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E-Learning and Data Quality Improvement Featured at CUGH 2016

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The International Training and Education Center for Health (I-TECH) is presenting three posters at the 7th Annual Consortium of Universities for Global Health (CUGH) conference in San Francisco on April 9-11. The theme of this year’s conference is “Bridging to a Sustainable Future in Global Health.”

A critical component in sustainability is the ability to collect accurate and meaningful data through electronic medical records (EMRs) – the subject of two abstracts from the I-TECH Kenya team.

In addition, online learning and electronic learning (e-learning) provides opportunities for health care workers in resource-limited settings to gain critical knowledge and skills while minimizing their need to leave the workplace.

In close partnership with the University of Washington Department of Global Health’s eLearning Initiative (eDGH), I-TECH piloted e-learning modules for KenyaEMR and transitioned the HIV management diploma program at the University of the West Indies into a blended learning program that incorporates online courses.

“Building Human Capacity for Optimal Use of an Electronic Medical Record System in Kenya: Results of a Pilot Evaluation of Two eLearning Modules”

The transcript tab allows learners to read along with the narration.
The transcript tab allows learners to read along with the narration.

Since 2012, the Kenyan Ministry of Health, PEPFAR, and partners have supported implementation of electronic medical record systems (EMRs) at more than 600 public-sector health facilities. The International Training and Education Center for Health (I-TECH) has supported scale-up at more than 300 of these sites.

However, implementation is just part of the story. Successful, sustained use of EMR data depends upon the knowledge and skills of front-line health care workers. To address this need, I-TECH and eDGH developed and piloted two interactive e-learning modules on EMR data quality and EMR data for decision-making.

I-TECH and eDGH found that facility staff were motivated to use EMR e-learning modules and apply what they had learned. Participants found the content relevant to their jobs and cited an interest in additional scenarios and modules. Self-paced e-learning modules were determined to be a viable solution for standardizing sustainable training on EMR systems.

“Institutionalization of a Routine Data Quality Assessment (RDQA) Procedure for Improved Data Quality of Electronic Patient Medical Records in Kenya”

To support progressive EMR data quality improvement, I-TECH developed a Routine Data Quality Assessment (RDQA) standard operating procedure and analysis tool. The RDQA procedure was defined in collaboration with the Kenyan Ministry of Health and integrated within existing policies and procedures.

From 2014 to 2015, 180 baseline and repeat assessments were conducted. I-TECH supported facility personnel to share results during county-level EMR review meetings; these presentations motivated other sites to plan for RDQAs and fostered a culture of ongoing data quality improvement. The RDQA procedure for EMR data has now been institutionalized as a method for progressively improving EMR data quality in Kenya.

“Train, Transfer, and Sustain: Building Capacity for Online Learning at The University of the West Indies Diploma in the Management of HIV Infection Program”

In partnership with the University of the West Indies (UWI), eDGH and I-TECH transitioned a one-year diploma program in the Management of HIV Infection to a blended learning platform that combines online courses with either a clinical practicum or a research project.

The shift in pedagogy, methodologies, and technologies was achieved through a three-phased approach designed to not only train UWI faculty and staff, but also transfer online facilitation skills to them and sustain those skills.

In its second year as a blended learning online program, the diploma program has scaled up to include health care workers from Cayman Islands, Jamaica, and Suriname.

These projects are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under U91HA0680, International AIDS Education and Training Center. The content and conclusions of this post are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U.S. government.

Mental Health – A New Challenge for HIV Treatment in Ethiopia

I-TECH-supported HIV care and counseling in northern Ethiopia, in 2009. Photo courtesy of Julia Sherburne.

Although HIV patients in Ethiopia have greater access to antiretroviral therapy (ART) than they did a decade ago, ensuring that patients adhere to a full course of ART is still a major challenge. In response, in 2008, the International Training and Education Center for Health (I-TECH) launched a landmark HIV/AIDS Case Management program in several of the country’s regions where HIV prevalence was high.

This project was supported by the U.S. President’s Plan for AIDS Relief (PEPFAR), through the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA).

The goals of the project are to help control the HIV epidemic in Ethiopia, minimize transmission of HIV, and help HIV patients lead healthy lives. The project actively targets and engages patients considered to be likely non-adherents by assessing clinical, nutritional, domestic, and economic indicators. Those at risk of non-adherence are transferred to I-TECH-trained case managers located within ART clinics.

“ART taken for life is a challenge, but missing a few pills can cause a rapid decline in the health of a patient suffering from HIV. A discontinued course of ART will create a resistant strain of HIV that is much more difficult to treat,” says Misti McDowell, former Country Director for I-TECH Ethiopia.

Poor adherence can also mean high risk of transmission in the patient’s community. The Case Management program helps mitigate that risk.

A new screening tool

I-TECH quickly realized that many patients attending adherence counseling sessions were suffering from mental health issues, including depression, anxiety, and substance abuse. It was also understood that many health workers did not have the competencies or skills to adequately engage in conversation with patients about their mental and emotional welfare.

