live from motech material making!

Material will be used for staff local clothes (a must to be worn on Fridays!) and incentives for participants involved in field work (good for swaddling the baby, carrying the baby, etc)

Esther is our tie and dye lady in Bolga.

Jess

Pictures from CHPS Workshops

Pictures from our workshops with CHPS workers last week are now posted on the MoTeCH Picasa page.

Navrongo SMS workshop

Paga Forms workshop

Live from our first MoTeCH CHPS System Workshop

Today we had our first workshop to introduce and test our mobile phone technology for MoTeCH to community health workers (CHWs) in the Upper East Region of Ghana. So far, much of our field research and testing has focused on building content for our “Pregnant Parents” application, but today we were focused on how MoTeCH can help practitioners deliver high quality antenatal and neonatal health care.

Our goals for the day were to learn as much about the challenges of entering patient information on simple mobile phones using structured SMS messages and also learn more about the types of features (notifications/reminders, queries, and reports) that would be helpful for CHWs to serve their patients better. We have had discussions with some CHWs in the past about MoTeCH functionality, but we had a feeling that until they saw the technology in action, they wouldn’t be able to completely grasp what we were building and how it could help them with their daily work. Hands on demonstrations would be essential for getting their creative juices flowing to contribute to our design process.

We started the day by having about 15 participants register their mobile phone numbers with us, load their phones with airtime, and receive ‘templates’ of the SMS message formats directly on their phones. These messages were saved to each person’s drafts folder so they could easily retrieve them later and enter patient encounters in the required format without needing to enter the full message each time. Messages looked similar to the following template:

Type=ANC
FacilityID=
RegNo=
Date=
VisitNo=
TTDose=
IPTDose=
HIVResult=







With Joyce Ndago and Maria Nuela, two of our MoTeCH field staff, facilitating the session, they showed everyone how to use the information provided on sample paper registers and enter this on the mobile phone. During the registration process, the MoTeCH team gave participants training on how write text messages on their phones, for those who were less familiar with SMS. We continued this training by working side-by-side with the CHWs as they entered information from the registers onto the phone. It was amazing how quickly even those who had not used text messaging in the past managed to begin entering data in the required formats.



To simulate the interaction CHWs will have with the system with data entry triggering notifications and reminder messages, we had a modem capture incoming SMS messages. Unfortunately, our plan of using FrontlineSMS to automatically send out reminder messages based on keywords of incoming messages didn’t quite work out (we accidentally used a GSM modem that was not supported and only worked intermittently). Luckily, we were able to recover and manually send out responses through another piece of software. It was amazing to see the surprise and delight of the CHWs as they received a reminder that “Amina Philip (c/o Azia’s house, SAH 64, Gaani) is overdue for her fourth TT immunization”. Suddenly, MoTeCH made sense to them! As soon as the first person received her reminder from MoTeCH, she showed it around and soon everyone was waiting for their messages to come from MoTeCH also, and quickly entering information to see the feedback as soon as possible on their own phones.

One of the best moments of the workshop came when Cecelia Addah, the very first community health worker for the CHPS system in Ghana, proclaimed how useful the system would be for catching and proactively reaching out to defaulters of their 3rd IPT dose – where compliance drops off dramatically from the first and second dose and women often deliver before receiving the recommended third dose. It was amazing to see that she could see the potential of the system to help with a wide variety of use-cases relevant to her work beyond just what was demonstrated.

Some of the other ideas for how our system could assist with the day-to-day work of CHWs in the Upper East Region of Ghana were as follows:

• Notifications of all types of defaulters: Overdue childhood immunizations, overdue TT immunizations, overdue IPT and IPTi treatments, missed deworming, etc.
• Reminders to follow up with patients that had been referred from the facility to another clinic: CHWs want to follow up with the patients they have referred both to ensure the patient has actually followed instructions to receive care at another facility as well as to learn from the outcome of the referral (how the patient was treated, whether the treatment was successful, etc) to educate themselves around effective referrals for the future.
• On-demand queries to help fill in their monthly reports

Data entry was not without its challenges though. With so many different phone models, it was impossible to anticipate and provide instructions on how to do things on each individual phone. We quickly found that the Nokia 1100, one of the oldest and most simple Nokia models owned by 3 participants, did not like the “=” signs in the message templates and prevented users from scrolling past the symbol to enter the value of the field. Other phones added in extra line breaks or strange characters when the messages were sent and received by our modem. But, seeing these realities first-hand by having users use their own phones (as we will do in our MoTeCH pilot), was invaluable to ensure we come up with a good design that works for all of our CHWs.

