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Group Care for Child Health

Our idea is a healthcare systems intervention that shifts routine pediatric, preventative care from an individual to a group setting.

Photo of Duncan Maru

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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.

Some highlights:
-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.

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Update: Group Care for Child Health prototype session [Jan 5]

Location:
Bageshwori Village, Achham, Nepal




Participants:

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

Goal:

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?

Our Approach:

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. 

Our Intervention:

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.

Innovation:

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.

Primary outcome:

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.

[Update 12/25]:

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.

[Update 1/3]:

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.

[Update 12/25]:

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.

[Update 1/3]:

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. 

[Update 12/25]:

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.

[Update 1/3]:

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?

Who will benefit from this idea and where are they located?

Parents and their children in Achham District in the Far-Western region of Nepal.

How could you test this idea in a quick and low-cost way right now?

We would use our existing healthcare staff in rural Nepal and conduct pilot groups in three of the villages that fall in our catchment area. As they have and are doing for other investigations, our research team would conduct focus group discussions and semi-structured interviews discussions. These data would give us quick yet deep insight into the functioning of these groups.

What kind of help would you need to make your idea real?

We could use the advice of parents, of individuals who have worked substantially in rural settings, and of professionals who understand early child development and health. There is a substantial technology component, so a partnership for hardware supplies (smart phones primarily) would be beneficial.

Is this an idea that you or your organization would like to take forward?

  • Yes. I am ready and interested in testing this idea and making it real in my community.

106 comments

Join the conversation:

Comment
Photo of COPE PAKISTAN
Team

How we can involve in this as a organization in Pakistan

Asher Nazir

Photo of Maurizio Bricola
Team

Congratulations, this is well deserved!

Photo of Prasanta Poudyal
Team

Congratulations team for the innovative approach.
I really liked the concept of Community Health Worker Leaders, Community Advisory Board and of course the use of mobile (technology) for effective data collection.
We have well thought of mobilising the health workers.But we could be more broader in our inclusion for primary level government school teachers and secondary level students.These modalities have been well used by B.P. Eye Foundation for past 25 years and found to be successful in creating demand creation and awareness in eye health as an example from "Little optometrist."
If we are to mobilise students for creating more demand and awareness for pediatic care, i would name them "Children for Children".
I think for the sustainability, we should always work with the government and thus strengthen the current
network(i.e. public private partnership). The children identified with illness/morbidity should be referred to Bayalpata Hospital and if needed further referred to Kanti Children Hospital, TUTH, Children's Hospital for Eye, ENT and Rehabilitative Services.
There should be a hierarchy that FCHV,health workers, teachers,students and key informants communicate well with community health worker leaders which in turn will be reporting to community advisory board and then to Bayalpata Hospital which further collaborate with national and international working group for delivery effective pediatric care.
I would love to share more ideas and work together in this great idea of access to pediatric care.

Good luck team!

Prasanta Poudyal
MBBS,Maharajgunj Medical campus,IOM
Diploma in global health,University of tampere
member,Universities allied for essential medicines
Universities Allied for Essential Medicines.

Mass education campaign should be focussed not only pediatric care but gender inequality, demand creation for proactive approach.The idea like street drama, role play has been more effective in the rural area like Accham.

Photo of Taz Fear
Team

Hi All

Congratulations on reaching the top 10!

I love the amount of research and work that you have done and the fact that you have used human-focused design to develop your idea in such an important area of supporting families in child healthcare. Spreading community knowledge and awareness of illnesses that children may face, as well as the availability of medicine is a cost-effective way of reducing mortality rates in such a vulnerable age group.

In relation to the collective clinics with mothers/fathers/carers etc., will the collective clinics be booked by groups in advanced or decided beforehand or a mix with some clinics as more educational sessions focused on a particular area of illness and treatment? If there are sessions decided beforehand, how will this be generally decided: will people give suggestions or will this be decided based most common areas of illness in the local area at the time (or a mix)?

Lastly, please could you be able to expand on the way that stock levels of medicine in local hospitals and other treatment centres would be communicated to families with vulnerable children i.e. is this done primarily through the group clinic or are there other avenues for communication that you will be using?

Kindest regards

Tara Fear

Photo of Adi Heller
Team

Congratulations on the progress! The CAB meeting sounds to have been very productive. I'm new to the community and am excited to have this as one of the first projects I follow and perhaps support in some capacity. As far as the mass education campaign aspect goes, it sounds ambitious - what might it include?

Photo of Laura Schwecherl
Team

Thanks, Adi!

For our first CAB meeting we received a large volume of feedback for all our program and implementation research so to lay out the specific plan to include CAB feedback we aim to follow up with our chairperson and include him in the coming discussions for Group ANC. Currently, we envision this process as ourCHW Leaders finding the pregnant women in the community and counseling them to come to our Group ANC. We can also include rally, role play, and community awareness programs as one of the intervention to solve the community problem in participatory action piece of Group ANC.

Photo of Subodh Gnyawali
Team

I congratulate the team for this wonderful initiative. The health care delivery in Nepal is not organized, out of pocket expenses for the people is increasing day by day and the government is not worried about it. Health care in the rural communities is far out of reach to the poor people. When an NGO goes to the community with certain health packages people just expect incentives in cash or kind, they do not realize the importance of their participation in their own and their children's health. The health care workers are corrupt, mostly they don't stay where they are deputed, if they do they run business selling essential free medicines provided by the government. Health programs should be more participatory, incentives in cash or kind should be discouraged and extensive health promotion works has to be carried out. I wish the team a great success in Accham, I am willing to support the mission in any ways I can from Kathmandu.

Photo of Laura Schwecherl
Team

Thank you so much for your words, Subodh. We obviously completely agree, as we work hard to align revenue with the highest quality of care (versus fee for excess service). We hope you continue to follow along as we continue to solve for the patients in Achham.

Photo of Athina Andrade
Team

Such a good idea! Nice to read the updated, and I'm looking forward to read more about it. Great job! :)

Photo of Scott Halliday
Team

Thanks for the warm feedback Athina. Indeed, we are excited to build out our idea and concept more in moving forward. Keep checking out our idea here and we always welcome suggestions and ideas for improvement.

Scott

Photo of Irene Blas
Team

Great idea team!! Nice pictures! I would like to see your idea developped! Good luck!

Photo of Scott Halliday
Team

Thanks Irene! As we continue to refine, develop, and prototype, we aim to post more pictures and updates. Stay tuned!

Scott

Photo of Ana Paula Menezes
Team

Great idea, Duncan! It is really nice to see how closely you are working with these communities and you are learning through them and their experiences.
Maybe you could check our team's idea. Our proposition is for rural villages in India and how we could use their cultural traditions in order to present them with educational songs, dances and performances.
https://openideo.com/challenge/zero-to-five/ideas/sing-learn-love
It would be great to receive your input.
Best of luck on your endeavours!

Photo of Scott Halliday
Team

Hi Ana. Thanks for reaching out to us and for your support. I just made a comment on your idea. I think there's some potential with your project. Keep refining, updating, and prototyping.

Scott

Photo of Shuting Zeng
Team

I feel excited learning about this great project! I especially like how the project started from collecting questions from mothers to define the need and use of this project. Already so many good questions and answers here too.

My mother was a CHWL when she was young, in the rural village she grew up. Back then China did not have much doctorate licensing going on and anyone who had reputation in and trust from the community can be a CHWL under the local government. Today it is not as easy to run one's clinic without any formal or regular licentiation. You mentioned that you have got concerns raised by public sector staff. I wonder if you also got concerns from citizens there, and how you convinced them of your project's value?