I-TECH formulated a mental-health screening tool for all ART patients to better assist patients with ART adherence and mental health issues.

“Many HIV patients in Ethiopia become overwhelmed by depression, and commit suicide. The mental health component to our work has helped to prevent these outcomes, and manage mental health issues related to HIV diagnosis,” says Dr. Manuel Kassaye, I-TECH’s Care and Treatment Programs Director.

Shared experiences can save lives

In Ethiopia, there are currently only 42 working psychiatrists catering to the needs of an estimated population of 93 million. “The country is in need of a strategy to deliver mental health services to people,” says Dr. Manuel. I-TECH-trained adherence case managers, working in partnership with hospital clinicians, have directly helped to address mental health issues related to HIV in Ethiopia.

The majority of case managers selected and trained by I-TECH have themselves been diagnosed with HIV, ensuring empathic relationships with their patients.

“To be a good adherence support worker, I believe it is necessary to have HIV,” says Mulugojam Yilikal, who was trained as a support worker by I-TECH in 2008. “The case worker will have enough experience to empathize with the patient, to help guide them through their mental and emotional issues.”

She adds that patients feel secure and comfortable talking to people who also have HIV. “By opening up and talking freely with us, it benefits their mental health, and their adherence to taking their medication.”

Mulugojam’s brother tragically committed suicide in 2007, after struggling to come to terms with his HIV diagnosis. “I know that if this support and counseling service [had been] available to my brother, he would have been saved from killing himself,” she says. “If a patient confides to a support worker that they want to take their own life, they can be prevented [from doing so] through counseling.”

Genet Behre, 30, is married and has a 5-year-old son. She discovered her HIV status during a pregnancy check-up in 2009. She immediately started taking ART and reluctantly disclosed the news to her husband—who subsequently left her. Once disclosure is made, there usually follows a period of emotional and mental distress that often leads to household dysfunction. “It was a terrible time when I first found out,” says Genet. “I was very distressed, and came into conflict with family and friends.”

After being screened for mental health, Genet was offered counseling and medical treatment for her depression and anxiety. “After six months, I had stopped fighting with my family,” she says. “My life is now stable again, my home life is peaceful, and I have an income selling injera. The counseling and medical support I receive has helped me to live like ordinary people, and not fear for the future.”

After counseling, new hope

A peer support group has been set up by I-TECH, in which patients have a platform to confide in others and speak openly without fear of being judged. Here, people are encouraged to share personal experiences and coping strategies. The group focuses on helping patients cope with the stigma associated with HIV, and overcome any barriers to ART adherence, including social and economic problems.

Zenabe Teklu, 35, silently sits with her I-TECH trained case manager at Gondar Hospital. Although she barely speaks, she is evidently happy to be in the reassuring company of her mentor. Zenabe had two children who both tragically died within six months of being born. After the departure of her husband in 2007, her mental health started to deteriorate. Then, after developing physical sores in 2007, she was tested for HIV, and promptly joined I-TECH’s case support program. However, between 2007 and 2013, she continued to suffer strong symptoms of mental disturbance and suicidal tendencies.

In 2013, I-TECH introduced the mental health screening service at Gondar Hospital. Up to this point, Zenabe was mistakenly told that her depression and suicidal thoughts were symptoms of ART medication. Zenabe started receiving the correct medication and counseling shortly after hospital staff members had completed I-TECH training in mental health screening.

Zenabe, who currently works as a cotton weaver, is happy to have turned a huge corner in her life with the support of I-TECH: “My life is stable compared to how I was before. I no longer feel full of anger and depression. I have experienced a lot of trauma, but the support I get from my case managers helps me to live a normal life”.

MOU Signed with the Ukrainian Centre for Socially Dangerous Disease Control

From L to R: Igor Kuzin, Head of the National M&E Center at UCDC; Dr. Natalia Nizova, Director of UCDC; Matt Heffron, I-TECH Informatics Implementation Specialist; Anna Shapoval, I-TECH Ukraine Country Director; and Mykhailo Rabinchuk, PR and Event Manager at UCDC.

From L to R: Igor Kuzin, Head of the National M&E Center at UCDC; Dr. Natalia Nizova, Director of UCDC; Matt Heffron, I-TECH Informatics Implementation Specialist; Anna Shapoval, I-TECH Ukraine Country Director; and Mykhailo Rabinchuk, PR and Event Manager at UCDC.

On March 11, the University of Washington Department of Global Health (DGH) signed a Memorandum of Understanding (MOU) with the Ukrainian Centre for Socially Dangerous Disease Control of the Ministry of Health of Ukraine (UCDC).

This landmark event consolidated cooperation between the International Education and Training Center for Health (I-TECH) — a DGH center — and UCDC. This partnership started in 2013 with the launch of the I-TECH-developed Clinical Assessment for Systems Strengthening (ClASS) tool within a project to build clinical and managerial capacity of HIV/AIDS services in Ukraine.

