlandMalawi #SMPhealthforum Strengths/potential: – Growing mobile coverage/reach – Relative affordability and access to handsets Concerns/obstacles – Security/privacy issues – Relevance of apps – Limits of existing tech systems/connectivity – Costs to individual – Commercial sustainability- many NGO-funded
- 6. Tweet us @ScotlandMalawi #SMPhealthforum
- 7. Tweet us @ScotlandMalawi #SMPhealthforum
- 8. Tweet us @ScotlandMalawi #SMPhealthforum
- 9. Tweet us @ScotlandMalawi #SMPhealthforum
- 10. Tweet us @ScotlandMalawi #SMPhealthforum
- 11. Tweet us @ScotlandMalawi #SMPhealthforum
- 12. Tweet us @ScotlandMalawi #SMPhealthforum
- 13. Tweet us @ScotlandMalawi #SMPhealthforum Dial a Doc Airtel 321 Mhealth on *567*41#
- 14. Tweet us @ScotlandMalawi #SMPhealthforum Toll free hotline “Tips and reminders” messaging
- 15. Emergency Triage Assessment and Treatment (ETAT) for children at primary care using mHealth SMP Health Links Forum
- 16. Barriers to recognition and treatment of meningitis at Primary Health Level Primary health level misdiagnoses High numbers of patients Erratic consultation systems Unsystematic Desmond et al 2013 PLOSone
- 17. Desmond et al 2013 PLOSone • Negative perceptions of health services • Low level of awareness of meningitis • Gender and age-based decision making in community • Financial constraints Barriers to seeking timely treatment for meningitis at community level Desmond et al 2013 PLOSone
- 18. Action Meningitis • Improved recognition of severe illness • Appropriate referral Primary Health Level Community Level • Community recognition & awareness of meningitis and triage system • Initiation of timely treatment Triage system Theatre Radio
- 19. Primary Health Clinics: Blantyre Primary Health Level Triage system
- 20. • Severe illness regularly missed • Limited number of HCW, equipment & supplies • HCW overwhelmed • Long queues Primary Health Clinics: Blantyre
- 21. Aims: 1. To develop a triage system, tailored for PHCs 2. To implement this system within 5 PHCs in Blantyre and 3 centres in Chikhwawa 3. To encourage appropriate referral decisions to hospital & track referrals 4. To monitor, evaluate and refine this system Implementation of Triage System
- 22. ‘mHealth’ Triage Tool • Emergency Triage, Assessment and Treatment (ETAT) protocol developed by the WHO. • Designed for hospital settings, in resource-poor countries. • Specifically aimed at lower cadre staff.
- 23. Emergency Priority CHILD IS VERY SICK. PRIORITY MUST BE GIVEN IN THE QUEUE Queue CHILD HAS MINOR INJURY/ILLNESS. TO WAIT IN THE QUEUE CHILD IS EXTREMELY SICK. TO BE SEEN IMMEDIATELY Triage classification ‘Chipatala Robot’
- 24. Improving patient pathways Patient enters PHC HCW conducts rapid triage Patient assigned E, P, Q Clinician conducts consultation & enters dataAdapted from Sarah Bar-Zeev (2012) Patient follows clinician instructions Patient Triage PHC ClinicianQECH Fieldworker If referred to QECH data entered on arrival
- 25. Bangwe clinic
- 26. Evaluation
- 27. “At Bangwe we are now working together as a team. It is helping us manage the children so much better. We are seeing them far more quickly than before” Patient Journey Modelling • Identified positive changes in patient flows Semi-structured interviews • Patient and health worker satisfaction high Medical Assistant, 2013 Summary
- 28. Next steps – three year time plan - Optimise ETAT system in 8 centres plus benchmarking 3 new clinics. - Provide evidence that mHealth triage can be successfully implemented country-wide in a sustainable and cost-effective way. - Produce a full implementation and management package for transference to MoH ownership Community Level .
- 29. Thank you SMP Health Links Forum
- 30. Can Mobile Communication be used to Promote Health Promotion in the Developing World? 14th May 2015 Department of Civil and Environmental Engineering University of Strathclyde
- 31. A bit about me… • PhD student , University of Strathclyde, Civil and Environmental Engineering. • Scotland Chikwawa Health Initiative, led by Dr Tracy Morse at the Polytechnic in Blantyre and Dr Tara Beattie at the University of Strathclyde. • SCHI, primarily funded by the Scottish Government, is working in the Chikwawa district to implement the WHO Healthy Settings approach to community living.