Based on the workshop, there are several things we will need to look into operationally. Some of the questions we will need to design around are:

• How will CHWs be able to confirm that all of the messages they have submitted for the day were successfully received by the system, so that their reports are accurate. Could we potentially provide a summary SMS message each day where they can easily see how many of each type of message was submitted and cross check the totals are complete?
• What will we do about the fact that many CHPS facilities do not have electricity and CHWs cannot charge their phones regularly? Many were concerned that their batteries will die after entering just a few messages per day.
• CHPS compounds are often ‘communication hubs’ with CHWs using their own phones to receive and make many calls to coordinate their work activities. There is often only one phone per CHPS compound. How will the CHWs manage to send and receive SMS messages to MoTeCH while constantly being interrupted by calls?

The workshop ended with a fun-filled contest where participants competed to enter messages as fast as possible. The first person to submit a message without any errors won a radio. Even after the winner was declared, everyone continued fervently racing to be the next one to get finished successfully. Our winners managed to finish in just 2-3 minutes per message – not bad for their first time using structured SMS messages of this sort! Our next steps will be to analyse the data that was entered to learn more about speed and quality of the data and use this as feedback to iterate on the design of the messages, as well as develop more detailed use-cases for reminders and queries that will help CHWs with their work. All of this, and more, will be re-tested in a mini-pilot with 4 nurses in Bongo district at the beginning of January where nurses will enter real patient encounter information on their phones as part of their regular routines so we can see how the system will operate in a real-life setting. All in all, our first round of design and testing with CHWs in the Upper East was a resounding success.

live from SR pilot

The photos show Maame-Yaa working the field, and the team de-briefing. During the pilot the team collected lots of suggestions for register tweaks and some learning about workflow and how to integrate mobile data entry into this process.

Music!: MoTeCH Pregnant Parents App

We’ve heard time and again over the past few months that music is central to Ghanaian culture and could be effective in its application to encouraging health seeking behavior in pregnant parents. To this end we have engaged a singing group in the Upper East Region to perform some songs related to pregnancy in the 2 major local languages, Nankam and Kasim. These songs will be featured in the audio messages made available to parents through phones as part of the “pregnant parents application”. For your interest, a translation of the songs is below, you can listen to a snippet on you tube, and there’s a photo of the singing group attached.

NANKAM

First Song: Antenatal Care

If a woman is pregnant and agrees to go for antenatal clinics and takes all the necessary injections, on the day of her delivery she will deliver safely and a healthy baby as well. This will make her husband happy. This is an advice to all pregnant women and potential mothers.

Second Song: Exclusive Breastfeeding

When you give birth don’t give water to the baby, the doctor said it. When you give birth don’t give water to the baby, the nurse said it. One breast is food for the baby. One breast is water for the baby. Giving the baby good health until six months.

KASIM

First Song: Antenatal Care

If a woman is pregnant, she should attend ante natal clinics for it has great benefits. If you do this on your day of delivery you will give birth to a healthy child and safely.

Second Song: Care Seeking Behavior

The health workers are here for us (the CHOs, community health volunteers and all health workers) to help us and our new born babies. All men should wake up and help us help us achieve this so we can get more help. Men should help their wives go for antenatal care and take their children for child welfare clinics.

BBC: Maternal mortality across the world

Last week, BBC had an interesting piece looking at maternal mortality around the world, including a video of a bicycle ambulance that is anecdotally reducing maternal mortality to zero in one village. I thought this piece would be of interest to everyone:

http://news.bbc.co.uk/2/hi/africa/8320781.stm

"Pregnancy Diaries" from Gaani, UER

On my first visit to Navrongo in July I worked with the health workers in one of the CHPS zones to invite a few women to keep “pregnancy diaries”. Below and attached is a summary of the issues raised.

 

We asked the women to record any issues on their minds related to their current or former pregnancies and their babies. Unfortunately we had not yet received Aliya and her shipment of voice recorders J so we could only ask literate people to take part, so the results are by no means representative. However, they are quite fascinating! Info like this will be very valuable for tailoring PP app content. My general takeaways:

-          It’s great to see questions that we can deal with not only about health issues but also the practice of care-seeking in general (eg the question about child records).

-          The questions reveal the real influence of local myths (eg confusion about value of fruits, night bathing and sleeping on your back) and traditions (eg eating sand).

-          I think it’s quite interesting how committed the women were to keeping their diaries, with so little encouragement over time and no incentives given except for answers to their questions (we committed to answering every question they asked) - an encouraging sign that there is a thirst for information out there.  

 

As an exercise it was all a bit ad hoc but I’m so happy that we’ve been able to hear directly from our customers in this way! I hope the below give us some good early insights, and I look forward to building upon this in a more systematic way as we get Navrongo ramped up over the coming weeks.

