Update: Community Advisory Board [Feb 23]
Our first CAB meeting was successfully conducted last week in Achham. Out of 12 members, nine of them were present, a success given many of the members lived over an hour's drive away on mountainous terrain, and we had to make a last minute shift in the date.
-We appointed a chairman, who will be working as a facilitator for one year.
-The meeting was active, and all of the members participated and presented their thoughts and feedback. We were able to focus the entire energy on our programs and research—including community group care.
-All of the members also provided constructive feedback with regards to our community and hospital programs. We've pulled a few of our notes from the meeting to share with OpenIDEO specific to group ANC care:
1. Cluster concept: If all pregnant women will participate in group ANC, then 2-3 clusters can be made in each VDC, since many pregnant women/women who recently gave birth need to walk for 2-3 hour to reach the health post.
2. Community social leaders should be included in every monthly meeting to discuss maternal health, child health, and related issues.
3. Mass education campaign should be one of the components of the program.
Update: Group Care for Child Health prototype session [Jan 5]
Location: Bageshwori Village, Achham, Nepal
1. 7 local mothers with children under 1
2. 1 Auxiliary Health Worker (AHW) from village clinic
3. 1 Community Health Program project manager, 1 research assistant, and 1 Impact Program project manager from Possible
After brainstorming, feedback loops, and comments from the IDEO community, we realized that a big bottleneck in programmatic and HDC design was getting parent buy-in. We tested a prototype of our Group Care for Child Health that focused on answering questions around acceptability and desirability.
What do mothers with small children care most about (in terms of their healthcare)? What do they hope to learn about in a group child healthcare session?
Our prototype session notes:
Dr. Bishal Belbase, our Community Health Program project manager, facilitated the discussion where we encouraged the women to talk about the problems and concerns they have when taking care of their child, as well as health problems they see in the community. Some common concerns raised were:
- What does it mean when my child makes grunting noises? - I feel like my child does not eat enough. - Is vomiting after breastfeeding normal? - My daughter is already over 6 months old and she cannot sit up. Should I be worried? - My daughter defecates once every 5-6 days. I do not know what the problem is. - Will these rashes go away, or should I go to the hospital?
We grouped these and other concerns into categories and put them down on a big piece of paper. Each woman was given 6 pebbles and asked to place the pebbles on the 3 categories in order of interest. The categories, in that order, were:
- Danger signs (18 pebbles) - Child development milestones (12) - Breastfeeding issues (6) - Normal/abnormal behaviors (5) - Weight and nutrition (4) - Immunization (3)
We learned that immunization, as well as weight and nutrition, are covered well by the village clinic staff through government programs, so they wanted us to address the other categories where there is a lack of proper education and counseling. Other observations: - The women seemed excited by the idea and were very engaged. A one-time program organized by a different organization drew 60 pregnant and recently delivered women. Even the one mother who did not speak much today had a question about a rash on her baby, and everyone seemed very interested in hearing the response.
- The women suggested forming child care groups within a village based on age, rather than lumping all children from a village together. They also believed that group childcare sessions should be held on a monthly basis.
Overall, this prototype session was very useful, and we would like to replicate it to see if we find common themes among mothers as we continue to refine our group care sessions.
Questions for the Open IDEO community:
What do you think of our prototype session? How would you do it differently? What similar user-feedback sessions have you done and how largely has it affected your idea?
Healthcare typically is designed for the doctor—patients travel long distances to wait in lines, be seen briefly and often brusquely, get a prescription, and receive limited counseling. Our team at Possible (possiblehealth.org) and the Healthcare Systems Design Group (hsdg.partners.org) work within public sector facilities to re-design healthcare for patients.
We will group parents (more commonly, mothers) and provide expert and facilitated peer counseling around parenting, create a shared learning and community action, and integrate into existing community health workers networkers who provide follow-up care and parental guidance.
Consider two different scenarios in rural Nepal:
1) A woman brings her 2-year-old child three hours by foot to a health clinic. The child has suffered from respiratory symptoms for four days. Upon arrival, the clinic provider recognizes pneumonia, but has run out of the antibiotic injectable ceftriaxone used treat it. She refers the mother to a hospital five hours away, and the child dies en route.
2) A woman with a 1-year-old child has been attending group pediatric care sessions with other young mothers, along with community health workers from her village. She has learned to recognize danger symptoms, and informs her community health worker of her child's difficulty breathing within 24 hours. The community health worker brings the child to the nearest clinic. That clinic has been the site of group pediatric care; one of the recent improvement-oriented discussions with the mothers and clinic staff has been their concern about the government's supply chain. This has led to a more reliable stocking of medicines, including ceftriaxone. The child receives ceftriaxone, is referred to the district hospital, and travels there with the help of the community health worker. He stays at the hospital for two days before being treated and discharged safely home.
Our intervention creates an environment in which the second scenario is the norm.
The approach we describe here, group pediatric care, draws on the strength within communities of parents to transform how they collectively raise their children and interface with and advocate for better public healthcare services. This in turn can help reduce the major killers of children in Nepal and other places—neonatal sepsis, pneumonia, diarrhea, dehydration, and malnutrition.
How human-centered design remains our core:
We have an intrinsically iterative design process for our work that fits well with IDEO's commitment to human centered design. In this process, we continuously incorporate provider-, patient-, and community-level input so that our healthcare deliver innovations are designed optimally for the patient. Additionally, we leverage public sector funding to have a durable revenue model without levying user fees that have been shown to reduce access.