All parties expressed confidence that this MOU would help foster relationships and the development of possible collaborative projects in capacity building, monitoring and evaluation, and research aimed at quality improvement of health care services in Ukraine.

“I-TECH is very excited about this new development in our collaboration with UCDC,” said Anna Shapoval, Country Director of I-TECH Ukraine. “The MOU will help to formalize, fortify, and, hopefully, expand our partnership with the UCDC in the coming year and beyond —  in particular in the area of health systems strengthening through development of human resources for health and supporting strategic information systems.”

E-Learning Increases Accessibility to HIV Diploma Program in the Caribbean

HIV Diploma Program in the Caribbean

Students of the graduate diploma program in the management of HIV infection have the opportunity to receive instruction from a hand-selected group of experts. Photo courtesy of Ben Depp.

In the Caribbean, an estimated 250,000 people are living with HIV (UNAIDS, 2013).  To address this epidemic, health workers must have the latest information to guide the treatment and care of those living with HIV and AIDS. The University of the West Indies (UWI) St. Augustine campus in Trinidad and Tobago offers a one-year graduate diploma program in the management of HIV infection.

In partnership with UWI and the Caribbean HIVAIDS Regional Training Network (CHART), the International Training and Education Center for Health (I-TECH) and University of Washington Department of Global Health’s eLearning Program (eDGH) helped to transition the program to a blended learning platform — one that offers courses online as well as an in-person practicum.

Support for this transition was provided by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the Department of Health and Human Services’ Health Resources and Services Administration (HRSA).

The program recently completed its first semester in this new format. With the expanded platform, students have the flexibility to access the course material “anytime and anywhere,” says Professor Zulaika Ali, Program Coordinator, “and it allows students to organize their training around their routine activities, which is important for mature working individuals.”

The conversion of courses online creates a one-of-a-kind program in the Caribbean, increasing access for mid-career health professionals working in the public sector, for non-governmental organizations (NGOs), and for commercial organizations. The program was designed for medical doctors, pharmacists and dentists, as well as nurses with bachelor degrees from any recognized university; registered nurses with a minimum of three years of experience; social workers; management staff from government ministries, private sector and NGOs; and tutors and lecturers in training institutions.

After a week-long online student orientation, students explore the following topics through online instruction and relevant resources, synchronous virtual classroom sessions, and collaborative activities and discussions. At the end of each semester, students complete an in-person exam. After completion of the online courses, students participate in an in-person practicum or dissertation. Courses include:

  • Research Methods and Design
  • HIV Epidemiology and Pathogenesis
  • Laboratory Techniques for Diagnosis of HIV
  • General Management of HIV/AIDS
  • HIV Co-Infection and Other Related Issues
  • HIV Health Systems
  • Sexual and Reproductive Health

In addition to the flexibility this part-time program offers, students also have the opportunity to receive instruction from a hand-selected group of experts from around the globe, including professors, health care workers from the Ministry of Health and NGOs, and professionals practicing in the region.

Transition from in-person to blended learning

In late 2013, I-TECH and eDGH were approached by UWI to convert the in-person diploma program into its second, blended rendition. The team started by piloting two courses online in the Moodle learning management system (LMS). From there, they obtained critical feedback for the remainder of the conversion.

Their research showed that students felt the course content was clear, appropriate, interesting, and applicable to their work and reported a preference for recorded lectures and relevant videos, anytime/anywhere access, and interactions with instructors and peers. Likewise, faculty enjoyed building new skills through online instruction.

“We conducted two in person, on-site faculty workshops, countless Skype calls, online trainings, and emails to build the capacity of faculty to develop and teach online,” says Elizabeth Scott, Senior E-Learning Developer with eDGH. “Working with faculty was a highly rewarding experience. They were motivated and dedicated, and they worked tirelessly side-by-side with us to create the best possible experience for students.”

As part of the project, the I-TECH/eDGH team also developed a commercial for the program (see below), as well as a number of introductory materials that can be used for a variety of online and blended learning programs. Among them are a general student orientation to help learners identify skills and characteristics necessary for success in online courses and an e-learning basics module for instructors.

“The informational materials developed for the program will help to improve the delivery of health care more generally,” says Dr. Ali.

A robust transition guidebook was also assembled, containing roles and expectations, best practices, online orientation materials, processes, budgeting templates, evaluation tools, job aids, and tasks and timelines for faculty and staff for ease of handover from year to year.

“The delivery of this program in the blended format will have a tremendous impact on the quality of care delivered to people infected with and affected by HIV,” says Dr. Ali. “The Faculty of Medical Sciences looks forward to welcoming regional and international students into the program. This new platform will surely enrich the learning experience of all involved.”



Stories of Success from Ethiopia: Mother’s Support Groups for PMTCT

In Mothers’ Support Groups, trained mentors counsel HIV-positive pregnant women and mothers on optimal child-rearing practices and encourage them to adhere to PMTCT programs. Photo courtesy of Julia Sherburne.

