Author: Lindsay Baldwin

Two-Way Texting for Post-Operative VMMC Follow-Up RCT in Zimbabwe

Voluntary medical male circumcision (VMMC) is considered safe and the vast majority of men heal without complication. However, guidelines require multiple follow-up visits, which can burden staff and facilities with clients who are typically healing well. With funding from the National Institutes of Health (NIH), ZAZIC recently conducted a prospective randomized control trial (RCT) to determine if two-way texting (2wT) was as safe as routine post-operative visits and if it reduced workload in two high-volume VMMC sites near Harare, Zimbabwe.

Image of the 2wT App used to support the study.

Both clients and providers felt satisfied with the 2wT system and felt it could be ready for scale. Many clients reported feeling confident, comfortable, satisfied, and safe with text follow-up. Importantly, clients felt that 2wT saved them time and money. Providers also noted 2wT saved them time, empowered their clients to engage in the healing process, and addressed gaps in MC service quality.

The results strongly suggest that 2wT is highly usable and acceptable for providers and patients. Men with concerns appeared confident and comfortable to receive guidance via text and providers noted that men engaged proactively in their healing.

It was recommended in the study that 2wT between providers and patients should be considered for future adaptation in other short-term care contexts. 2wT also appears far less expensive than active follow-up to improve patient safety: on average, post-VMMC follow-up under 2wT was $0.098 compared to $0.955 under routine care. 2wT was both less costly and more effective in identifying AEs relative to the expected rate of AEs.  As such, I-TECH aims to scale 2wT in further testing among rural clients and guardians to improve patient care at lower cost.

The trial is registered on ClinicalTrials.gov, trial NCT03119337, and activated on April 18, 2017. https://clinicaltrials.gov/ct2/show/NCT03119337. This RCT was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW010583.

Increasing VMMC Delivery and Safety in Zimbabwe

Employing modern medical male circumcision within traditional settings may increase patient safety and further male circumcision scale up efforts in Sub-Saharan Africa. ZAZIC established a successful, culturally sensitive, partnership with the VaRemba, an ethnic group in Zimbabwe that practices traditional male circumcision. The VaRemba Camp Collaborative (VCC) was created to provide safe, standardized male circumcisions and reduce adverse events (AEs) during traditional male circumcisions. ZAZIC supported the VCC by providing key MC commodities and transport to help ensure patient safety. In 2017, the VaRemba granted permission to ZAZIC doctors to provide oversight of MC procedures and post-operative treatment for all moderate and severe AEs within the Camp setting. Of the Camp residents, 98% chose medical male circumcision.

The multi-year, iterative cycle of meetings and trust building ultimately resulted in the successful VCC, a model that may be replicable for others trying to combine modern male circumcision and traditional practice.

Achieving Targets through Performance-Based Financing in Zimbabwe

ZAZIC employs an innovative performance-based financing (PBF) system to speed progress towards ambitious voluntary medical male circumcision (VMMC) targets. The PBF schedule, which started at $25 USD and now varies from $6.50-$14 USD depending on the location and the circumcision team, is continually refined to set the program up for sustainable transition. The PBF is an incentive that is intended to encourage underpaid healthcare workers (HCWs) to remain in the public sector and to strengthen the public healthcare system. The majority of the incentive supports HCWs who perform VMMC alongside other routine services; a small portion supports province, district, and facility levels.

I-TECH conducted a qualitative study to assess the effect of the PBF on HCW motivation, satisfaction, and professional relationships. The study found that the PBF appreciably increased motivation among VMMC teams and helped improve facilities where VMMC services are provided. However, PBF appears to contribute to antagonism at the workplace and create divisiveness. To reduce workplace tension and improve the VMMC program, ZAZIC increased training of additional HCWs to share the PBF incentive more widely and strengthened integration of VMMC services into routine care.

Ensuring High-Quality Service Provision in Zimbabwe

Describing Adverse Events within VMMC Programs at Scale

I-TECH works diligently to review and revise procedures to identify, manage, and report adverse events (AEs). I-TECH’s previous publications on AEs reveal efforts to maintain high quality programming and emphasize patient safety alongside achievement of targets.