Thanks a lot for sharing this great project.

Photo of Scott Halliday
Team

Hi Shuting! Thanks for offering your experiences here.

Indeed the private sector healthcare in Nepal is weakly regulated. Many providers claim to practice evidence-based medicine, yet they lack formal medical training. Patients end up being the primary victims at the expense of a private sector that provides incentives for excess healthcare at the cost of practicing evidence-based medicine. Its an important regulatory issue to address!

To answer your question: we have formed a Community Advisory Board, comprised both of healthcare staff, local government officials, and members of our community. They are tasked with providing input and critical feedback on the design of community health programs, the status of existing programs, and development plans for our district healthcare system. The board is critical to developing our idea in moving forward.

Feel free to keep engaging with us! We're always welcome to feedback.

Photo of Shuting Zeng
Team

Congratulations on being selected as top idea Scott and team! I just saw from OpenIDEO's newsletter about the news and can't wait to come congratulate you guys! This is really a great idea and I cant wait to see how much more impact it will bring to the Nepalese community and beyond! I truly admire you guys' work.

Yes I could imagine the lack of regulation in Nepal since in today's China the healthcare "marketplace" is still very chaotic. I also have volunteered in Nepal - an orphanage in Kathmandu, and didn't see how the kids can possibly go to doctor far away. The housekeeper, a nice grandma to all, served as everything to them, including giving them medicine when they felt stomachaches etc.

My mum stopped being a CHWL after a few years, since she moved to the city where a CHWL is not accepted. I bet there must be a lot to do to develop the curriculum and regularize the training to the CHWL. This is all amazing! I wonder if you provide further professional development to the CHWLs and if there is a lot of flexibility for them to rotate to different areas.

Did you go through adjustments within the Community Advisory Board to make sure the right streaming and decision making? For example, the ratio of the different member consistency, the topics to be discussed.

Also, do you also get feedbacks from kids besides researching among mothers?

Ah I can't wait to see updates about this project and knowing how you are going to expand the impact! Namaste!

Photo of Scott Halliday
Team

Hi Shuting!

Although resources in rural Nepal are scare, we do believe in formalizing roles, providing training, paying, and equipping all of our healthcare staff with the tools for success, especially Nepal's Female Community Health Volunteers. This is critical for healthcare systems strengthening. As far as rotating the CHWLs, I'm not sure if we would do that, since those women are residents of the villages they serve. However, I do think there is potential for mutual collaboration and observation to inform their work. This could be part of the iterative process of feedback.

We're currently working collaboratively to figure out the next stages of prototyping. This will involve insight from OpenIDEO and our community. No, we have not yet convened a meeting of the Community Advisory Board; we're still aiming to have this meeting by the end of the month. An additional, but still important, prototyping session would be with children. However, its worth noting that even though we are broadly targeting all children under 5, much of the focus will be on neonates, infants, and children under 2. In rural Nepal, and indeed in other low- and middle-income countries, under 5 mortality is strongly pulled by neonatal and infant mortality. Still, getting user feedback from children in our communities, is important!

Keep pushing us to be better!

Photo of Shuting Zeng
Team

Hi Scott,

Thanks a lot for your answer and it all sounds great! Good luck with the prototyping! Hope to see another amazing update of the idea later!

Photo of Anne-Laure Fayard
Team

Congrats Duncan and team! Looking forward to seeing this idea move forward!

Photo of Laura Schwecherl
Team

Thanks a ton Anne-Laure!

Photo of Meena Kadri
Team

Congrats Duncan and team! Have been highlight impressed by your insightful and iterative human-centered approach throughout. Best of luck in your strides towards continued impact at Possible and next steps with the Amplify Challenge.

Photo of Laura Schwecherl
Team

From our whole team, thank you so much! Appreciate your support, and excited to dive into the final round.

Photo of Nirajan Khadka
Team

Dear Duncan and the Team ; This is indeed a great idea to support a system of rural health care delivery. In Nepal's context, where people have to walk long and long hours to reach a health facility and even have to wait for additional hours to see a health service provider ; this intervention could be supportive to manage child health issues at household and community level. As, community participation has been an important aspect of primary health care , involving community people (fathers,mothers,youths,adolescents etc.) for health advocacy at community level is very crucial and cost effective. The idea to conduct group education sessions on pediatric care at ward level (the smallest administrative unit in Nepal) could be beneficial in sensitizing mothers for appropriate health care advice, management of illness at household level, on time visit and referral to health facility etc. High Proportion of Severe Malnutrition, Severe Dehydration and Severe Pneumonia has still been a public health challenge in child health. It seems this intervention (Group Education, Follow up care,Parental guidance,Community Participation,Strengthening health facility) is well designed to address real challenges of pediatric health care in poor resource settings. My suggestion is to involve different existing community level structures like Mothers' Group, Female Community Health Volunteers, WASH committee, Community Forest Users Group, Women Saving Groups, Key influencing people of the community etc. to have strong community mobilization and sustainability of the intervention.

Photo of Duncan Maru
Team

Thank you Nirajan bhai.

I very much agree-- there are multiple levels of Achhami society that are organized into groups and communities, and the clinic-based, individual care model really fails to integrate with and leverage the strength of those communities.

Photo of Julian Marembo
Team

Dr. Duncan, please help me understand the program design.

According to what I have read, the mothers have village meetings once in a while to be educated on danger signs of various diseases, they ask questions and get the experiences of an older mother attending the meeting.

Then when a mother identifies danger signs in her child, she contacts the village health worker who assists her with transport, that was collected in the savings scheme, to the clinic. In this way the child's gets help faster. Do I have it right?

So the health worker's responsibility is what exactly? Is it to only provide help in reaching the clinic? Or she will also diagnose and prescribe medicine?

My other concern is, how will this program be able to sustain the supply of adequate medicine to the clinics?

I have followed this idea from Ideas phase but lost track of how the updates fit together. Please help. I love the idea.

Photo of Scott Halliday
Team

Hi Julian!

I'll attempt to shed some light on these areas of confusion. Thanks for spurring us to clarify our idea!

Re: village meetings. The group pediatric care sessions will be held in the villages -at local village clinics- and will be comprised of mothers, their children, and healthcare staff members facilitating the session. Our future prototyping work will determine the frequency of the sessions and the ideal group composition. Currently, older mothers in the community are not part of the groups. However, if future prototyping sessions reveal this as important, we will consider revising the program accordingly. This is a great idea!

The sessions are intended to include both a learning and participatory action component (the content determined by the prototyping sessions such as warning signs) and a clinical component by the local healthcare provider at the village clinic. The participatory action component is in a group session while the clinical component is done individually with a healthcare provider. If a mother needs healthcare at a different time from these sessions, she is welcome to seek healthcare for her child through the existing public sector healthcare system or through various provide sector healthcare providers.

Re: roles/responsibilities of CHWs.
-Each village is staffed with CHWs under the policy of the Government of Nepal. These CHWs are trained to triage for basic primary care and maternal and child health services. If the child's disease or illness warrants examination by the village clinic staff or higher level hospitals, they will refer them.
-Usually, CHWs do not accompany patients to the village clinic or district hospital, but they may in certain circumstances.
-CHWs primarily act in a triage role, although they are trained in diagnosis of some basic maternal and child healthcare issues. They also provide immunizations and vitamin A supplements under the Government of Nepal policy.
-Currently there are around 50,000 CHWs serving in Nepal.