 

Jess

 

---------------------

Problems Encountered During Pregnancy

-          Feeling Dizzy

-          Sleepless night

-          Swollen legs

-          Feeling pains on the ribs

-          Vomiting after eating

-          Severe headache

-          Body pains

-          Some feel lazy

-          Discharges in the vagina

-          Abdominal pains

-          Pregnant while bleeding

-          Women do encounter several problems during pregnancy – for instance, headaches, vomiting, swollen legs, menstruation and others. Why?

-          During my time of pregnancy I always had pain under one of my breast why?

-          Why is it that you have headache when you are pregnant?

-          Why swollen legs when pregnant?

 

Questions about Pregnancy

-          I want to know why one may give birth to only boys or sometimes girls.

-          Why do you say that fruits are good meanwhile our local people are against that?

-          Why is it that the baby struggles in the womb and does not spoil the womb?

 

Advices during pregnancy given to us by people in our homes. Are these right?

-          Some foods like flour, pork, mudfish, leftover T.Z. are not to be taken.

-          We should have sex with our husbands in the seventh months.

-          We should not sleep on our back.

-          We should not sleep outside when the weather is cold.

-          We are not to be eating fruits.

-          We should not bath in the night.

 

Babies

-          In association with the children, when they are about to develop fresh teeth, they begin to fall sick, experience stomach aches, some unconsciousness, dysentery, followed by malaria. Why?

-          The diseases that usually affect us here are malaria and diarrhoea.

-          Why should they say children should not eat fruits, for they will be attacked by fever but in your [health workers] instruction, you say children should take fruits, why should you say that?.

-          Why is it that when you get malaria sores are always found around you mouth?

-          They say children should be taking eggs, what is the purpose of that?

-          The child health records that we have, please can you tell us the purpose of it?

-          What kind of disease is called kwashiorkor?

-          Feverish condition

-          Vomiting

-          Running diarrhoea

-          Body weakness

-          Crying

-          Things I think are good for my child: Fruits are good, Exclusive Breast feeding, Fruit juice, groundnut, millet and Beans are good for the child. Because of all this we and our children are suffering too much because if you are pregnant some people say that don’t eat fruits like mango and others.

 

Foods that I mostly eat when I am pregnant.

-          Eating a lot of White sand

-          Eating of plenty salt

-          Eating a lot of T.Z and vegetables and groundnut soup

-          Eating a lot of baobab fruits

-          Shea nuts, oranges, water melon, banana and sugar cane

-          Eating a lot of okro stew and Banku 

 

Reasons for pregnant women not allowed to sit one way or lie on their back

-          The baby may die in the womb

-          It may also be difficult for you to give birth

-          It may also cause sickness to the pregnant woman too.

Article: Soil-transmitted helminthiasis

The practice of eating clay, charcoal or soil is common, particularly amongst pregnant women and babies, in this region. I was interested to recently learn how damaging this is for health, particularly for a pregnant woman. Intestinal helminths transmitted through the soil can cause or worsen anemia. In developing countries anemia has an extreme impact on maternal mortality and morbidity, with some studies estimating that 20% of maternal deaths in Africa are attributable to anemia or its related illnesses – it is associated with increased risk of hypotension, tachycardia, preterm birth, and delayed social and emotional development in the child.

 

Here are some articles about this issue which I found interesting:

http://tps.sagepub.com/cgi/pdf_extract/26/3/167

http://linkinghub.elsevier.com/retrieve/pii/S0035920398909105

http://www3.interscience.wiley.com/journal/118667618/abstract?CRETRY=1&SRETRY=0

http://emedicine.medscape.com/article/996482-overview

 

Jess

Ghana: Pregnant Women Turn to Prayer Over Medicine

A while back, I stumbled upon an interesting article titled "Pregnant Women Turn to Prayer Over Medicine"

I wanted to share it with the whole team, because it has some interesting information for the work we're doing and can really inform the design of the MoTeCH system and content delivered by MoTeCH to pregnant parents.

Soon after arriving in Ghana, Jess noticed the importance of appealing to the religious nature of individuals here as a way of fostering adoption, comfort and interest in content we will be delivering to pregnant parents with MoTeCH. I think this article validates Jess's instincts about the value that this could have. It's also very clear that we need to balance this closely with providing really solid scientific and medical information (which was always our goal) to ensure women begin to have a more accurate and complete understanding of health issues in pregnancy.


Jess and Kirsten both pointed out the fact that this article also indicates a strong need to educate expecting families that maternal care is free in Ghana. This is something we can address with reminders in our content throughout the pregnancy that free services are available through delivery. This is clearly low-hanging-fruit which we can address and hopefully with this education, we will see an increase in the number of women seeking ANC at facilities.

