"Going global" and www.jopsa.org

Hi Everyone,

This will be my last post on mobilesinmalawi.blogspot.com. The project is expanding, and I have moved to a new site - www.jopsa.org

It's been wonderful staying connected to everyone here, and I hope you'll all make the jump with me to jopsa.org. All of the posts (and your comments) have been transferred.

See you there!

- Josh

Why FrontlineSMS Fits

Why was FrontlineSMS the right tool for St. Gabriel's Hospital?

I wrote a bit about the virtues of the software in July, amidst the implementation period. The program has been running for six months, and my latest trip allowed me to document the project's impact on primary care, treatment coordination, and hospital efficiency. Further, the SMS program has saved thousands of hours of travel time for CHWs and hospital staff, and bolstered the CHWs' status within their respective communities - which are now connected to the hospital's resources.

As Ken Banks recently stated, whether or not a mobile tool is suitable is "all about the context of the user." In succinct terms, here are a few reasons that Ken's tool was a the right fit for St. Gabriel's:

1. It's free.



2. It works with simple, readily-available hardware. I used recycled phones and didn't need to worry about the donated laptop's specifications.



3. It doesn't require an internet connection. The hospital's web access is shaky, at best.
   



4. It is incredibly intuitive and easy to use. The nurse running the program had never used a computer in his life. After one hour of training, he was off and FrontlineSMS-ing.



5. The hospital found the tool - not the other way around. After I spent time at the hospital two summers ago, the need for connectivity was clear. To meet that need, a tool was employed. It wasn't forced on me or the hospital.



6. Straightforward features allowed the hospital to take ownership and get creative, which encouraged user-driven functionality. One example: Auto-replies set to provide CHWs with immediate drug dosage and usage information.



7. A ten-second demonstration can illustrate the program's purpose. This hooked clinical staff working within various hospital programs (e.g. HIV treatment coordinator, TB officer, PMTCT director).



8. Past text messages, and vital patient informaiton, are just two clicks away.

In examining the success of the SMS initiative over the last half-year, the appropriateness of the technology cannot be ignored.

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.

Antiretroviral Texting

Grace Kamera runs the HIV treatment program at St. Gabriel's. She oversees atiretroviral therapy (ART) for the catchment area - which includes 250,000 people and an HIV prevalence rate of 15%. While there are a few government-run health centers in the area, St. Gabriel's Hospital is the only facility offering HIV tests, and the only place to get treatment.

Many of the CHWs are ART monitors - they are trained to check in on HIV patients, to see if they're complying with the treatment regimen. Noncompliance deducts from the treatment's efficacy and contributes to drug resistence. Given a limited number of choices for drugs, patient adherence is critical.

Before FrontlineSMS and the accompanying cell phones arrived, Grace was receiving 25 paper reports, per month, from the ART monitors. With 21 ART monitors equipped with cell phones and trained in text messaging, she's received 400 adherence updates since the outset of the project (15/week).

If the paper trail had continued, each report would have been hand-delivered by a CHW. The average round trip is about 6 hours, so the SMS program has saved ART monitors 900 hours of travel time.

If Grace receives an SMS regarding a patient's missteps, she will counsel them when they return for more drugs. The patients are well aware that the CHWs have cell phones, and they're grateful for the connection to the hospital (and Grace). Of all the patients who enroll in the ART program, 80% agree to be monitored. The remainder fear stigmatization within their communities.

Some patients do not turn up to receive their HIV medication. Grace says this is rare - "They usually come a day or two late" - but it happens. She's used the SMS network to track 25 patients who have failed to show, asking the nearest CHWs to report on their status. Sometimes they've left, other times they're unable to travel or they've passed away.

The hospital and the people it serves can't afford a lack of connectivity. With Grace at the reigns, ART monitors will continue serving their communities, 160 characters at a time.

Full Charge!

This morning, we distributed the first batch of solar panels from G24 Innovations. I was also able to reconnect with CHWs I hadn't seen in a while. Everyone was extremely happy - I'll let the pictures tell the story.

Of course, Alex ran the session. The instructions were quick and easy, and everyone was rather celebratory:


To close the meeting, the CHWs sang a song for me that they had prepared - I'm not sure what the lyrics were, but "phones" and "messages" were included! Afterward, I traveled with Dickson Mtanga and Mary Kamakoko to their villages - it took a good two hours on a bicycle. We spent another 3 hours biking around and seeing patients, before I started back to the hospital. Dickson and Mary, using their new panels:

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.

Tuberculosis, Meet FrontlineSMS

On Christmas morning, Silia stopped by the guest house to talk about the SMS program. He's responsible for testing, drug provision, and follow-ups for TB patients. He described how he's using FrontlineSMS and the network of cellphone-wielding CHWs. Almost all of what follows developed in my absence.


Some sputum-positive patients don't turn up to receive their medication. It's Silia's job to track these patients and get them back on their drug regimens. Before the SMS program, he was visiting an average of 17 patients per week - this took him three trips on his motorbike. Each trip would take ~9 hours. That's 27 hours per week spent tracking patients in various villages.

The SMS network has allowed Silia to share his workload with the CHWs. He now tracks an average of 20 patients per week via SMS. He simply texts CHWs nearby patients that haven't turned up. As Silia says, the CHWs provide "immediate feedback."

The program has been running for roughly 26 weeks. With the shift to SMS-based patient tracking, Silia had an additional 700 hours to utilize. Not surprisingly, he's been using FrontlineSMS to supplement other areas of his work.

He now visits an average of 4 patients per week, for different reasons. Some messages from the CHWs tell of patients who are too ill to travel to the hospital. Silia will respond by bringing a new supply of drugs. Other messages relay symptoms of community members - e.g. "A man has a chronic cough, and we suspect TB." Silia will visit the patients, and collect a sputum sample. He'll return to the hospital to do testing and send the results, by SMS, back to the CHW.

Finally, when patients at the hospital test positive for TB, they're told which CHWs near their home have cell phones.

Some numbers from the TB program for the last 6 months:

700 hours of follow-up time saved
450 follow-ups via SMS
(At least) $2000 in motorbike fuel saved
100 new patients enrolled in TB treatment program

Coming up: Impact on Home-Based Care, PMTCT, Public Health, and HIV/AIDS programs