Re: higher referral centers/community savings fund
-Each village has a clinic that is staffed under the Government of Nepal's policy by an Auxiliary Nurse Midwife and a Health Assistant. Together, they provide basic primary healthcare services and can prescribe medicines from the Government's list of 40 essential medicines. All healthcare services provided at the village clinic is free under the Government of Nepal's policy.
-If the condition is more serious, the mother and child may be referred to the district-level hospital or other higher levels of the healthcare system. In the case of an emergency, ambulance service is available at the district hospitals.
-Government of Nepal healthcare facilities do have discretionary funds that they can use to fund patient transport for referral care. However, this is not the same thing as a community savings fund.

Re: medicine supply chain
-In our district healthcare system, supply chain management is principally done through the Government of Nepal. Because our hospital and village clinics are integrated as part of the public sector healthcare infrastructure, no additional medicines are needed to support this program.

I hope this clarifies some points of confusion for you!

Photo of Bettina Fliegel
Team

Hi all.
Interesting idea! I am a pediatrician working in culturally diverse low resource urban communities in the US. The idea of seeing mothers/children as groups for part of a primary care visit was a thought I had in the past, so it was so interesting to read your post! It will be interesting to see how this evolves in rural Nepal. Is Possible actively providing pediatric primary care in Nepal? Is there primary care for children in rural Nepal? You mention the groups are run by experts. Who are they?

There are many insights from the first prototype! Will clinicians who will facilitate groups participate in the design process? Do you anticipate groups will be lead by the same facilitator overtime? Would this program become integrated into a current health network?

Will direct patient care be included in the group sessions? If yes how would this work? Will the facilitator become a primary care practitioner for these children?

If groups meet monthly maybe alternating between anticipatory guidance and approach to the care of a sick child, which is a primary concern at least in the first prototype, would be one way to tackle age related issues in small children?

The UX map indicates that one focus of the groups will be advocacy for better services and improved access to medications. How will this work?

Good luck developing your initiative.

Photo of Isha Nirola
Team

Hi Bettina,

Thank you so much for your thoughtful response. I have jotted down some of the answers to your questions below. We are currently running a Group ANC program that groups women from the same village cluster that are of the same gestational age. Their are similarities to the structure of our group ANC program and our group pediatric care in that the goal is to generate social support among mothers that are from the same area who may be facing similar challenges.

1) Is your group actively providing pediatric primary care in Nepal?
Not yet. We have recently tested out a prototype of our Group pediatric care. As mentioned above, 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.

2) Is there primary care for children in rural Nepal?
There is primary care for children in rural Nepal but the amount of time with a provider, quality of care delivered, and access to quality care is this region is limited. The group pediatric care aims to address these issues.

We have found that our group ANC program has been able to address these issues. The primary outcome is maternal mortality and morbidity and the secondary outcomes are 4 ANC visit completion and institutional delivery.

Firstly, we have found with our group ANC, carrying out group counseling allows pregnant mothers to interface with a clinician for a longer period of time then they would during individual visits. Secondly, our group ANC program was designed collaboratively with clinicians and public health professionals in Nepal and an OBGYN doctor from Bringhams Women's Hospital in Boston who has visited Achham district a number of times. They built in proper clinical care during these visits (ie lab tests, USG) that wouldn't otherwise be provided. During the redesign phase we have done a lot with building out proper referral care for women that are at risk of complications (ie - High BP, malpresentation, RH negative...etc). Lastly, the group ANC program is carried out at government health posts that are easier for women to access than a larger hospital where comprehensive care is available. This allows pregnant women, who live in extremely remote and mountainous areas, to access quality care closer to their homes. Additionally, the group sessions strengthen support among women, who are from the same area and facing similar challenges during pregnancy. Our sessions include a group participatory component that focuses on identifying contextual factors that create barriers to care and ways these women can work together to break down those barriers.

Our group pediatric care is designed to address the same issues. We want to bring women who are facing similar challenges as primary child care providers of children under two years, so that they have clinical support on how to best care for their child at these sessions, and social support that is generated at these sessions but extend beyond the health post. Additionally, these sessions will focus on identifying contextual factors that create barriers to care and support mothers to find ways to break down those barriers.


You mention that the groups will be run by experts. Who are they?
The group pediatric care program is being developed by clinicians and public health professionals in Nepal and Duncan Maru, a pediatrician that also serves as the Chief Programs Officer for Possible.

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Congrats on being a Featured Contribution in our Refinement phase!

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Thats so great. Thanks!

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The women's suggest to hold sessions specific to children's ages fits with the approach taken in other group medical visits such as Centering Parenting--that way age-specific support can be given!

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Definitely! The critical health issues of relevance will vary by age and our model has to be responsive to that. Implementation will be important when designing, recruiting, and executing on the final group model by age group. The Centering Healthcare Institute has some innovative ideas and materials that we hope to draw from in moving forward. This process will certainly be iterative and require much fine-tuning.

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As a note: we took much of our inspiration for our current group prenatal care intervention from Centering, and our lead physician consultant/researcher on that program (Sheela Maru) is an OB/GYN who learned the rigorous Centering Pregnancy approach during her residency at Boston Medical Center. We actually met with Sharon Rising (midwife who founded Centering) prior to designing the group ANC and in fact during our conversation with her she herself spoke about their work around Centering Parenting for early child care. That conversation helped spawn the present idea. We couldn't apply Centering for group prenatal care precisely owing to challenges within our own context, but have used many of its principles and the literature supporting it.

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Dear Laura, Duncan and all, the idea of having group care it feels very effective to me and very innovative and future proof even for the so called modern world. The function of a generic family doctor as we know it it might be provided soon by a combination of cloud services and personal medical devices. Keeping health a group and social subject ensures healthy peer pressure. To be honest I liked this ideas since you have post it.
Reading your scenario 2 I felt it might be an idea to think about (or elaborate more on) a strategy to ensure transportation (i.e.: group savings loan to pay for the transport and/or medical expenses) to the district hospital.
According to a recent report of the Nepal Telecom Authority http://blog.sparrowsms.com/2014/11/telecom-penetration-in-nepal-hits-95.html it seems that in Nepal mobile phone are quite well spread.
In order to enhance the group care skills, build the engagement and provide the group with reliable and updated decision trees to assist them in recognising dangerous symptoms you might consider to use a SMS service, you can see an example here of an SMS interactive decision tree http://vimeo.com/72253940
Cheers

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Thank you Maurizio for your comment and suggestions.

Transportation is a major issue when working in rural healthcare, and it is about more than the patients' ability to pay. Very few villages here in the hills of Achham have access to roads, and the public transportation infrastructure is very weak. We have a fully staffed hospital providing free healthcare, but patients in distant villages only make the long journey (much of it on foot) when the illness has progressed too far.

This is why our community health workers who hail from the villages they work in are so important. They visit patients at their homes, refer them to our hospital when needed, and provide group antenatal care at the local health posts. They already carry smartphones with structured forms (built on the ODK platform) that walk them through each patient visit/group anc session. These phones could be leveraged for group pediatric care in a similar way.