The following is the second in a three-part series of I-TECH success stories from Ethiopia.

In Ethiopia, only 24 percent of HIV-positive pregnant women receive antiretroviral therapy (ART) to prevent transmission of the virus to their children (UNICEF, 2012). The importance of counseling for these pregnant women is critical to increase treatment rates and ensure more children are born HIV-free.

In 2009, the International Training & Education Center for Health (I-TECH), with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), began managing support groups for HIV-positive pregnant women and mothers in three regions of Ethiopia: Axum, Gondar, and Dubti.

This case management program, which came to a close at the end of 2014, was the first of its kind in the country, training a group of 63 mentors to counsel pregnant HIV-positive mothers on optimal child-rearing practices and offering psychosocial support to help them adhere to prevention of mother-to-child transmission (PMTCT) programs.

Yirgalem Taye is one of the trained mentors from the Mother’s Support Group based at St. Mary’s Hospital in Axum, Northern Ethiopia.

In addition to urging mothers to follow treatment regimens, “we encourage mothers to give birth in a hospital to reduce the risk of transmission during delivery,” says Yirgalem. “We teach mothers breastfeeding practices, family planning, as well as the importance of disclosure to a partner and the need to get all partners to come and test with us.”

Offering consolation, solidarity, and friendship

Alem Tsehaye sits by a bowl of smoldering frankincense while playing with her 7-month-old baby girl, Heyab.

In 2009, Alem tested HIV-positive, forcing her to change her plan to move abroad and work as a domestic servant. In 2013, she became pregnant, which caused anxiety about the well-being of her child.  She enrolled herself in the Mother’s Support Group at St. Mary’s Hospital and started to receive counseling.

“I learned that it’s possible to be HIV-positive and have a HIV-negative child,” says Alem, “which might not have been possible had I not joined the group.”

Alem notes the consolation and solidarity she derived from spending time with other young mothers in the support group. “If one of us came to the group feeling low, we would build each other up again,” she says. “I have made new friends. Between us we continue sharing the support within the community.”

One of the biggest challenges facing a woman diagnosed with HIV is disclosure to her husband. If a person with HIV status fails to make a disclosure to his or her partner, the uninformed partner becomes a risk to home and community health. One role of a Mother’s Support Group mentor is to mitigate this risk by encouraging group members to inform their partners so that they can be tested without delay.

Real results for child and mother

From 2009 to 2014, nine hundred mothers were enrolled in the mentorship program at Gondar University Hospital. Out of those 900 births, only 72 infants – or 8 percent – tested HIV-positive. The World Health Organization estimates that, in the absence of any intervention, transmission rates can range from 15-45 percent.

Outside the Mother’s Support Group ward at Gondar University Hospital is a courtyard where a group of young mothers sit doting over their babies. Many of these mothers do not have an appointment but have come to see their mentors.

“The mothers love the support and security of this small community group,” says Rachel Birhanu, a mentor. “The mentors attend their children’s birthdays and ceremonies. We have become close. They confide in us and know we are the few people who will listen and not judge them.”

The I-TECH program may have come to an end, but the Mother’s Support Groups are acknowledged for their comprehensive service delivery and for their successful efforts to reduce the number of HIV-positive babies born in Ethiopia – and to increase the productivity and well-being of HIV-positive mothers.

Helen Alebachew has two children. In 2007 she discovered her HIV-positive status after undergoing a test while suffering from tuberculosis. She says she benefited from learning about HIV-friendly family planning practices and coping strategies within the group.

“The solidarity I experienced in the mother’s group saved me from losing my mind,” Helen says while roasting coffee beans in a pan over a small fire.  “After starting ART treatment, I made a fast recovery and was soon living a normal life again.”

Haiti’s Electronic Medical Records System iSanté Proves Useful Tool to Improve Patient Outcomes

For nearly a decade, iSanté has allowed providers to share information among care team members and health professionals.

For nearly a decade, iSanté has allowed providers to share information among care team members and health professionals.

Over the past several years, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has invested heavily in health systems and clinical data analyses in low-income countries around the world, in its efforts to support the care and treatment of those affected by HIV and AIDS.

With the support of PEPFAR, through the Health Resources and Services Administration (HRSA), in 2005, the International Training and Education Center for Health (I-TECH), together with Haiti’s Ministère de la Santé Publique et de la Population (MSPP) and the U.S. Centers for Disease Control and Prevention (CDC), developed and implemented iSanté — an electronic medical record system to capture and report information on patients living with HIV and AIDS.

For nearly a decade, this system has allowed providers to document HIV patient care, look up patient care histories, and share information between care team members and health professionals.

The MSPP has been particularly concerned with patient adherence to antiretroviral therapy (ART) and treatment failure due to a number of factors, including the 2010 Haiti earthquake. While iSanté has gotten kudos in Haiti for storing and linking patient data, three recent papers, lead-authored by I-TECH Research and Evaluation Advisor Nancy Puttkammer, have illustrated the potential of using this data source to identify and help solve the challenges of adherence and patient attrition.