Video of MoTeCH song

As promised, here's the video of local artists singing the MoTeCH song!

http://www.youtube.com/watch?v=fSV9Qo_InpA

live from naga

Quite heated focus group discussions with key players in pregnancy: mothers, fathers, landlords and mothers-in-law. Scenery is beautiful here. Notes to follow.

The FGD took place next door to a clinic. While we were there a mother delivered! With no noise and no fuss, we didn't know until we heard the baby crying!!

Not-quite Live from Singing Group

(from thursday): a singing group in Vunania performs songs they prepared for us about ANC, exclusive breastfeeding and importance of male involvement, in both Kassim and Nankam (main local languages). Video and audio recordings on the way. They put these together in just a day and it sounded great!

Live from Content Creation Workshop

National-level GHS staff and key NGO stakeholders provide their input on recommended week-by-week content for the “pregnant parents” application. BabyCenter topics are provided as suggestions and have been great conversation starters. We are split into 3 groups, focusing on a trimester per group. Tomorrow we will present each trimester to the entire group for comments.

 

Looking forward to repeating sessions like this in the regions.

 

Live from eve's pregnancy school

Florence, founder of Eve's Pregnancy School, gives one of her bi-monthly classes to pregnant women and mothers. Singing and music is an important part of Ghanaian culture and this class opened with the women singing a local song about womanhood, empowerment and feminine beauty! It definitely got people excited! Part if the class was then given over to the group chanting "positive utterances" such as "my body is strong", "i will have a safe delivery", "my family loves me", "my husband loves me". Teaching was interspersed between these more fun and participatory sessions.

 

The trials of IVR in Uganda showed that people want the services that we create to be fun as well as informative - not simply recorded information. Including some local songs in the audio recordings could be a good way to engage users.

 

(Eve's Pregnancy School has offered lessons about pregnancy and motherhood to women in Accra for 10 years and has seen over 2,000 mothers through safe pregnancy and delivery. The founder, Florence, attended our first content workshop this week and had lots of fantastic input).

MoTeCH Field Report: Gaani, UER

Report of Observations for the Upper East Regional Health Administration

Gaani CHPS Zone

5^th August, 2009

 

By chance the health worker at Gaani CHPS Zone, Jennifer, was doing outreach for baby-weighing, so I had the opportunity to join. The main CHPS nurse was in town dropping off DHIMS records so they were short staffed. This meant that Jenny welcomed some help doing the registers for the 75 babies we weighed at that outreach session. It was great to experience first-hand the complexities of the current recording system.

 

Inconsistencies in Fields

There were inconsistencies in some of the fields. It’s important that MoTeCH takes note of these as they will likely affect phone-based registration systems for pregnant mothers and babies. We should think in particular of which fields, or combination of fields, we can use to locate an existing record or to identify duplicates.

-         Sometimes the baby name field was blank in the register (since families often prefer not to name their baby until they are a few weeks old).

-         Sometimes the name initially given to the baby had later been changed, so that different baby names appeared in the register versus the child’s record book.

-         It is common for people to have 3 or 4 different names, so different combinations of those names had been used in the register versus the record book – this applies both to baby’s and mother’s name.

-         Names have alternate spellings and mothers and health workers are usually not particular about pinning down a particular spelling, so often this differs in the register versus the record book.

-         Place name seemed to be spelt quite consistently (in Uganda it was common for a single place to have multiple accepted spellings. It’d be good to see if this applies here also).

 

Challenges in using the Register

Each child’s record book (kept by the parents) contained the child’s ‘serial number’ and ‘register number’, which was supposed to correspond to the equivalent fields in the register. The register was ordered according to register number, and using this field the health worker finds the baby’s entry in the register in order to enter the child’s weight result. In actual fact, there were quite a few discrepancies in this system – not surprising given the volume of information and complex manual system:

-         Sometimes the same serial number or register number had been allocated to more than one baby.

-        Sometimes the incorrect register or serial number had been written on the child’s record book.

-         In cases of the above you had to search for the child according to Date of Registration (ie the date when the baby was first brought for care), since the register was chronological.

-         There were 2 registers, one for babies aged 0-11 months, one for babies 12-23 months. The same register numbers are used in both registers (1,2,3,4…). So, before you can start searching for the baby’s entry in the register you have to determine the child’s age (using Date of Birth field in the child’s record book) to determine which register you should search in.

Because of all these factors it sometimes took quite some time to locate the baby’s entry in the register, adding to the time the nurse spent on paperwork, and detracting from her time attending to patients.

Live From Recce in Navrongo

 

Live from the Road to Navrongo!