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Dear Anat thanks for your reply. You are totally right about the challenges related to transportation, we have experienced the same in Malawi while assisting Community Health Workers using a mobile application for features phones (CommCare http://www.commcarehq.org/home/) which is an application build on the javarosa supported version of ODK.
What we experienced was that once we "fixed" the information/communication gaps, people needed to actually get the health service, and that is only possible if there is transportation (hence we bought several bicycle ambulances) and the health facility needs to have the minimum equipment and shape to attend the patients (hence we renew few shelters, bought additional beds and provide some basic maternal and child health equipment). What I was trying to say is that your idea would come across stronger (to me) if there was some kind of more in depth strategy about securing transportation to the referred patients. Having a CHW walking with a patient for 5 hours to the hospital might be difficult to achieve if the CHW is a volunteer, since s/he won't b able to attend her/his other (and personal) duties. Are the CHWs volunteers in Nepal or are they paid? In Malawi they are not paid, so it is difficult to organise them fully and give them critical tasks, since they have their own families to take care of too, I don't know in Nepal how that works.
On the use of ICT, my suggestion was more geared to provide individuals directly with tools to enable them to recognise dangerous symptoms with the assistance of a decision tree, instead of having them fully depending on CHWs' visits. CHWs are definitely precious, still if their intervention could be augmented and enhanced by a SMS or USSD service geared towards their clients the whole intervention could have more impact. All the best! Group care is a great concept!
Cheers,
Maurizio

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Dear Maurizio,
Thank you for clarifying your questions and sharing your experience. It is always interesting to see how similar problems are being solved in other contexts as they can provide valuable insights.

When it comes to transportation, the topography of this area is such that there is no option but to walk (up or down) the steep terraced hills to the nearest "roads". Instead, our focus has been on improving quality of healthcare and providing counseling at the local health posts (HP), where group pediatric care would be conducted, so that:

a. Fewer patients need to be referred to the hospital
b. Patients are referred before complications arise

In addition to introduction of innovative interventions like group ANC at the local HPs, we currently have a HP strengthening project underway. There are 4 components to our structured quality improvement HP strengthening intervention:
1. infrastructure
2. technology (integrated EMR, optimized solar systems)
3. structured mentorship and on-site training
4. integration of CHWs into routine follow up to identify/reduce risk for further health exacerbations at clinic and home level, where much of the burden and challenges for, eg, chronic disease management and behavior change lie.

We also prepare a monthly "HP Readiness Scorecard" that looks at how well stocked each of the 14 HPs in our catchment area is, and if it has basic health systems in place. (The average “HP readiness” last month was 81%.)

In the community health program, we have introduced an additional tier of Community Health Worker Leaders (CHWLs) who are full-time paid staff that work closely with the Community Health Workers (CHW) who are volunteers. We do compensate our networks of volunteer CHWs for their time; indeed, we think this should be the norm for all healthcare workers to avoid the romantic poverty notion that women engaged in healthcare work should do so voluntarily, as inspiring as this Alma-Ata-based "barefoot" HCW idea was. This unique structure has helped us mobilize our community health workers more effectively and efficiently.

Also, patients are not necessarily escorted to the hospitals, especially when they are capable. When patients need immediate advanced care, we do have ambulances that when called go as close to the patient’s locations as they can (just last week an ambulance had a bent axle from driving on rough seasonal roads to get a patient).

It is great to hear that you are using CommCare. We will very likely be moving to that platform as well, and would be interested in hearing about your experience with it. And thank you again, keep pushing us to refine our idea!

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Dear Anant thanks for your great clarification and extensive reply.
We will be happy to share more in details with you our experience with Commcare in Malawi. We started in 2011. Each year we were able to register about 3000 clients among pregnant women and infants 0-2.In total we trained about 70 CHWs in 3 different districts and 15 nurses in 3 different health facilities (one main hospital - Montfort Hospital near Chikwawa - and 2 health centers). Each implementation site has employed a dedicated ICT officer in charge of training the CHWs, managing the phones, administering and creating the Commcare applications. The health secretaries of the dioceses were very happy with the data analysis and reports they could get from the platform.
From our monitoring system we can say that CHWs have gained confidence in their skills, while their clients feels better attended and trust the CHWs more now that they are connected with the hospital by phone.
We still run into some challenges like CHWs accidentally deleting the Commcare app from their phones. (This won't probably happen if we were to use smartphones) The drawback with smarphones is battery life. It is hard to have access to electricity in remote and rural Malawi. We actually first distributed solar chargers to CHWs and then substituted the chargers with a permanent solar installation at the village chief's premises because the solar charger where not effective has we thought (one actually need to stay at close range watching his/her phone and charger while charging under the sun since they might get stolen, not very handy set up)
All the best with the next phase!
Let's keep in touch it would be great to share process and ICT experiences.
Cheers

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Thanks Maurizio! That's really helpful, and seems like CommCare has worked really well for you. We run into similar challenges related to phone usage, but like you said, the CHWs are getting better with training and as they get used to their phones.

We can definitely learn from each others' experiences. Thanks again and keep in touch!

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Ok – some serious awesome-ness going on here! I'm digging the comparative structure of your User Experience Map. But am seriously blown away by your community-centered inquiry on what mothers find most important. HCD at it's best.

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Thanks Meena! It really was useful thinking through the execution and discovering the different strengths & pain points from the mother's themselves. It will also be really interesting to replicate this to be able to identify common themes.

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Congratulations on making the Zero to Five Refinement list, Duncan! We love the community-based approach of your idea and that you have existing partnerships with some of the key players you’ll need to cooperate with to make it a reality. We’re also impressed with how collaborative you have been, sharing your expertise with the OpenIDEO community. One thing we’d like to clarify is whether your idea is to extend a program that you’ve already started or whether you are looking to begin this idea in areas where you are already doing other work? Based on your experience so far, what challenges do you anticipate facing as you begin to roll it out? How or why will Community Health Workers and staff at district hospitals make time to participate in this project? How would Amplify support help you implement this idea? What could you do to get a better sense of whether parents would be interested in this type of model? Are there cultural barriers to group care? We’d love to better understand what this could look like for families – please update a User Experience Map http://ideo.pn/0to5-map and check out tips for Refinement http://ideo.pn/0to5-tips-refine here.

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Thanks so much. We're going to divide and conquer all of these great questions. Excited to make it to refinement!

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Thank you for these great questions! I'd like to tackle two of these, specifically two you mention below:

(1) What could you do to get a better sense of whether parents would be interested in this type of model? and


We do believe that group care presents tremendous opportunity for participatory learning and engagement around problems that affect entire communities, and individual families. Strong community networks are vital to this endeavor, and so linking these efforts to other levels of existing social support (e.g., existing mothers groups, district offices of child and women’s development) will be key – they will not work in isolation. Evidence has also shown that group care has been more acceptable, enjoyable, and has led to, e.g., increased maternal and newborn health outcomes (http://apps.who.int/iris/bitstream/10665/127939/1/9789241507271_eng.pdf and http://wordpress.sph.harvard.edu/mhtf/wp-content/uploads/sites/17/2014/08/HSPH-Group5.pdf), so we are optimistic we can build off of, and add to, existing evidence here.

In addition, we suspect that parents would be quite interested in group care sessions based on our experience piloting group antenatal care visits with pregnant women in our catchment area during the past 6 months. We have witnessed deep, earnest moments of fun and togetherness that women really value. There is always at least a little bit of laughing (usually a lot), and it is wonderful to see women open up, air their concerns and get feedback from a group of peers who have experienced similar things, as well as clinical insight from an government auxiliary nurse midwives rather than just coming for a quick, “routine” check-up.

Perhaps most importantly, our Community Advisory Board will be key in providing feedback on the feasibility and acceptability of our intervention model. The CAB will be comprised of government healthcare workers (rotating quarterly), members of the Nepal Women Association and Nepal Chamber of Commerce chapters in our district, teachers, social workers, and our own team members. This board will be at forefront of garnering support and promoting involvement of the greater community in program design and rigorous impact evaluation.
.
(2) Are there cultural barriers to group care?

The question about cultural barriers is an excellent one. As a medical anthropologist, I am continuously amazed at the syncretic, medically plural approaches to healing and wellness in Nepal. These practices, along with common issues of concern, are routinely shared around hearths, on the trail, at meetings, and of course when loved ones and neighbors fall ill.