- 32. Why mHealth? 30% of the population own a mobile phone with a 70% increase in subscribers in the last 6 years (ITU, 2014). 94% of the country has access to adequate mobile coverage, reaching 79% of the geographical area of Malawi (GSMA, 2012). Therefore due to wide accessibility of mobile coverage the potential for mobile communication to aid the health sector in Malawi is promising.
- 33. Advantages to Health Recently in the news that Malawians spend 56% of their monthly income on their mobile phone, the biggest mobile phone expenditure in the world (ITU, 2014) Advantages of mHealth: o Quick information output to large numbers of participants o Access to messages without restrictions on time or location o Anonymous access to information (on their own phone)
- 34. mHealth Intervention Process Post Intervention Measures Implementation Baseline Measures Message Creation Target Health Areas
- 35. Target Health Areas • Focus Group Discussion for baseline data of SCHI • Secondary Analysis for health issues 0 1 2 3 4 5 6 7 8 9 10 General Leadership Men Women Elderly Male Youth Female Youth Frequency Sample Population Health discussion by topic and focus group HIV/AIDS Family Planning Hygiene Malaria Cholera Diahorrea Nutrition Early Pregnancy/Marriage Rabies Elephantiasis
- 36. 0 1 2 3 4 General Leadership Men Women Male Youth Female Youth Frequency Sample Population Health Education request by topic and focus group HIV/AIDS Family Planning Malaria Hygiene Nutrition Health Education “…lack of health education provision was highlighted by male youth specifically the need for hand-washing.” Kalonga Village Profile “Men requested health education on how to achieve the six food groups” Kalonga Village Profile
- 37. Youth Friendly Services mhealth can be used to engage adolescence into health services It won’t replace their need for support and counselling…but will improve their knowledge until such services can be put in place “…the lack of youth friendly services was noted by male youths and is a deterrent to them accessing health education and services.” Thukuta Village Profile Male youth in 5 of the 18 villages mentioned the need for youth friendly services
- 38. Message Creation Based on specific health issues from focus groups and on WHO guidelines SMS or Voice Messaging [potential for role modelling] -Biran et al., (2014) Promoting Hand washing in rural India -Irivine et al., (2012) SMS intervention for Disadvantaged Men Translated into Chichewa Piloted for cultural relevance
- 39. Design Intervention Group Control Group • Baseline measures • Intervention access • Post-intervention measures • Baseline measures • Usual healthcare services • Post-intervention measures
- 40. Implementation
- 41. Evaluation Evaluation is key -effectiveness of the intervention -relevance to the people of Chikwawa -cost-effectiveness Are mobile health interventions feasible as a health education tool in Malawi?
- 42. Next Steps… August-October; Focus groups and message creation Call for Technical Experts… • Experience using Telerivet or similar programmes, it would be great to get some input.
- 43. Malawi Ml lennium Pr oject The M a l aw i Po l yt echni c Rebecca Laidlaw PhD Student Scotland Chikwawa Health Initiative University of Strathclyde rebecca.laidlaw@strath.ac.uk References Biran, A., Schmidt, W., Varadharaian, K., S., Raiaraman, D., Kumar, R., Greenland, K., Gopalan, B., Aunger, R., & Curtis, V. (2014). Effect of behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. The Lancet, 2(3), e145-e154. Groupe Speciale Mobile Association. (2012) TNM – Malawi – Feasibility Study. Retrieved from: http://www.gsma.com/mobilefordevelopment/tnm-malawi-feasibility-study International Telecommunications Union. (2014). Measuring the Information Society Report; Executive Summary. Retrieved from: https://www.itu.int/dms_pub/itu-d/opd/ind/D-IND-ICTOI-2014-SUM-PDF-E.pdf International Telecommunications Union; Facts and Figures. (2014). Mobile-Broadband uptake continues to grow at double-digit rates. Retrieved from: http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2014-e.pdf Irvine, L., Falconer, D., W., Jones, C., Ricketts, I., W., Williams, B., & Crombie, I., K. (2012). Can text messages reach the parts other process measures cannot reach: an evaluation of a behaviour change intervention delivered by mobile phone? PLOS ONE, 7(12), 1-6.
- 44. mHealth in Malawi Tweet us @ScotlandMalawi #SMPhealthforum
- 45. Malawi Floods 100 days on… Tweet us @ScotlandMalawi #SMPhealthforum
- 46. Tweet us @ScotlandMalawi #SMPhealthforum
- 47. Tweet us @ScotlandMalawi #SMPhealthforum
- 48. Tweet us @ScotlandMalawi #SMPhealthforum If you are a citizen of a developing Commonwealth country, you can apply for • Scholarships for Master’s and PhD study at a UK university • Split-site Scholarships for split-site PhD study at a UK university • Shared Scholarships for Master’s study at selected UK universities • Distance Learning Scholarships to study UK Master’s degree courses in your home country • Academic Fellowships for early career academics to spend time at a UK university • Professional Fellowships for mid-career professionals to spend time at a UK host organisation • Medical Fellowships for doctors and dentists to spend time at a UK hospital
- 49. Tweet us @ScotlandMalawi #SMPhealthforum
Editor's Notes
- Hi.