  • Before and After the Earthquake: A Case Study of Attrition from the HIV Antiretroviral Therapy Program in Haiti,” published in Global Health Action in August 2014, compared attrition from the national HIV ART program at two large public-sector hospitals where I-TECH works. One site was less than 30 km from the epicenter of the devastating earthquake of January 2010, while the other site was outside of the area strongly affected by the earthquake. Surprisingly, the paper showed that attrition improved after the earthquake in the site closest to the epicenter. This finding underscores the resilience of patients and providers, and contributes evidence that it is possible to maintain continuity of HIV services even in the context of a complex humanitarian emergency.
  • “Patient Attrition from the HIV Antiretroviral Therapy Program at Two Hospitals in Haiti,” currently in press at the Pan American Journal of Public Health, examines ART attrition at the same two hospitals, during the period 2005-2011. The study found higher risk of attrition among patients who lived farther away from the hospital, who started on non-standard ART regimens, who did not receive ART adherence counseling before initiating ART, and who rapidly started ART following their enrollment in HIV care and treatment. The findings suggest opportunities for several quality improvement interventions at the two hospitals.

“This research has provided a valuable contribution in documenting health outcomes and encouraging improvement in the ART program in Haiti,” says Dr. Scott Barnhart, Professor of General Internal Medicine and Global Health at the University of Washington. “We are at the dawn of translating large investments in EMRs into useful data for improving the care of patients, as well as supporting important pub

KenyaEMR Implemented at More Than 340 Sites in Under Two Years

The I-TECH Kenya team celebrates implementing KenyaEMR at more than 340 facilities -- along with a congratulations card from I-TECH HQ.

The I-TECH Kenya team celebrates implementing KenyaEMR at more than 340 facilities — along with a congratulations card from I-TECH HQ.

A shifting government structure, power outages, and even the threat of crocodiles didn’t deter the International Training and Education Center for Health (I-TECH) from implementing the electronic medical records system KenyaEMR at more than 340 clinics and district hospitals across Kenya.

One of the largest EMR rollouts in Africa, this work was supported by the U.S. Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

When PEPFAR care and treatment partners in Kenya identified lack of timely and complete patient data as a major barrier to effective HIV/AIDS patient management, I-TECH and in-country partners set out to design and develop KenyaEMR, expanding on the OpenMRS platform to build an EMR system to collect health data and improve patient care.

These efforts were first led by I-TECH Kenya’s then-Country Director, Dr. Patrick Odawo, and were assumed by his successor, Dr. Willis Akhwale, supported by dedicated teams in Nairobi and at Seattle headquarters.

Challenges along the way

The KenyaEMR team wades across the Turkwel River.

The KenyaEMR team wades across the Turkwel River.

This was no small feat – there were many obstacles overcome to equip the sites in just under two years.  Among these were the devolution of the Kenyan government to a county-based government halfway through the implementation, lack of reliable power, and establishing server rooms in facilities that were never designed to protect electronic systems.

In fact, Implementation Assistant Wilfex Terer remembers obtaining an escort and wading across a crocodile-infested river to reach a health facility in North Rift Valley, one of the most remote areas of Kenya.

“Because of high insecurity in the southern parts of Turkana County, we hired two Kenya police reservists to provide security escort,” says Terer. “We then left our vehicle and waded across the Turkwel River to a health facility vehicle awaiting us on the other side. After some minutes we arrived at the facility in wet clothing.”

Implementing the system

KenyaEMR is a customized system that supports the care and treatment of HIV/AIDS. The system was designed and developed by I-TECH and partners in 2012, following Standards and Guidelines developed by I-TECH in collaboration with the Kenyan Ministry of Health.

The pre-implementation phase comprised engaging stakeholders, specifically the Kenyan Ministry of Health, forming technical working groups to share strategies, and assessing the networking and hardware at the facilities.

Particularly important to effective implementations were sensitization meetings with county, hospital, and facility administrators to build their awareness of the benefits of KenyaEMR and to obtain their support for its implementation and operations.

During implementation, the team purchased hardware, installed intranets, and set up and deployed the software. This phase also included mentorship and on-the-job training: I-TECH supports use of the system by building the capacity of Health Managers and through on-site training to mentors, who then train staff at local facilities.

This approach to capacity building allowed I-TECH to maximize training time, build local capacity, and ensure sustainability when staff transition to other facilities. To date, I-TECH has oriented 625 Health Managers and trained 1,409 system users and champion mentors.

The future of KenyaEMR

Wired for a training in North Rift.

Wired for a training in North Rift.

Post-implementation, I-TECH is providing ongoing software maintenance, support for use of system, and guidance on data use for patient monitoring.  I-TECH is working on expanding the functionality to handle pharmacy and laboratory orders, as well as additional functions at the facility.