However, personal health issues often carry stigma, and speaking of, for example, adverse outcomes in birth and childhood is sometimes a perceived etiology of further misfortune. We not discussed in larger groups but are kept within a smaller circle of relatives and close friends. We will certainly be attendant to this, though ultimately we hope problems that are shared will lead to group solutions!

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Hi David, thanks for this comprehensive answer! I see you are finalizing your Community Advisory Board - will representatives of some of the mothers also be on it? In the groups that you've begun to hold with mothers, what changes did you make to the initial program in responses to the challenges you faced? What feedback have you gotten from mothers about the group care component?

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Thanks Chioma for your follow-up questions, my apologies for the delayed reply. Yes, we’re in the final throes of finalizing the composition of our Community Advisory Board, which is very exciting. We have not selected mothers directly from our intervention as members of the CAB, however we have selected rotating (q6months) female community health workers – who are directly linked to, and act as representatives of, existing mothers groups in village units throughout our catchment area. We are also inviting an elected member of our district chapter of the Nepal Women’s Association serving on the board. In addition, we have determined that our CAB will be comprised of a minimum of 50% women.

Regarding the changes we’ve made during our piloting of the group antenatal care program, there continue to be many. Part of our iterative approach to implementation research demands we practice PDSA cycles (plan, do, study, act), so that we have a necessarily reflexive and cyclical process for design, implementation, observation/evaluation, and re-design. Some examples of changes includes: re-drafting facilitator guides based on the feedback around the interest and utility of material to help troubleshoot major barriers to birth planning material (this came from mothers, as well as community health workers and primary clinic staff); adjusting data collection techniques and tools (eg, group session checklists) to hone in actionable information to improve the content of sessions and to ultimately increase ANC completion; and altering the dates and times of scheduling group ANC to better match the needs of pregnant women and primary clinic staff, ie, to better align with the government determined gestational windows for visits so all expecting mothers can receive the Safe Motherhood program incentives for completion of 4 ANC visits (http://bit.ly/1I4Kmqm).

Another goal is to eventually migrate group care data collection processes onto mobile forms using smart phones that community health worker leaders are inreasingly familiar with, as they are currently enumerating our catchment area population for a “continuous household survey” to produce an up-to-date, adaptive census that will eventually include vital events registration (ie, births and deaths)

Finally, we anticipate the CAB will have a large role in funneling feedback directly from the community to the implementation and research teams at Possible to assist with continuous quality improvement of the group care intervention.

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In addition, we'll be conducting baseline and endline surveys to assess changes in knowledge and delivery location, as well as to describe birth planning practices, barriers to institutional deliver, and rates of patient satisfaction/acceptability with our group ANC sessions. we are definitely interested in understanding the mechanisms of impact here, so gathering this feedback from mothers will be key. a rigorous suite of qualitative methods is required here.

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Thanks David!

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Great to see your insightful, iterative, impactful updates on Christmas day!

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Tis the season :)

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Hello Duncan,

Great idea. This is a good modality of integrating maternal and child healthcare into Primary Healthcare setting, especially in an environment where there is need for a long waiting time before accessing specialized care. This is a little different from our environment where children and mothers can access specialize care on time without long time waiting appointment, if problems are recognized on time and referred early. We are focusing on early detection of problems in maternal and child health at immunization clinics, which represent the most likely clinical setting and convergence where mothers and their children can be assessed together in most environment.

Great job again! I specialize in the area of child early physical and emotional development as well and also a mental health professional (Psychiatrist).

Best wishes in pursuance of your idea.

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Thank you for the support. And please do keep up your work on mental health-- it is among the globe's most neglected public health problems. Our team continues to struggle to address; currently through clinic- and home visits with CHWs and non-doctor mental healthcare workers.

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All the Best Duncan!

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Excellent scheme for the health care team to came out this idea, I can understand how vital is for timing in small villages to see a Dr or health care. Group session is very good idea and would be more valuable for parent to have more time with Heath care encase they want put on more information or gain more skills about particular illness also learn from other parent what they going through with child. Providing them follow-up care and parental guidance is very useful. The other thing that fascinating this programme is how can help reduce the major killers of children in Nepal and other places—neonatal sepsis, pneumonia, diarrhea, dehydration, and malnutrition.

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Thanks for your comment Diini. Please continue to engage with us and push us to refine our idea!

I think you touched on some good points here in your comment. Indeed, our proposal to provide group pediatric care is intended to facilitate group counseling sessions and a responsive, community-driven model of healthcare that meets the community's healthcare needs and the major causes of mortality. I do also want to emphasize that our idea though is also about healthcare systems strengthening. The healthcare landscape of rural Nepal is characterized by systems that fail to serve the patients; this manifests in terms of problems with human resources, supply chain management, providing follow-up and referral healthcare, and basic quality healthcare services. Implementing group pediatric care will involve developing clinical and community health protocols specific to these causes of mortality, but it is meant to do so through strengthening the existing public-sector healthcare infrastructure to serve the patient.

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Lovely idea, a great way to look at situations like this is from within the body, so well done! Perhaps you could think about what is being consumed specifically and what are the causes to give you a better idea of what could prevent it?

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Hi Masheyat, thank you for this comment! Indeed, dietary transitions in areas like northwest Nepal are a key factor in the etiology of under-nourishment. As livelihoods in northwest Nepal where we work change from agro-pastoral and trade based ones to strategies involving cash income and migratory labor, many communities are faced with the challenges of obtaining ample, self-determined sources of food. These issues of food sovereignty are a huge challenge, as we see the large consumption of simple carbs in the form of white rice (food aid or packaged), wheat roti, and other packaged goods supplant the eating of once previous hardy hill grains consumed through trade and grown (e.g., buckwheat, barley, millet, amaranth).

Parental groups are a key way to understand these ‘changing foodways,’ or the ideas, values, and practices around growing, procuring, cooking, and consuming food, as well as how diet and taste shape and are shaped by social, political and economic relations. Thank you for the nudge here to get at the embodied experience of hunger. As I’ve often seen in discussion with elders, talking about the old days will immediately conjure references to food as a criterion for the ‘good life.’ So, we’ll need to know what parents consider the good life in terms of their children’s wellness moving forward.

Thanks again! Look forward to iterating on these ideas.

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I'm a student at UCSF and am doing research on various kinds of group visits. It seems like there are some existing models of pediatric group visits in the US and I've wondered if people are taking them up internationally. Would your group visits including the well-child medical visits as well as peer support & support w/ parenting? Looking forward to following this project.

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Hi Ariana! Yes, our group visits would combine both medical visits and peer, parenting support.

do you have any good examples of existing US models that also take this approach?

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Hi Laura, Sorry for the delay. The main US model I know of that does this combination is Centering Parenting (and Centering Pregnancy). I've been working at LifeLong Medical Care which does the Centering Parenting model with families of babies up to age one and providers, other health care workers and patients all love it. http://centeringhealthcare.org/pages/centering-model/parenting-overview.php

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Very cool, thanks for sharing!

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Congratulations Duncan and your amazing team on getting this far!! I hope lots more success comes your way, although I have a few questions.

Is there something fathers can do or take part in??
Have you tried out the group setting design procedure?? To assure it will work and especially in Nepal??
Also is there a way to expand to other low income communities around the world?? If that was a possibility I think that will be pretty amazing.

Thanks and good luck!!

