I-TECH, in close partnership with voluntary medical male circumcision (VMMC) implementing partner, the Aurum Institute and technology partner, Medic, is conducting a five-year study funded by the National Institutes of Health to further evidence on the efficiency, safety, and scalability of two-way text-based (2wT) follow-up for VMMC services.
2wT is SMS-based telehealth, providing direct patient to provider communication that improves the quality of post-operative VMMC care. A daily educational message is sent to each participant, requesting a response to report potential complications. 2wT allows the nurse to triage men to care when needed or desired while supporting most men to heal independently at home. 2wT-based follow-up dramatically reduces unnecessary post-operative visits, saving patient and provider costs, while improving patient care quality through swift identification and referral for potential adverse events. In South Africa, the 2wT intervention benefits were similar across routine VMMC programs in both rural and urban settings.
A new five-year research project will study two-way texting as a means of communication between healthcare providers and male circumcision (MC) patients in South Africa. It will build on previous research conducted in Zimbabwe.
Caryl Feldacker is the Principal Investigator (PI) on this RO1, which will support research through 2025. The multi-stage implementation science study is based out of the International Training and Education Center for Health (I-TECH), and will be implemented with Dr. Geoffrey Setswe, PI for South Africa partner, Aurum Institute, and with technology partner, Medic Mobile.
“Previous research shows that healthcare workers waste a lot of time and money reviewing MC clients without complications,” Feldacker said. “So, in partnership with Medic Mobile, we developed a two-way texting (2wT) system to identify and refer men with potential medical issues to in-person care while allowing the vast majority to opt-out of routine post-operative visits.”
Programs providing voluntary medical male circumcision (MC) in sub-Saharan Africa are struggling to meet the annual goal of 5 million MCs. However, chronic human and financial resource shortages threaten achievement of MC targets, reducing impact of this effective HIV prevention intervention. Although MC is safe with an adverse event (AE) rate of less than 2% , global MC guidelines require one or more in-person, post-operative visits within 14 days of MC for timely AE identification. With low AE rates, overstretched clinic staff likely waste invaluable resources conducting unnecessary routine reviews for MC clients without complications while men healing well needlessly pay for transport, miss work, and wait for reviews, discouraging MC uptake.
In South Africa, the International Training and Education Center for Health (I-TECH) has begun facilitating an in-service skills development training program for community health workers (CHWs) and their supervisors in their roles on the Ward-Based Primary Health Care Outreach Team (WBPHCOT). To maximize the impact of this training, I-TECH is working with two PEPFAR District Support Partners across seven of South Africa’s nine provinces to reach an estimated 20,000 CHWS, which is approximately half of the country’s CHW workforce. Training began in February 2019 and will continue through September 2019.
The WBPHCOT In-Service Skills Development Package aims to strengthen the capacity of CHWs to provide high-quality health services in the community. The program emphasizes development of core, cross-cutting service delivery skills, including communication, screening, psychosocial support, ethics, and confidentiality that enable CHWs and their supervisors, known as Outreach Team Leaders (OTLs), to effectively carry out their work.
During training, CHWs and OTLs build their skills in both classroom and on-the-job settings using group discussions, case presentations, scenario-based role play, small group activities, and interactive presentations. Priority health conditions and related clinical topics are included, and the realistic scenarios cover all components of the CHW scope of work.
Leveraging Technology to Improve Training
All training data collected for the skills development program will be captured via a mobile application and stored using the CommCare platform, a mobile data collection system developed by Dimagi. The app allows I-TECH access to real-time data, which can inform targeted measures to ensure that all CHWs are receiving high-quality trainings.
To tailor the program to the needs and realities of the field, I-TECH has implemented a blended tablet and paper-based data collection approach.
“There is such a large number of CHW trainees in the field that using this blended approach allows the OTLs to dedicate their time to training CHWs rather than focus on paperwork,” says Ilyse Jacobson, I-TECH South Africa Technical Director of Programs. “This flexibility allows for more in-depth and efficient training.”
Due to its role as the sole repository for all training-related data, the CommCare database will also generate reports linked to an interactive stakeholder dashboard.
“The dashboard not only brings I-TECH’s data visualization and dissemination approach into the 21st century,” says Jacobson, “it allows project stakeholders access to the data that helps with decision-making both in and outside of this program.”
The design of the Stakeholder Dashboard allows donors, implementing partners, and the National Department of Health to track current progress against training targets on a weekly basis.
I-TECH supported the National Department of Health (NDoH) in the process of strengthening the policy management and implementation systems with a focus on reaching the 95-95-95 targets and provided ongoing technical assistance as the NDoH beta tested the policy information management system (PIMS) developed in COP 2017.
I-TECH supported the revision and finalization of a Policy Manual and coordinated with the NDoH Policy Project Steering Committee to promote engagement from NDoH staff.
I-TECH supported Human Resource and Primary Healthcare Directorate-led training and capacity development initiatives through training and mentoring activities based on gaps identified from assessment of health care worker competencies, with emphasis placed on the Professional Nurse.