“The main focus now is on improving meaningful use of data and defining exactly what that is,” says Steven Wanyee, Implementation and Interoperability Manager.

One example of “meaningful use” is that physicians and other health workers can now see a summarized profile before meeting with a patient, which helps improve quality of care and physician decision making.

Likewise, at the policy level, an electronic database means that various stakeholders in Kenya can collect public health data to assist them in assessing needs and making broad-reaching policy decisions.

“EMRs have been seen as very useful in discussions about the HIV treatment cascade,” says Wanyee, and there is interest in finding out how KenyaEMR can help to identify gaps.

“This project does more than just save space dedicated to paper records,” he continues. “It helps to inform and improve patient care at every level.”

Collaborative Creates ‘Culture of Quality Improvement’ in Jamaica

A JaQIC team's storyboard illustrates inspiration points and accomplishments.

A JaQIC team’s storyboard illustrates inspiration points and accomplishments on the journey toward quality improvement. Storyboards are a creative way for teams to learn from one another.

Despite strong clinical capacity, systemic barriers may prevent local care teams from executing CD4 count and HIV viral load tests. These tests are critical for monitoring the health of people living with HIV — and their response to antiretroviral therapy (ART).

In response to this challenge, in October 2013, ten treatment sites from the four Regional Health Authorities kicked off the Jamaica Quality Improvement Collaborative, or JaQIC (Ja-quick).

The collaborative is led by the International Training and Education Center for Health (I-TECH), in partnership with the Caribbean HIV/AIDS Regional Training Network (CHART), and supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Health Resources and Services Administration (HRSA).

The project is coordinated by I-TECH Senior Quality Improvement Advisor Shay Bluemer-Miroite, with Dr. Chris Behrens, Clinical Associate Professor of Medicine, Family Medicine & Global Health at the University of Washington, serving as clinical advisor.

“The aim of the project was to significantly increase CD4 and viral load testing by March 2014, and it succeeded in that in all ten sites,” said Bluemer-Miroite, noting that within six months, JaQIC was seeing measurable results. (In fact, from baseline to March 2014, sites improved incidence of CD4 testing by up to 34 percentage points.)

“But,” she added, “the collaborative has achieved so much more than that.”

Working Together to Improve Quality

Building on the existing investment in training and capacity development, quality improvement collaboratives such as JaQIC empower frontline health care workers to implement best practices and improve quality of care.

They also rely on the knowledge of existing clinical care teams, who are most familiar with health systems challenges and best positioned to identify solutions to resolve them. These challenges run the gamut from the availability of patient forms, to problems with transport of samples, to equipment failures during sample processing.

Through the collaborative, sites identify potential problems that can crop up at each step in the process, test these ideas via plan-do-study-act (PDSA) cycles, and share learning. As JaQIC teams gathered during a series of Learning Sessions to “share seamlessly, steal shamelessly,” they not only improved the quality of care, they also built excitement for quality improvement and demonstrated that frontline staff can make impactful changes.

Far-Reaching Impact

“Programs struggle with obtaining the data to prove that they are having an impact,” said Bluemer-Miroite. “Through the collaborative, tracking data became particularly meaningful to the health care teams – because they were the ones who were using the data. By tracking patient-level data from the outset, it’s easy to see how the quality of care is being affected, and it increases the data quality, too.”

The success of the program has led to the buy-in of the Jamaican Ministry of Health (MOH) – so much so that the MOH has added the role of QI Coach to its Treatment, Care and Support Officers (TCSOs), and all of the collaborative’s activities will fully transition to the MOH in December.

The collaborative has also spread to four additional countries in the Caribbean (CaReQIC): Trinidad and Tobago, Barbados, the Bahamas, and Suriname, which have joined a new group from Jamaica to form CaReQIC. While gearing up for CaReQIC Learning Sessions, coordinators realized that more foot soldiers would be needed to liaise with the sites directly, so I-TECH helped to develop training for a cadre of QI Coaches in all five countries.

The effects of this program will be far-reaching, even after its transition.

“What’s really exciting about JaQIC is its potential for a sustained impact on multiple levels,” said Dr. Behrens. “JaQIC has dramatically increased rates of CD4 and viral load testing via systemic changes that are likely to persist into the future. More importantly, however, JaQIC has introduced a ‘culture’ of quality improvement in the region that has been enthusiastically adopted across a broad spectrum of local and regional stakeholders.”

Stories of Success from Ethiopia: The Tsadkane Holy Water Well

Samuel Tadessa at the Tsadkane monastery.

Samuel Tadesse found consolation at the Tsadkane monastery, but he saw that more needed to be done.

The following is the first in a three-part series of I-TECH success stories from Ethiopia.

Samuel Tadesse discovered he was infected with HIV in 2004, after undergoing a routine test as part of a U.S. visa application. He spent the next four years feeling utterly hopeless.

Although not a church-going man, Samuel visited one of the country’s largest holy water springs as a last resort: The Tsadkane monastery, located within the Amhara region of Western Ethiopia.