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Thank you so much for your great questions Musa! I wanted to address some of your questions below:


1. Is there something fathers can do or take part in?

This program design aims to create a safe space for the primary caregiver to be able to identify symptoms that may be detrimental to their child's health. Effectively engaging men is definitely on our radar as we build out the design but the challenge is two fold. One, is the migratory patterns of men. Most fathers travel to India for work and the primary child care responsibilities fall solely on the mother. This is compounded by my second point, women's lack of agency at the household. Many of the women live with their in-laws and are restricted to go to health appointments and are forced to do laborious work late in their pregnancy and immediately after they deliver. This can have grave consequences for both the mother and the child. This program will provide supportive guidance to mothers on how to best protect their child from harm or illness.


2. Have you tried out the group setting design procedure?? To assure it will work and especially in Nepal??

As we've mentioned in our description, we have begun piloting our Group ANC program and we are encouraged by results. These group sessions have been a safe space for women to speak up about the barriers to care and find solutions and support to overcome those barriers. We plan to build off this existing structure for our group pediatric care.


3. Also is there a way to expand to other low income communities around the world?

We absolutely want to expand to other low income communities but we want to do it responsibly. We have an iterative design process that allows us to continuously integrate feedback from patients, providers and the community so that the group pediatric care program is solving for the patient. Once we have done this successfully and measured the results, we will explore how we can build a scalable model that can work in other settings!

Thanks for your great questions!

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Duncan and team,

We think this is a great idea- and one that is clearly thought out. Not surprisingly, our experience has shown that groups of community members who have an opportunity to engage health care professionals learn far more than they would on their own, and have the courage to ask questions that they might not otherwise- especially young women and mothers. That being said, our antenatal care is currently one-on-one with mothers, though we recently starting offering group malnutrition education. It also seems like an efficient and effective way to provide services or education that address more aspects of a families well-being than just under 2 care. A couple questions that come to mind:

1) For the pilot groups you've implemented, have you found logistics challenging? We often find that mothers will come the week of their scheduled ANC appointment, but not necessarily on the day. Obviously they'd understand that a group session requires better planning, but it could continue to be a challenge for us.

2) The core of our team's idea is mapping under 5 data, and turning it into information that our community health workers can leverage. It sounds like you all have started down the path of geographic data collection, which is exciting to see. Are you all linking data that you collect on community members' health with their locations? Or focusing more on where community members are living i.e. a census? It sounds like distances involved within your catchment can be very large, which makes for an even more compelling case for understanding how location influences outcomes.

Thanks again- we're very interested to see your result and to share more ideas about healthier mothers and children.

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Hi guys! Thanks for your questions. To provide some insight..

1) Yes this is a big challenge. Mothers have so many responsibilities and often so little support. Our CHWs focus specifically on facilitating their attendance. This comes to a head of course at the time of delivery-- we provide free ambulance service in addition to the government's 1000 rupees ($10) because the financial/logistical barriers are so enormous.

2) Yes our CHWs use smartphones and an ODK application to tag all the households in our 36,000 person catchment area. We believe continuous and complete enumeration + vital registration + verbal autopsy + near miss reporting is the only way to go. Sampling techniques just leave too many holes, especially with mortality data.

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Hi Duncan & team,

Thanks for sharing this idea! My team's idea, "Maternal and under-5 health and education clinics," is very similar to yours, and I'm sure that since we both come from already-existing organizations (I currently work for Village HopeCore International in rural Kenya: villagehopecore.org), we could learn a lot from each other and help better each others' ideas.

Some questions and suggestions I have for you and your team are:
- How will you promote your clinics and let parents know about them? Some suggestions we've thought about include: using local schools in the area (our NGO currently has 72 partner schools in which we hold mobile health clinics, so we plan to leverage these relationships to get the word out about our clinic), asking the help of "champion" parents for help letting their peers know about our clinics, and collecting mobile phone numbers of all mothers who attend our first clinics so that we can SMS them to let them know when we will be returning.
- What kind of health-related topics do you plan to discuss? Currently, we are piloting our program by discussing five topics that target mothers and under-5 children: hygiene, nutrition, breast feeding, immunizations, and family planning/birth spacing.
- How will you be facilitating peer sharing of parental advice?
- Have you thought of any ways you could ensure networking between parents even when you're not there conducting your discussions?

If you have the time, we'd love to hear comments/suggestions from your team about our idea as well! (https://openideo.com/challenge/zero-to-five/ideas/maternal-and-under-5-health-and-education-clinics) Looking forward to possibly collaborating with you. Thank you!

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Thanks for your ideas Natasha. Your organization has a diverse and important range of initiatives and programs that are all integrating to promoting the health of under-5 children! I'm looking forward to reading more about your idea. To address some of your questions:

-How will we promote our clinics/inform parents: We work within the existing government healthcare infrastructure in our catchment area population. Our clinics are staffed by government employees and are the primary centers for the practice of evidence-based medicine in our area. Informing parents begins with our community health workers, also government workers, who are leaders of these communities. In tandem, these clinics and community health workers are the core of our program's outreach. We also are trying to leverage the potential of mHealth technologies to improve communication between mothers.

-Which health-related topics: A core focus will be on infant care since under-5 mortality is largely driven by neonatal and infant mortality. We'll work on incorporating WHO's Essential Newborn Care and Integrated Management of Childhood Illness into appropriate community-based care into these discussion points. To reiterate though, through the existing clinics and community health workers, healthcare would be responsive to the actual cases in the community. To state another way: comprehensive primary care will be delivered for all children in our community with appropriate and coordinated follow-up care for complex cases.

-How will you facilitate peer-sharing: Peer-sharing of advice will be facilitated by local community health workers and clinic staff (which includes auxiliary nurse midwifes and health assistants). Parents will be encouraged to participate in these coordinated group pediatric care sessions by the community health workers upon presentation of cases at the local clinics. Sessions will be coordinated by the district level hospital team and their community health department. M/E and program impact (including process measures, mixed methods analysis, and overall health outcomes) will be assessed by the research team.

-How will you ensure networking: mHealth has the potential, when used in concert with strong organizational management processes, to improve communication between community members and in this case, mothers and parents. However, we are actively looking for feedback and ideas as to enhance this aspect of the project.

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Hi Scott! Thanks for answering my questions - as I continue to learn more, it seems like our organizations are very similar (except for our locations) and we could learn a lot from each other, in general.

Thank you for mentioning WHO's Essential Newborn Care and Integrated Management of Childhood Illness in terms of what resources you'll draw upon to educate parents. We have been having focus groups of local mothers to learn more about what they would like to learn about and common misconceptions they have about raising under-5 children, which may be an avenue you'd like to look into, but we haven't done anything to align ourselves with any WHO- or large health organization-related information yet.

I'm interested in following up with you later to see how mHealth has helped you with networking and communication, as well as how you plan to carry out M&E to assess your program's impact.

We've added more to our idea and any additional comments, questions, or suggestions from you or your team are always greatly appreciated! (https://openideo.com/challenge/zero-to-five/ideas/maternal-and-under-5-health-and-education-clinics)

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re:

**For the pilot groups you've implemented, have you found logistics challenging?

Yes this is a big challenge. Mothers have so many responsibilities and often so little support. Our CHWs focus specifically on facilitating their attendance. This comes to a head of course at the time of delivery-- we provide free ambulance service in addition to the government's 1000 rupees ($10) because the financial/logistical barriers are so enormous.

**The core of our team's idea is mapping under 5 data, and turning it into information that our community health workers can leverage. It sounds like you all have started down the path of geographic data collection, which is exciting to see. Are you all linking data that you collect on community members' health with their locations? Or focusing more on where community members are living i.e. a census?