An evaluation published in the Journal of the International AIDS Society found that AEs were uncommon, with 0.3% of surgical and 1.2% of PrePex (a non-surgical VMMC device) clients experiencing a moderate or severe AE. However, the evaluation also found that younger clients were at greater risk of infection.

Increasing Understanding on the Timing and Type of AEs in Routine VMMC Programs at Scale

As VMMC expands in Sub-Saharan Africa, I-TECH works to ensure program quality matches efforts to increase program productivity. I-TECH ensures patient safety through patient follow-up to identify and treat AEs. The timing of routine follow-up visits in MC programs is designed to ensure patient safety by identifying, treating, and managing complications. Although routine follow-up timing may differ by country, in Zimbabwe, three follow-up visits are scheduled to ensure quality service provision and patient care: Visit 1 (Day 2); Visit 2 (Day 7); and, Visit 3 (Day 42).

I-TECH’s implementation science efforts use routine data collected from clients with AEs and has found that AEs followed distinct patterns over time. Using these findings, ZAZIC has been improving VMMC care by 1) improving counseling about MC complications following initial visits for clinicians, clients, and caregivers ; 2) distributing wound care pamphlets to clients and caregivers; and 3) emphasizing follow-up tracing for younger boys, ages 10-14, and their caregivers to provide additional targeted, post-operative counseling on AE prevention.

Increasing AE Ascertainment through Routine Quality Assurance Efforts

To further increase ascertainment of AEs, I-TECH recently conducted a quality improvement (QI) initiative to improve provider identification and reporting of AEs. ZAZIC Gold-Standard (GS) clinicians prospectively observed 100 post-MC follow-ups per site in tandem with facility-based MC providers to confirm and characterize AEs, providing mentoring in AE management when needed.

The QI data suggested that AEs may be higher and follow-up lower than reported and ZAZIC’s Quality Assurance Task Force is replicating this QA study in other sites; increasing training in AE identification, management, and documentation for clinical and data teams; and improving post-operative counseling for younger clients. Additional nurses and vehicles, especially in rural health clinics, are currently being trained and leveraged to further improve client follow-up and AE ascertainment.

Improving Data Quality

ZAZIC undertakes weekly, monthly, and quarterly data quality audits (DQA) to ensure data correctness and completeness. Intensive DQA processes were documented and availability and completeness of data collected before and after DQAs in several specific sites was assessed with the aim to determine the effect of this process on data quality. ZAZIC found that after the DQA, high record availability of over 98% was maintained and record availability increased. After the DQA, most sites improved significantly in data completeness and ZAZIC continues to emphasize data completeness to support high-quality program implementation and availability of reliable data for decision-making.

Empowering Young Mothers in Namibia

A young woman learning to weave a basket during the September 9-13, 2019 craft-skills training session.

A young woman learning to weave a basket during the September 9-13, 2019 craft-skills training session.

Young mothers enrolled in the DREAMS program in the Zambezi region of Namibia had the opportunity to learn the traditional art of basket weaving through a series of craft-skills trainings facilitated by the International Training and Education Center for Health (I-TECH) and the Integrated Rural Development and Nature Conservation (IRDNC).

The all day, weeklong trainings taught the young women the basics of basket weaving and also empowered them to create marketable items that could lead to greater economic independence. For the trainings, I-TECH and IRDNC invited a Master Weaver to teach women about the technique, the types of natural fibers and dyes, and the necessary tools used in the craft. All of the women who participated in a training made at least one basket by the end of the week.

“Basket weaving is a traditional craft in this area and it is often a source of income for families,” explains Sharon Zambwe, Program Lead for DREAMS Zambezi. “One of the best parts about this program is that it not only teaches women the skills needed for basket weaving but it also connects them to a market for their works, and with each other for ongoing support and encouragement.”

The baskets that the young women crafted were made available for purchase during an event marking the end of their training. The event was attended by representatives from the Society of Family Health; Zambezi Regional Council; and Regional Ministries of Health & Social Services, Education, Arts & Culture, and Youth and Sport. The special event provided attendees with a background of the DREAMS program and included a keynote address from the special advisor of the Zambezi Governor’s Office who presented the future vision of the DREAMS program.