The holy water site is visited daily by up to 5,000 pilgrims, all in search of a cure to their ailments by way of prayer, holy water consumption, and bathing. The majority of these pilgrims are extremely ill, and a large group have been diagnosed with advanced HIV/AIDS.

Samuel immediately experienced consolation and decided to live at the site of the well. However, he soon realized that many of the people living by the well, waiting for a miracle, were dying. He also understood that the strict diet of holy water and a single daily portion of dried barleycorn flour was inadequate nutrition for those who were sick. He resolved to try to improve the welfare of the stricken community.

Samuel’s fundraising efforts, launched at local bus stations, quickly gained momentum, and soon he was able to buy and distribute bread and blankets to the dying pilgrims at Tsadkane. In just a few months, the number of people benefiting from the new funds had grown from 115 to 1,200.

But Samuel knew that blankets, bread, and water were only a short-term solution.

“I realized that many of these people were dying,” says Samuel. “It was frightening because there was no medical care, and I knew many more would die if we did not create a link between the well and a nearby health center.”

So he approached the local Church.

Historically, the relationship between medical science and the Ethiopian Orthodox Christian community — the country’s largest religious group — has been contentious. When the AIDS epidemic began to spread rapidly in Ethiopia, any discussion in favor of antiretroviral treatment (ART) was discouraged. According to the Church, there was only one treatment for HIV patients: faith, prayer, and holy water.

The Church donated a small thatched hut to shelter HIV victims, but despite Samuel’s commitment, he didn’t have the capacity to accommodate the ever-growing numbers.

A Successful I-TECH Partnership

The facilities at Tsadkane

The facilities at Tsadkane provide HIV testing, counseling, treatment, and care.

It wasn’t long before the International Training and Education Center for Health (I-TECH) learned about the growing HIV community living at the Tsadkane holy water site and the urgent need to scale up Samuel’s operation. In response, I-TECH formed a partnership with the Ministry of Health in 2008, based on a commitment to promoting access and adherence to ART as well as providing care and support services for HIV-positive people seeking a holy water cure.

Between 2009 and 2013, with funds made available through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), I-TECH provided more than US$200,000 in support to the shelter. During this period, 1,370 HIV patients were successfully rehabilitated after being brought to the shelter in a critical health state.

“I-TECH was a lifeline for me,” says Samuel. “I was feeling very overwhelmed and frightened at how many people were going to die as a result of limited support to people with HIV. Up to five people a day were dying in my arms.”

With I-TECH support, Samuel was now able to offer and deliver extensive counseling on HIV testing and ART services to the community of people that had gathered in search of his help.  “It was a huge relief” to have I-TECH’s support, says Samuel.

Within a year, the project had sourced a hub of buildings as a base for the rehabilitative shelter 5 kilometers from the holy water site and was accommodating a steady influx of HIV patients. HIV testing, counseling, ART treatment, and care had been made available to the holy well community.

Fighting Stigma and Discrimination

The shelter community is widely recognized for having succeeded in empowering a large HIV community to overcome fear and stigma and reach out for ART.

With the support of I-TECH management and training, the shelter has been one of the few places in Ethiopia to offer rehabilitation and care to those who have been excluded from their family and community because of their HIV status, says Misti McDowell, Country Director for I-TECH Ethiopia.

“Tsadekane has provided support and acceptance to people living with HIV when so many others have rejected them,” she says. “The shelter offers them a safe place to receive health services as well as working with their home communities to reduce stigma and discrimination.”

Strengthening the Community

The bakery at Tsadkane provides nutritious food.

The bakery at Tsadkane supplies both nutritious food and income for patients.

To help patients rehabilitate, I-TECH funded the installation of a bakery, a dairy, a restaurant, and a seed-oil extraction mill to offer income-generating activities. The aim of these activities was to provide economic empowerment and livelihood training for patients so that they could have an active role in their home community.

The Tsadkane shelter also prioritizes the security and welfare of children born to HIV-infected mothers by providing a dormitory, a playground, schooling, and immediate HIV testing of all children entering the shelter.

According to Dr. Manuel Kassaye,I-TECH’s Care and Treatment Programs Director, “I-TECH played a key role in transforming an informal community group into a community-based organization dedicated to increasing access to HIV care services including mental and spiritual health, as well as increasing the number of ART users.”

To help the shelter improve its service delivery, I-TECH conducted an organizational capacity assessment in 2012.

Another Story of Hope

In early 2014, Tsige Birhanu, 38, arrived at the shelter center on a stretcher. She was weak and emaciated; many feared she would not survive another week. She had been sleeping on a plastic sheet by the well for nine months. Like many pilgrims, she had been subsisting on a diet of holy water and small amounts of barleycorn flour. After suffering frequent bouts of vomiting and diarrhea,she was carried to a nearby hospital where she was diagnosed with TB and HIV.