Yes our CHWs use smartphones and an ODK application to tag all the households in our 36000 person catchment area. We believe continuous and complete enumeration + vital registration + verbal autopsy + near miss reporting is the only way to go. Sampling techniques just leave too many holes, especially with mortality data.

Photo of Anne-Laure Fayard
Team

Great idea! It reminded me of a project I posted about where the community was very much involved: https://openideo.com/challenge/zero-to-five/research/what-can-we-learn-from-the-jungle-mamas

You mentioned a technical component but I did not see it at play in your idea. I'm also wondering what might be the issue with the technical component as from I read in this challenge and in other challenges, and from our collaboration with Women for Human Rights in Nepal ( https://openideo.com/challenge/womens-safety/funded-impact/bindis-community-concierges-to-inform-connect-and-empower ), internet is not widely accessible. Hence, I'm wondering if smart phones is the best option?

Still I can see how you might want to think of developing a text message system such as https://openideo.com/challenge/zero-to-five/research/toto-health

Last, as Meena suggested, developing some personas and scenarios would be helpful to understand better your idea (and for you to articulate it further).

Thanks! Looking forward to seeing this idea evolve.

Photo of Duncan Maru
Team

Thanks!!

I think this kind of intervention doesn't need a tech component specifically, or rather, the tech component could be leveraged from whatever is available locally. The "package" need not have a dedicated app/software application.

For our work in rural Nepal, we will incorporate this both in an electronic medical record and a household surveillance system we are developing. But the group pediatric care is a separate intervention that leverages that existing tech component.

Photo of Anne-Laure Fayard
Team

Congratulations! Looking forward to seeing this evolved during refinement.
I'll make sure to follow your idea during this phase.

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Team

Very interesting idea! A few questions come to mind:
1- How is pediatric (especially preventive) care currently delivered? Is this idea replacing another model or integrating into it? Would this be given alongside vaccines, for example? Do you think women would utilize this service? Would incentivizing the process for women by linking it to something they already do or need to do be useful? In our context, I'm not sure that it would be well patronized without tying it to something tangible (at least that has been our experience after trying group delivery of advice on various topics). But that's just our experience in rural Ghana, a whole world and culture, away.
2- Re: promoting parenting strategies, how are you planning on determining which ones to focus on in a culturally appropriate way? How will you set the curriculum? We are going to run into the same issues with our program (https://openideo.com/challenge/zero-to-five/ideas/mother-mentors-for-child-development)- would love to hear your ideas for planning.

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Thanks for your questions and comments. Where we work in Nepal, preventive pediatric care is characterized by late presentations of children either already chronically undernourished or very sick, delivered through government run vaccination campaigns (which we will not duplicate or be a part of currently), or demographic health surveys that produce measures at a highly aggregated level. Other forms of predominantly ephemeral care here in Nepal are those run by medical voluntourists and legions of NGOs conducting so-called "health camps," dispensing antibiotics a week at a time, or albendazole - which is a useful drug, but not a substitute for a durable model of preventive and longitudinal care.

Our idea replaces individual patient interactions and we hope, and suspect, women would participate in group sessions, and that they would be preferable to individual clinical interactions; evidence suggests that engaged, participatory sessions have been well received by in other parts of Nepal, and are increasingly recommended by the WHO (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1079874/; http://www.ncbi.nlm.nih.gov/pubmed/12886798; http://www.who.int/maternal_child_adolescent/documents/community-mobilization-maternal-newborn/en/).

Re: your question about incentivizing these sessions, it is a good question, and of course PDSA cycles are important here to the implementation research process here. We feel that access to healthcare providers and community healthcare workers at one's own home, paying attention to the concerns and extant health and healthcare needs of mothers will create buy-in. To be sure, the precedent of participation = money, or rice, or some other commodity has been set here in Nepal, but I don't personally believe it is the way to go.

Great question about parenting strategies. We would need to conduct some formative qualitative research first to understand perceptions around 'good parenting,' which would be a departure point for identifying and discussing approaches in groups with facilitation support by trained community healthcare workers and nurse midwives. WHO guidelines around parenting can act as a reference, and fidelity measures to any that seem amenable to the area where we work may be used, but ultimately it will be culturally humble and evidenced based approaches that will help design a curriculum, and link it to action in already existing women's groups.

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Team

Hi Duncan!

Really like your idea, I've read so much on this challenge about informing parents and group learning, and this really seems to deal with these issues nicely! Your project focusses on Achban district in the west of Nepal - do you think this project could also be rolled out to other regions? I lived in Pepsicola in Kathmandu for a few months, and it really seems like this project would be hugely beneficial there as well! While there are some medical facilities, there is very little support that is available for supporting and educating new mothers outside of their immediate families!

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Team

I love that this idea promotes community! This sounds like a great open space for parents to interact and share tips with each other!

How do you plan on identifying parents who qualify form his program?

Curious to hear your thoughts!

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Team

Duncan, from our interviews with community leaders in Kampala and Wakiso districts the issue of bringing community people to address common ECD challenges is loved by the leaders. However, they have serious concerns around people's attitudes to working together. It seems you have experience forming groups and making them interact to solve health issues. Could you share your experience with us so we understand how to better refine our idea and catalyze the process of community core groups to mobilize other community members for community led ECD in Uganda?

See the updates in our idea for your feedback and sharing of experience: https://openideo.com/challenge/zero-to-five/ideas/our-village-raising-our-children

Photo of Scott Halliday
Team

Hi Alex! I'll try to chime in here with some of our experiences in Achham, Nepal. Note- I love the honesty and openness with which you're updating your experiences on your page.

I think one point to emphasize when forming groups, regardless of whether the goal is to foster dialogue about community involvement in promoting early child development or to deliver group pediatric care, is that no one is trying to step on the toes of parents. The community is not trying to replace the parents. Rather, how can we learn from each other?

In our case, we work with the Government of Nepal, specifically Nepal's network of Community Health Workers (CHWs), referred to locally as Female Community Health Volunteers. These CHWs are a vital link in assessing local patterns of healthcare resort, understanding the healthcare landscape of their communities, and promoting collaboration between program implementers and local women. This also underscores one of our principles, which is to work in a public-private partnership to do this. NGOs and non-profits can achieve success working in isolation or in tandem with other organizations. But working in partnership with the government bolsters those relationships.

I hope that's helpful to you. Please reach out if you have more questions or ideas. Keep up the great work!

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Team

Interesting conversation about community involvement guys.

As to the concerns you raise Alex from your conversation with the leaders you have been having dialogue with one suggestion I have is to go to the community itself. Can you go to a marketplace, a health center, or a church and invite the community to a meeting where you can openly discuss your ideas? In my experience the group that show up to events like these is self selected - they are the ones who will be interested, or at least curious, in the topic you have brought to them. Are there other examples of community cooperation in Uganda? Examples of neighbors helping neighbors, sharing of resources?

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Team

Scott, you mention that the community health workers are women. Are they exclusively women? Is it exclusively a voluntary position?
Scott does your team see this group as a part of the team for the pediatric group care model, either as community messengers, or as a potential resource to be trained to assist in providing this care?

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Team

Hi Bettina! Thanks for the feedback. We had focus groups with mothers and fathers too. We will share the updates later today. Yes, there are groups that are formed by communities themselves. I talked of village savings and loans associations (VSLAs) as some of these groups.

Photo of An Old Friend
Team

Scott, thanks for the feedback!