A basket woven by one of the participants at the September 9-13 craft-skills training session.

A basket woven by one of the participants at the September 9-13 craft-skills training session.

I-TECH launched the DREAMS program in the Khomas region in February 2018 and expanded the program to the Zambezi region in June 2018. Since the launch, I-TECH has enrolled over 20,000 girls and young women aged 9-24 years old in the program. DREAMS is a PEPFAR-funded initiative that aims to shape girls and women to be Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS). The program not only addresses the HIV epidemic through prevention and treatment, but it also focuses on the structural drivers of the epidemic, such as gender-based violence (GBV) and poverty.

“The DREAMS program has been able to provide girls and young women with the mentoring and social support needed to help encourage them to make positive and healthy decisions in their everyday lives,” says Ellen MacLachlan, DREAMS Program Director for I-TECH. “The activities in Khomas and Zambezi have had a profound impact on the girls and young women in the program. Economic strengthening activities such as the basket weaving classes can directly empower women by giving them a way to make their own money so they are less dependent on a male partner, especially one who may put her at risk of HIV.”

Since the DREAMS program first launched in the Zambezi region, it has provided social and health services as well as HIV/GBV prevention education to girls and young women and in August 2019, the program expanded into the field of economic empowerment by providing craft-skills trainings. Since the beginning of the service expansion, I-TECH and IRDNC have trained 82 young mothers, aged 15-24, in the art of basket weaving.

While the craft-skills training program in Zambezi is still in its infancy, there are plans to expand the scope of the training to incorporate other crafts skills such as clay pot artistry, knitting, and needlework. In addition to expanding the scope, DREAMS Zambezi plans to partner with tourism organizations as a way for the women participating in future trainings to showcase and sell their wares.

“We have been impressed with the response from the women who have participated in the program over these past four weeks,” says Zambwe. “We can’t wait to expand this program to incorporate more skills that will benefit not only the young women and their families but the community.”

OpenELIS Selected for Google’s Innovative Season of Docs Program

Google has selected OpenELIS Global, a laboratory information system stewarded by the Digital Initiatives Group at I-TECH (DIGI), as a participant in the first year of its Season of Docs, a unique program that pairs technical writers with real-world open source projects. DIGI implements OpenELIS Global in Côte d’Ivoire and Haiti and manages contributions to the software as a part of the global developer community.

“We rely on talented contributors from the global health software community to ensure that our tools have the biggest impact and are available to the widest audience possible,” explained Casey Iiams-Hauser, Senior Digital Health Specialist with DIGI and the OpenELIS Global Product Owner. “By being transparent about our challenges and triumphs, we benefit from peer-to-peer sharing to problem solve for the benefit of the whole community.”

Technical writer Areesha Tariq was paired with the OpenELIS Global project as a part of the initiative. Based in Islamabad, Pakistan, Areesha has a background in software engineering and her writing focuses predominantly on user guides. She will work to improve OpenELIS Global end-user documentation by turning the current user manual into more pragmatic and accessible job aids.

Areesha is excited to join the team, saying, “I feel great to be selected as the technical writer for OpenELIS Global. It will be a new learning experience to work in an open-source community. I hope that I will be able to complete the project and continue working with the team so that I can contribute to a global cause.”

By participating in Google’s Season of Docs initiative, DIGI will not only benefit from Areesha’s contributions, it will also have the opportunity to increase awareness of OpenELIS in the global community by having our projects posted to the initiatives website and reviewed by a large number of technical writers, open source organizations, and contributors. “We are excited to be a part of Season of Docs,” said DIGI Managing Director, Joanna Diallo. “During the application process we met a number of highly qualified technical writers and observed a lot of interest in ‘global goods’ like OpenELIS.”

The idea for DIGI’s technical documentation project grew out of a proposal to PATH’s Digital Square project, which like Google’s Season of Docs, invests in critical technology that can be accessed worldwide. DIGI’s proposal was only partially funded by Digital Square to develop practical designs and generalizable approaches to achieve interoperability among open-source, clinic-level data management systems via the OpenHIE framework. These systems include OpenELIS; OpenLMIS, a laboratory management information system; and OpenMRS, an electronic medical records (EMR) system. However, the OpenELIS documentation scope of work remained unfunded.