With a fast deployment of care, nutrition, and ART at the shelter, Tsige’s health improved dramatically in just two months. “The shelter saved me,” she says. “Because of the treatment and care I received, I can now look forward to living a normal, healthy life. …Living, working, and serving here has given me a renewed sense of purpose and confidence.”

I-TECH and DGH Leadership Visit I-TECH Ethiopia, Speak at Outpatient Clinic Launch

Dancers prepare to perform at the University of Gondar's Diamond Jubilee.

Dancers prepare to perform at the University of Gondar’s Diamond Jubilee.

Earlier this month, a distinguished group from the University of Washington’s International Training and Education Center for Health (I-TECH) and Department of Global Health (DGH) visited Addis Ababa and Gondar, Ethiopia, for several days of discussion, workshops, events, and celebration — including the University of Gondar’s 60th anniversary Diamond Jubilee and the inauguration of the University of Gondar Comprehensive Outpatient Center.

Workshops and discussion at the I-TECH Ethiopia offices

I-TECH has had a presence in Ethiopia since 2003, and in that time, has become a guiding force in antiretroviral therapy service delivery and human resources for health, building the capacity of the Regional Health Bureaus (RHBs), universities, and health facilities; introducing innovative initiatives such as task sharing; activating effective monitoring and evaluation interventions; advocating for and implementing TB prevention programs, including MDR-TB; and building the capacity of health facilities and regional labs. The team acts in close partnership with the RHB offices of the Ministry of Health in Afar, Amhara, and Tigray and will be transitioning most of its programs to the RHBs in September 2014.

In advance of this transition, Dr. King Holmes, Chair of the DGH, and Dr. Ann Downer, I-TECH Executive Director, met with staff in Addis Ababa during a July 4 coffee ceremony. The meeting was an opportunity to say farewell to some incredibly valuable members of the I-TECH Ethiopia team who are leaving as projects are transitioned to the RHBs and discuss highlights of more than a decade of outstanding work in Ethiopia.

Bryan Verity, I-TECH HQ Director of Human Resources, was earlier on hand to facilitate a four-day career transition series with materials adopted from the UW career center. The series was co-facilitated by Tigist Dagne, Human Resources Manager at I-TECH Ethiopia.

“We had a great level of involvement by the staff, especially during the ‘assessing personal strengths’ workshop,” said Verity. During this exercise, a staff member shared experiences, while “listeners” tracked skills/strengths that the speaker employed during the experience.

The series also covered writing curriculum vitae (CV), conducting a job search, and strengthening interview skills. In addition, Verity presented a 60-minute training on personal financial management.

“It’s been a tremendous honor to work with such a dedicated and talented group of people,” said Dr. Downer. “I am so pleased that King and I had the opportunity to express our gratitude in person for the fine work this team has done to combat HIV/AIDS in Ethiopia. Everywhere we went in Ethiopia we heard about the positive reputation and valued contributions of our I-TECH Ethiopia team.”

Much to celebrate at the University of Gondar

Ethiopian Prime Minister Hailemariam Desalegn

Ethiopian Prime Minister Hailemariam Desalegn

Speaking alongside Ethiopian Prime Minister Hailemariam Desalegn and U.S. Ambassador to Ethiopia Patricia Haslach, Dr. Holmes delivered a keynote address at the inauguration of the Gondar Comprehensive Outpatient Center on July 6. The launch was bookended by the university’s graduation ceremony and its 60th anniversary Diamond Jubilee conference.

The center was a collaborative effort of I-TECH, UW, the University of Gondar, and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) representatives in Ethiopia: the U.S. Centers for Disease Control and Prevention (CDC) and the Health Resource and Services Administration (HRSA).

The construction of this center was critical to address the significant burden and impact of disease in Ethiopia to comply with the Ethiopian Ministry of Health’s (MOH) mandate to increase the number of health care workers and to support the goal of PEPFAR to improve delivery of acute and preventive services related to HIV, TB, and malaria.

To meet these goals, the building can provide care to approximately 350,000 patients per year and serve as a training center for clinical outpatient care in TB, infectious disease, adult medicine, surgery, pediatrics, and emergency care. It houses a state-of-the-art TB facility.

Dr. Holmes visits his namesake CPD center.

Dr. Holmes visits his namesake CPD center.

I-TECH and the UW, through funding from PEPFAR, were instrumental in the conception and execution of the center, serving as consultants for both facility design and curriculum development. In this work, I-TECH helped to ensure that the facility allows for the integration of clinical care, teaching, and training. Dr. Scott Barnhart, an I-TECH principal investigator and a UW professor of medicine and global health, brought in Christine Kiefer, a Harborview Medical Center architect, to consult on the project.

In the days following the inauguration, Dr. Holmes and Dr. Downer led conference sessions on Innovations in Global Health and Effective Teaching, respectively.

Dr. Holmes also had the opportunity to visit a namesake training hall at the University of Gondar: the King Holmes Continuous Professional Development Center. “What a wonderful and humbling experience,” Dr. Holmes said of the visit. “And what a great way to end the trip.”