- Barriers to recognition and treatment of meningitis identified at primary level include: 1. Misdiagnosis of meningitis, commonly with malaria 2. Unsystematic prioritisation – adults and children sitting together and seen on a first come first served basis rather than prioritised systematically. High numbers of patients on a daily basis in busy PHCs create additional burdens on healthcare workers, which further exacerbates an erratic consultation system
- The study also identified barriers to seeking timely treatment for meningitis, including: Negative perceptions of health services in Blantyre - appropriate HSB discouraged by long wait times, and expectation of poor care at Primary level Low recognition of meningitis and its symptoms within communities Cultural decision making practises within households in Malawi. For example Gender and age-based decision making in community Financial constraints in community The research very much pointed to the need for an intervention to focus on the recognition of and response to severe illness, both within community and at primary care level.
- Action Meningitis is MRF’s health initiative to improve outcomes from meningitis in children in Malawi. This project is a direct follow on from the MRF-funded barriers study. This initiative began early 2012. 2 arms of the project: The first targetted to primary health level: - Improving recognition of severe illness by HCW at primary clinics and making appropriate decisions on referrals. TRIAGE SYSTEM Improving patient pathway through the clinic The community level arm aims to promote positive health seeking behaviour complements the primary health level intervention. The community health education aspect improves the recognition of child illness by parents and guardians & encourage timely HSB We are concentrating on the Primary Level intervention today, and particularly the use of mobile technology in triaging at a primary care level.
- MRF carried out a Situation analysis, visited all primary clinics within Blantyre, (of which there are 17 run by MOH), consulting clinicians at QECH, health workers at PHCs, and MoH officials at national and district level.
- Found that: lack of effective triage at PHCs meant that severe illnesses were regularly missed. Limited number of health workers, equipment and supplies Health workers explained they were overwhelmed by high patient numbers, so emergency signs are missed. Long waits to see a clinician or receive treatment meant some children die waiting in the queue before ever being assessed.
- Aim = Implement a triage system within 5 PHCs in Blantyre and 3 in Chikhwawa To develop a triage algorithm, specific for Primary Health Clinics To implement prioritisation system within each clinic To encourage appropriate referral decisions by HCW to tertiary centre & track referrals To evaluate triage system – in order to develop and refine it
- Let’s first take a look at the Triage system itself ..... This uses the ETAT (Emergency Triage, Assessment and Treatment ) protocol, developed by the WHO (originally developed in Malawi for hospitals in resource-poor settings). It is specifically aimed at lower cadre staff. It has had a huge impact in hospital settings, where it has cut mortality rates. Our triage tool is based on Emergency Triage component of ETAT The triage tool, or triage protocol is basically an app on a mobile phone. From a practical point of view = its an ideal tool for HCW to quickly navigate around crowded clinics, assessing patient after patient Benefits – ensure hcws stick to protocol, don’t skip step. The phone acts as a prompt to the user to identify severely ill children. Action Meningitis is the 1st intervention of its kind combining triage and mhealth. In close collaboration with MOH, Action Meningitis established a triage system, The Action Meningitis ETAT system has been sucessfully implemented within 5 PHCs of Urban Blantyre, and three centres in Chickhwawa Urban and peri-urban clinics with varying catchment populations
- System for triage – Chipatala Robots The intervention was developed using the concept of the Chipatala Robots (Chipatala meaning health centre and robots meaning traffic lights). Chichewa We created Chip as a character to guide patients and carers through the system. The clinics’ HCWs assess a child’s symptoms on arrival using a mobile phone app. It’s based on a traffic light system of triage developed by the World Health Organisation. Patient is triaged through a series of simple questions on the smartphone screen asking about key clinical signs to identify severe illness Screenshot of the triage app. Each patient is given a unique personal identification number assigned through the phone. Helps HCWs quickly and accurately identify severe illnesses, like meningitis - so emergency cases are fast-tracked to hospital. Responses to the series of questions lead to an assignment based on the traffic lights system where Red depicts an emergency meaning the child is extremely sick and should be seen immediately, Yellow .... Green .... Patient health passports are stamped with a Chip symbol And patient provided with a coloured strip which helps to guide them through the system.