“Having focused our thinking already on OpenELIS documentation gaps for the Digital Square application allowed us to pull together our Season of Docs application quickly,” explained Diallo. “It was fortuitous timing – and it is inspiring to see both PATH and Google investing in open source organizations.”

New Digital Group Offers Full Range of Digital Health Services

In winter 2019, the International Training and Education Center for Health (I-TECH) launched a new unit: the Digital Initiatives Group at I-TECH (DIGI). The DIGI team builds upon 15 years of experience at I-TECH designing, developing, implementing, and evaluating health information systems (HIS) around the world.

The group — co-led by Dr. Nancy Puttkammer, Assistant Professor in the Department of Global Health, and Jan Flowers, Clinical Faculty and Director of Global Health Informatics in the Clinical Research Group (CRIG) — provides services to help programs scope and build technical solutions to manage program or clinical data.

“The shared faculty lead role helps the group leverage diverse resources from departments across the university,” said Joanna Diallo, DIGI Managing Director.

By promoting open-source “global goods” that are supported by implementer communities, DIGI helps partners such as Ministries of Health to be able to own and continue to develop long-term solutions.

In April, Flowers received a Digital Square award to lead an online community of practice on open-source lab information systems like OpenELIS, and Dr. Puttkammer received a Digital Square award to design and test practical and generalizable solutions for interoperability between OpenELIS and two other leading open source tools: OpenMRS and OpenLMIS.

DIGI partners with global communities to develop and enhance digital tools and provide technical assistance for effective implementation and sustainability. The team works closely with on-the-ground experts and stakeholders to guide and facilitate governance, capacity building, and continuous quality improvement using a maturity model lens.

DIGI works in the following technical areas:

  • Software Design & Development
  • Health Data Exchange Standards
  • Health Systems Architecture
  • Information Security
  • Evidence-Based Evaluation and Implementation
  • Digital Health Workforce Development

“With investment from the I-TECH center to launch DIGI, we have been able to approach the work in a new way that is flexible and responsive and promotes cross project sharing,” explained Dr. Puttkammer. “We hope this will continue to strengthen the department’s standing as a leader in digital health.”

Cervical Cancer Screening and Treatment Strategy Support in Malawi

Cervical cancer is the leading cause of cancer death among women in Malawi.1 In response, the Ministry of Health (MoH) in Malawi developed the National Cervical Cancer Control Strategy 2016-2020. The strategy outlines comprehensive interventions, including the integration of cervical cancer screening services into HIV care.

In 2019, I-TECH supported the review and update of the National Cervical Cancer Guidelines and the monitoring and evaluation (M&E) framework in partnership with the Department of Reproductive Health and the Department of HIV/AIDS in Malawi. As part of that support, the team conducted a survey to establish which sites in the South West Zone had received equipment for cervical screening and treatment services from the MoH and found that 45 health facilities offer services.

To ensure that the strategy endorses current evidence-base approaches and M&E frameworks, the team convenes cervical cancer partner meetings to draft standard operating procedures and the M&E framework, revise monitoring tools, and conduct situational analyses.

In addition to contributing to national strategy updates, I-TECH is working with the MoH to ensure same-day treatment or follow-up for all pre-cancerous lesions.

1 Government of Malawi, National Cervical Cancer Control Strategy 2016-2020.

HIV ECHO Tele-Mentoring in the Caribbean

I-TECH facilitates an HIV ECHO® program, a distance-based tele-mentoring program for providers and clinics across the region. Weekly sessions provide access to brief HIV clinical updates along with an opportunity to present and receive consultation on challenging or unusual clinical care issues from a team of multi-cadre HIV experts as well as from other members of the community of practice. In response to an identified need, the program added a monthly mental health and HIV session.

In 2019, I-TECH began supporting the Medical Research Foundation to initiate a similar HIV/STI ECHO® program that will target HIV and STI care and treatment sites in Trinidad and Tobago as well as with in other countries in the region.