The primary outcome is under-two mortality. We measure it through the surveillance system described below. We choose this rather than under-five mortality since most of under-five mortality is captured by under-two and because of substantial methodological issues/constraints with our under-five mortality metric.
Key Secondary outcomes:
1] Pediatric care readiness score at the clinics we work in
2] Integrated Management of Childhood Illness protocol adherence
3] Distribution and number of visits for pediatric well-child care
Progress since ideas phase:
We've piloted our group antenatal care visits
At six primary clinics surrounding a government hospital that we run, we have piloted group antenatal care over the last six months. We have confronted anticipated challenges—concerns raised by public sector staff, coordinating mothers’ busy schedules, developing trust between the different clinicians and the pregnant women. We are following this cohort of women through their pregnancies later in 2015 and comparing their institutional delivery rates and complications to seven clinics where we are doing a standard antenatal care. Both group and individual antenatal care is integrated within our community health worker program.
During the redesign phase we have changed the following:
Our original intervention groups women of the same gestational age that are from the same VDC (Village Development Committee). However, in some of the smaller VDCs there were not enough pregnant women of the same gestational age at different times of the year and we did not have the minimum number of participants needed for a group. So we are developing a second guide broken down into trimesters (instead of weeks) so that we can widen the window for participants, meaning that this will allow us to have larger groups so that there is better participatory action.
While piloting this intervention at the health posts, we realized that the health posts had a weak referral system for women who were at risk of have complications during pregnancy. To address this we are working on a referral guide for health post midwives so they can effectively refer patients.
During the first few months of implementing the Group ANC intervention, we found there was a weakness in the health post referral process for Group ANC participants that were identified as having a high risk pregnancy (ie: high blood pressure, sero positive, RH negative, uterine prolapse, malpresentation (beech pregnancy)...etc).
As a result we have been refining and redesigning the intervention in two ways:
1) Developing a guide to assist health post Auxiliary Nurse Midwives (ANMs) with referrals of pregnant women that are at risk of having complications (during gestational period or intrapartum).
2) Developing protocols for CHWs so they can assist these pregnant women with the referrals during home visits (ie: educate them about their condition, help garner familial support for the women to get the treatment she needs, or even escort women to hospital...etc).
We’ve started our household surveillance system in our communities
We have developed a system that leverages a fundamental, national reality since the Female Community Health Volunteer program was pioneered in 1989: that, at the village level, there exists a woman who interacts with literally every household in her village over the course of a year. Our system uses GPS mapping from handheld devices to continuously enumerate the population, creating an electronic census list that is adaptive and updated by the community health worker. This system will be critical to assessing the results of our group pediatric care program.
We have visited roughly 2500 households in our catchment area with the help of 13 CHWLs (Community Health Worker Leaders) accompanied by CHWs from respective wards to collect data on maternal health and under-2 mortality.
After finding no stillbirths in the first two weeks of data collection, we had to briefly stop and troubleshoot the situation. Zero stillbirths is inconsistent with what we anticipated in our catchment population. Using our extensive network of CHW's we discovered that we had missed 2 cases of stillbirths, and the CHWLs are aware of other stillbirths in households they haven't yet visited. CHWs and CHWLs are very connected to the communities they live and serve in, so leveraging their knowledge is crucial in getting at sensitive data that isn't easily disclosed, as well as validating collected data. We also retrained the CHWLs on looking out for key words or phrases, and probing further with sensitivity.
As we've gathered more input from the Open IDEO community, we are building off their ideas and our own to refine this idea to include an additional focus of smartphone technology.
As mentioned, we are currently piloting a continuous household survey through which we are able to collect the data necessary for computation of key population parameters such as under-two mortality, contraceptive prevalence rate, institutional birth rate, and antenatal care attendance. To accomplish this, each Community Health Worker Leader carries a smartphone with the ODK collect software (an Android mobile data collection tool) on which we have downloaded forms with skip logic and repeating substructures that guides the CHWL through each visit.
After a few weeks of supervised visits, the CHWLs have become familiar with the smartphones and the data collection tool. New forms can be added based on need, and it can be used in the group pediatric care setting to guide the discussion, provide counseling and collect data for research and improvement.
Do note that this process remains constantly iterative, and we are updating forms as we encounter implementation hurdles (innovation) from CHWLs. We are leveraging these mobile data collection tools to produce an up-to-date census of our catchment area, eventually capturing vital events registration (births/deaths) to produce disaggregate, district-level baseline measures for our outcomes of interest, as no reliable data exist.
This improvement is the real-time feedback loop of data > re-design that is at the heart of continuous quality improvement.
We’ve developed a community advisory board
We have engaged in the process of finalizing and forming a community advisory board to provide advice and critical feedback on the relevance and feasibility of programs and studies to the community. This is an integral part of our broader implementation research team and strategy. We plan on including our group pediatric care model, and invite comments and ideas from other people who have formed community advisory boards in this challenge.
Our Director of Research is now in the process of finalizing the charter of our CAB, translating it into Nepali, and working with the Community Health Program to select key rotating team members who comprise the board. We aim to convene our first CAB meeting by the end of january, sending out formal invitation letters and CAB packets by the 1st week of January.
We finalized our CAB overview and charter in English and Nepali, our invitation letter was finalized in English and Nepali, and our Director of Research, Poshan, and other members of our impact team are headed to district headquarters to invite members of CAB this week. We are still aiming/on track to convene our 1st CAB meeting by the 3rd or last week in January.
How you can help us design better:
1] Do you have experiences with group care in other settings (e.g., chronic diseases, antenatal care, mental health)?
2] Do you have comments or ideas based on your expertise and experiences in early child development and health?