- walk through the system... Patient - all children under 15yrs. Initial triage by HCW Assigned triage classification – Emergency, Priority , Queue Clinician triage and consultation We expected that the system would encourage appropriate referral decisions to tertiary care (Queen Elizabeth Central in Blantyre) We have fieldworkers at referral hospital - phones. Collect data on all referrals that arrive to hospital, so we can track whole patient pathway, through primary to tertiary From all of the five primary centres. [short video clip] In this clip i hope you are about to see, Triage system being used at a crowded clinic in Bangwe, a healthworker assesses a sick baby girl. Guided by a series of questions on his phone he quickly identifies her as a ‘Priority’ for the doctor.
- It improves chances of survival by helping healthworkers quickly and accurately identify severe illnesses, like meningitis - so emergency cases are fast-tracked to hospital. The clinics’ healthworkers assess a child’s symptoms on arrival using a mobile phone app, specially created by the charity. It’s based on a traffic light system of triage developed by the World Health Organisation. [Sounds from clinic] In this crowded clinic in Bangwe, a healthworker assesses a sick baby girl. Guided by a series of questions on his phone he quickly identifies her as a ‘Priority’ for the doctor.
- To date 193 Health Care Workers have been ETAT trained using the mHealth tool and 215,000 children 0-14yrs were triaged. Evaluation showed the system improves patient pathways and has increased recognition of severe illness among lower level HCW unfamiliar with triage beforehand. See separate handout for complete overview of project together with evaluation and results.
- Overall the intervention has been viewed very positively by primary health staff with a strong perception that it had improved patient pathways through the clinic. Patient and health care worker satisfaction high. One comment that was mentioned time and time again and reflected in this quote is how the intervention brought the hcws together to work as a team.
- mHealth technologies have the potential to improve primary level services with high patient numbers and over burdened staff. Building on a successful foundation we aim to provide MOH with evidence that ETAT can be successfully implemented in a sustainable and cost-effective way.
- Hi.
- 1st year PhD student working at the University of Strathclyde, in the civil and environmental engineering department…I’m a Health Psychologist to trade so frequently get some funny looks from my engineering colleagues, however I am working within the Scotland Chikwawa Health Initiative based in the environmental side of the department. My PhD project is based within the Scotland Chikwawa Health Initiative, led by Dr Tracy Morse in the Polytechnic in Blantyre and Dr Tara Beattie at the University of Strathclyde. For those of you know don’t know…the Scotland Chikwawa Health Initiative is a consortium based up of the Scottish Government, University of Strathclyde, University of Malawi and Ministry of Health in Malawi. The project works in the Chikwawa district to implement the WHO healthy settings approach which aims to maximise disease prevention via a ‘whole system’ approach, i.e. looking at all aspects of community living from individual home to markets and schools. My role is to form part of the research component of the project, along with another PhD student who is based in Malawi. My project is looking at the feasibility of using mhealth to increase health promotion impact.
- mHealth has become increasingly popular throughout the developing world. Primarily due to the wide accessibility of mobile technology which has increased in the last few years. Approximately 30% of the population own a mobile phone and this number has risen dramatically in the last few years with a 70% increase in subscribers in the last 6 years, and the number is still on the rise. Along with increased mobile phone ownership, there has been improvements in cellular coverage; with rates currently stand at 94% of the population having access to adequate mobile coverage, reaching 79% of the geographical area of Malawi. The discrepancies between these figures is predominately due to 80% of the population living in rural areas and thus are harder to reach. Therefore due to wide accessibility of mobile coverage the potential for mobile communication to aid the health sector in Malawi is promising.
- Recently in the news that Malawians spend 56% of their monthly income on their mobile phone, the biggest mobile phone expenditure in the world. Although this is horrendously expensive, it does shows that mobile phones appear to be a priority in the Malawian culture, and as such is an area which should be utilised for health, in this case health education. Using mobile phones for healthcare have many advantages, which you have seen from the other presentations, such as; --quick and relatively cheap way to get health information to a large number of people --access to health information without having to attend appointments or prearranged visits, i.e. can access when and wherever they like --anonymous access to information, which is especially relevant for sensitive information such as reproductive health and contraceptive options
- So my research is going to be looking at implementing a mhealth intervention in the form of sending text or voice messages to personal phones to inform residents of preventative health information. This represents the plan of my research, which I will go through in more detail now.