In collaboration with the University of KwaZulu-Natal, and The Knowledge Translation Unit, I-TECH worked with the National Department of Health (NDoH) in South Africa to strengthen the integration of mental health services into routine chronic care within the primary health care system.
The Mental Health Integration (MhINT) program improves access to care for common mental disorders and benefits adherence and engagement in care, aligning with the UNAIDS 95-95-95 strategy. I-TECH provided technical assistant to the NDoH and district support partners (DSPs) as the MhINT Program was scaled-up in priority districts identified by the U.S. Centers for Disease Control and Prevention’s Global AIDS Program (CDC GAP), South Africa, through the President’s Emergency Plan for AIDS Relief (PEPFAR). I-TECH also supported the NDoH as it conducted an in-depth policy situation analysis to inform the development of a national policy incorporating the MhINT program.
Through the South African Men’s HIV Self-Testing, I-TECH demonstrated the feasibility and efficacy of an intervention model utilizing community health workers and outreach team leaders to increase uptake of HIV testing and treatment initiation among undiagnosed HIV-positive men.
Aaron Katz is a principal lecturer emeritus of Health Services, Global Health (adjunct), and Law (adjunct) at the University of Washington School of Public Health where he teaches several graduate level courses in health policy. He also has an adjunct appointment at the University of Queensland (Australia) School of Public Health. Aaron has held numerous academic leadership positions, including his current role as faculty coordinator of the Health Systems and Policy Concentration of the Health Services Master of Public Health (MPH) program and was founding director of the Leadership, Policy, and Management track of the Global Health MPH program. He was director of the UW Health Policy Analysis Program from 1988 until 2003 and editor-in-chief of the School’s biannual journal, Northwest Public Health, from 1999 to 2008.
Aaron received the American Public Health Association’s Award for Excellence in November 2006 and the Outstanding Teaching Award from the UW School of Public Health in 2004. At the 2011 “State of Reform” Washington Health Policy Conference, Aaron received the Health Reform Leadership Award.
Aaron has developed a deep understanding of the U.S. health care system and its strengths and weaknesses during a career that has spanned 40 years and four “bouts” with health care reform. He has worked in health policy and planning in Washington state since 1978, serving as a health planner, policy and planning consultant, lobbyist, and political adviser. Aaron has directed numerous policy analysis and policy development projects for legislative bodies, state and local public agencies, and private sector clients, including work on health system reform, public health reform, managed care, rural access, HIV/AIDS, workers compensation, long term care, medical economics, and services for people with low incomes. Since 1999, Aaron has collaborated on policy development and advocacy projects with colleagues in various countries in southern Asia, sub-Saharan Africa, Latin America, and Japan.
Aaron has served as a peer reviewer of articles for the International Journal for Equity in Health, Health Affairs, Journal of Health Care for the Poor and Underserved, Global Health Action, and the American Journal of Public Health. He has served on numerous community boards, including the Washington State Budget and Policy Center, Northwest Health Law Advocates, Washington Physicians for Social Responsibility, and Health Alliance International.
Aaron received a bachelor of science degree from the University of Wisconsin – Madison in 1974 and a certificate [master] of public health degree from the University of Toronto in 1975.
In honor of National Women’s Day in South Africa on 9 August, members of the International Training and Education Center for Health (I-TECH) team in South Africa organized a personal donation to faith-based organization Participate, Empower, Navigate (PEN), which provides services and support to at-risk populations such as the homeless, sex workers, and orphaned children.
“We were interested in supporting a program that works with women and we were introduced to the Ladies Arise program at PEN,” explains Lebogang Ntswane, I-TECH South Africa program manager.
Ladies Arise is a community support program for homeless women provided through PEN. Many of the women seeking support from the program have been forced into sex work to make an income. Through Ladies Arise, the women can access a drop-in center where they can use the facilities to shower, do laundry, and eat a meal.
The drop-in center also coordinates activities for the women like art classes, crochet, and Bible study. In addition to the fun and sometimes income-generating programs, Ladies Arise provides the women with social and mental health services, such as counseling with PEN’s volunteer social worker.
PEN is a donor-funded non-profit organization and relies on donations of all kinds to continue offering much-needed services in Pretoria. In addition to fundraising events and a major supermarket that donates food to the center on a monthly basis, PEN also relies on donations of clothing, toiletries, and shoes from the community.
“One of our colleagues had seen the idea of filling handbags with toiletries in a magazine,” says Ntswane, “and we decided it would be a great way to commemorate National Women’s Day and assist the women in our community.”
I-TECH South Africa staffers donated the bags filled with new toiletries, as well as clothing and new packs of underwear, a particularly high-need item at the center.
In addition to donations, I-TECH team members had the chance to sit down with recipients over breakfast to learn about their stories. “One woman reported that she met with the center coordinator and was introduced to the Ladies Arise program. She is now attending a cosmetology course,” says Ntswane. “We are so glad that we found this organization, and we look forward to continuing our personal support of PEN whenever possible.”