- Target Health Areas; in order to understand what issues needed focused on I conducted a secondary analysis of village profiles which SCHI put together from initial data and focus group discussions. Explain graph….groups are the focus groups, secondary data from village profiles which were made up from focus groups in 18 villages. In each village there was 6 focus groups, as can be seen on the graph and I have added in a general group, from unknown sources in the village profiles. Health was a predominant focus of the discussion, with the participants stating many different health issues from HIV/AIDS to cholera and rabies. This graph shows the different types of focus groups and the breakdown of topics discussed.
- Not only did the participants discuss health issues, they also recognised their own need for information on specific topics. This covered 5 main areas which can be seen in the graph, HIV/AIDS, family planning, malaria, hygiene, nutrition. Interestingly it was the male youth which were the most vocal about this need, and were quite on point with their need for health education on HIV prevention, hand washing practices and family planning information such as contraceptive options. This data has provided a starting point for target areas, the 5 mentioned, and also target groups such as family planning/HIV/AIDS information for youth, which was the most common focus. Other target areas could be hygiene and nutrition, with residents asking for information on hand-washing and also about the 6 food groups and nutritional advice for cooking. These two topics are straightforward health information which could be implemented, potentially as a pilot to go through the motions of the intervention and then complete it on a larger scale for the family planning and HIV/AIDs.
- Youth has been targeted as a group which were the most vocal about needing health education, frequently requested their need for ‘youth friendly health services’. Somewhere separate to get contraception (culturally not supported to be, private areas for HIV testing etc, girls get hit on by the men) Male youth in particular mentioned this need in just over 25% of the FGDs. Therefore, we can try and focus on and engage youth using technology they already have to broaden their knowledge on health issues. It will in no way replace their need for direct one-to-one contact, support and counselling but will highlight health information to them and and aim to improve their knowledge until such services can be put in place.
- Message creation; Will be based on the health issues from the focus groups (and I will conduct my own focus groups to narrow these target areas down when I am over in August) and also based on the WHO guidelines for example their guidelines on family planning. -looking to create interesting and engaging messages, with the potential to use role modelling. i.e. messages which include information about a fictional character or appear to be send from a fictional character to try and let adolescents relate to the messages. Other studies such as the Biran study in India, created a campaign based around videos and leaflets of a mother caring for her child and as part of this, handwashing was introduced. In Dundee, there has been a SMS intervention aimed at reducing binge drinking in disadvantaged men whereby they receive texts from a fictional character who is trying to stop drinking and his progress is followed throughout a 6 week text message discussion. Messages will be translated into chichewa, then piloted for cultural relevance i.e. shown to a few to see if they understand them/make sense. Super Amma – hand washing with mother figure looking after child Binge Drinking Study—male fictional character giving up drink and texting journey --seem to have worked well, relatable.
- So there will be two groups, one intervention groups which will receive baseline measures, have access to the intervention and then we will conduct the same measures post intervention. And then there will be a control group, which will receive the questionnaires at the same time as the intervention groups but will receive usual healthcare services instead of access to the mhealth messages. The measures we are looking at are primarily knowledge and behaviour change. This will include conducting a questionnaire or interview on current knowledge for example of reproductive issues such as contraception, HIV and pregnancy. Behaviour change will be measured through another questionnaire or interview examining current behaviour regards to family planning, risky behaviour etc. There is also scope to use intention to change measures to see if the mhealth information provided influenced adolescence on their intentions to conduct a behaviour in the future i.e. no intention to use a condom in a relationship, after the messages an intention to use one. Or behaviours could be use condom first sexual encounter and after the intervention intend to use one every time….this is may not be the same as actual behaviour but it is very difficult to measure behaviour accurately after prolonged period of time after the intervention.
- Technology to send messages; Telerivet, free up to 100 contacts and 100 messages per day, reasonably priced after that, software to organise mass messaging Advertising- village reach implemented service for maternal health, a phone line and text message service for pregnant women and parents of children under 5. Will need to use advertising campaign like this in the villages of Chikwawa. Implement- so that individuals can access the health messages.
- Evaluate (key) as most of the literature in this area is pilots and not many go on to upscale, so want to evaluate this research as much as possible. Will be looking at the effectiveness of the intervention, the relevance it had to the people of Chikwawa and its cost-effectiveness within the project. Ultimately want to be able to answer the question; are mobile health interventions feasible as a health education tool in Malawi?
- Next Steps… I will be returning to Malawi in August for a three month trip and will be conducting my own focus groups to determine more specific information regarding the target health issues. It is important to involve the community as much as possible as this intervention is for the residents of chikwawa because they requested health education, so it needs to focus on the information they require. Then will start to create the messages, and begin the process of translation and piloting them. There are still some technical aspects which need to be ironed out, so if anyone has used telerivet or programmes like it, it would be great to get some input and advice.