Photo of Laura Schwecherl
Team

Bettina, the community health workers are all women. Through our partnership with the government, we work with Nepal's Female Community Health Volunteers (FCHV's) who traditionally work on a volunteer basis. Their involvement with Possible is unique, though, since we provide a performance-based stipend to increase quality and accountability to the program.

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Team

To follow up on Laura's point, we view the role of the community health workers as being integral to the group pediatric care model. Community health workers are great for helping to coordinate follow-up and longitudinal care, welcoming mothers and their children into the groups, and simple triaging for health conditions. Within the existing network in Nepal, these community health workers are not the primary providers of healthcare and are principally engaged in health promotion activities. However, they are involved in some basic curative services including acute respiratory disease control and diarrheal disease control.

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Team

Interesting stuff, Rubina! We thought you might be keen to know that other people from Nepal are participating on our challenge here: https://openideo.com/challenge/zero-to-five/ideas/conducting-parents-training-workshops-on-income-generating-activities-along-with-parental-education-on-prenatal-health-immunization-exclusive-breast-feeding-and-weaning-psychological-aspect-and-good-hygiene Perhaps you'd like to join in conversations with them as well?

Photo of Meena Kadri
Team

Great stuff guys – and I'm digging how it builds on the success of antenatal support by doctors and midwives. Perhaps, during our Ideas phase, you could kickstart your focus groups and report back here what you learn (you can update your post to include insights) We're looking forward to hearing how things go!

Photo of Meena Kadri
Team

You might also consider helping people better grasp how this idea could play out by describing some example scenarios which describe user journeys through some of the proposed activities you've outlined. Check this example: http://www.openideo.com/open/e-waste/concepting/neighbourhood-e-waste-champion/ where a few simple scenarios were created in an attempt to explain the goodness on the idea in a human-centered way.

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Team

Thanks! Will try to get some content out soon. Great guidance.

Photo of Laura Schwecherl
Team

great advice indeed! we are speaking with our community health director to get her expert insight on some real-life scenarios.

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Team

An old adage says, future of a nation depends on its children. More inclusive the opportunity of education and better the quality of education better is the quality of nations’ work force. Science tells us that Vision contributes to 76 % of child’s learning and hearing contributes to another 12%. Between them the two contribute close to 90% of child’s learning. Altogether an estimated 20% of Nepal’s 12,000,000 children- a staggering 2.4 million children- are suffering from moderate to severe hearing and visual impairments which restrict their educational performance, interfere with their cognitive development, limit their opportunities for employment when they grow up perpetuating a state of intergenerational poverty. Hearing impairment in early life interferes seriously with speech and language- a serious disadvantage to individuals in this competitive society where communication is of utmost importance in promoting services and goods.

Therefore, that huge number of children are marginalized, cannot be acceptable to a civilized society. Out of this concern for children was born the Children Hospital for Eye, ENT and Rehabilitation Services (CHHERS). It is not one of the many conventional hospitals engaged in only providing “reactive clinical care”. CHEERS is a proactive facility which, in addition to its institution based services screens children before clinical manifestation, identifies children at risk and intervenes before they become symptomatic and provides services close to homes of people who are not able to come to hospital. This does not complete the identity of CHEERS. Its educational program works hard to raise awareness of the community and sensitize it to its rights to public services and their duties as citizens of the country. Its spectrum of care extends, beyond the frontiers of medical care, to prepare the incurably blind or deaf children to send them back to the community as productive citizens by enabling them to learn compensatory knowledge and skills at its innovative “Enabling Center” where children as young as 2 to 6 years of age are imparted skills of daily living and prepared for enrollment at Early Childhood Development Centers, a right denied to them until our ground breaking work to unlock the closed doors (doors closed because of their young age and because of their disability). In addition to children, the Enabling Center also caters to the needs of adults and elderly persons with sensory disability to return them to productive life and improve the quality of their life. CHEERS therefore is a unique blend of health, a pre-primary education and a range of rehabilitation services under one roof committed to provide a continuum of care, metaphorically speaking, from womb to tomb. Our ultimate goal is to reach them even before a fertilized ovum is implanted in the womb.

We are grateful to government of Nepal and friendly countries, our well wishers who have supported us through the years in establishing an institution devoted to development of children with health and education as door openers to help children achieve their full potential and contribute to their own as well as to this country’s prosperity.
Please visit us for further queries and our working model.
www.bpeyefoundation.org
http://www.bpeyefoundation.org/Outreach-services.aspx
http://www.bpeyefoundation.org/CHEERS.aspx
http://cheersnepal.wordpress.com/

Support the children in need...
http://www.bpeyefoundation.org/Gift-of-Service.aspx
http://www.bpeyefoundation.org/Sponsor-a-Child.aspx

Volunteer in your desired field
http://www.bpeyefoundation.org/Volunteer.aspx

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Team

This reminds me of CenteringParenting and CenteringPregnancy - which has shown in the US to reduce the number of low birth weight babies born in inner city areas in the US. I worked with CenteringPregnancy for a few years, and really like the model! http://centeringhealthcare.org/pages/centering-model/parenting-overview.php

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Team

Brilliant work Duncan. We are working on related issue. We could partner together on this one.

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Team

Hi. Please help us to fill our survey question below here. Thank you in advance.
Does a parenting kit with simple guidelines on how to practice best parenting skills during first five years of child development milestones (in form of DVDs or printed templates) would provide opportunities to parents in low-income communities accessing parenting skills information?
Please answer YES on NO
If YES why?
And
If NO why?
To see the IDEA follow this link: https://openideo.com/challenge/zero-to-five/ideas/first-five-years-parenting-kit

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Team

Great post and a great selection of the focus area. It would be great if you could address associated issues of Achham and also describe on the existing facilities you have in the district

Photo of Duncan Maru
Team

Thanks Agraj. The group I work with, Possible, publishes Quarterly impact reports that do describe the data and challenges:
http://possiblehealth.org/what-we-do/our-impact/

Photo of Meena Kadri
Team

Impressive, Duncan! Could be good to add that link directly to your post so folks can find it easily.

Photo of Susanne van Lieshout
Team

Hi Duncan, this could work here (in Myanmar aka Burma) too. One of they key problems that pediatric nurses and health care workers are facing is being understaffed and have too much work and pressure. Reaching out to the community could alleviate that pressure, as well as a more systematic approach to case management by health care workers. Let's stay in touch.

Photo of Duncan Maru
Team

Agreed; key to healthcare design is to "make things as simple as possible, but not simpler" :). Designing complexity is easy; simple elegance is hard. That's been our experience with group antenatal care in far western nepal-- have to push to remove complexities and inefficiencies and make this work for providers and patients.

Photo of An Old Friend
Team

David, thank you for inviting me to take a look at your idea. I must admit it is amazing. When I read it, I remembered the research that Bettina posted: https://openideo.com/challenge/zero-to-five/research/the-value-of-community-trust-when-providing-services-to-it

I know you intend to do this in Nepal but I think this idea could form an integral part of my idea:https://openideo.com/challenge/zero-to-five/ideas/our-village-raising-our-children#c-0b4ac5cb7c30eab756e8d88b3104f22a

How can we work together and try to make your idea a piece of what we can use to catalyze community engagement in taking good care of the children here in Uganda?

Thanks!

Photo of David Citrin
Team

Hi Alex, apologies for the delayed response.

Being able to connect community healthcare workers to families for follow-up is key here to engaging communities. Where you work, Alex, do you have mothers groups or other committees established to address issues raised in the community. For our group ANC intervention, we are trying to leverage already existing mothers groups to move towards action on issues identified in group sessions, around birth planning, transportation plans, other concerns of expecting mothers.

We are also happy to provide updates on our intervention as we move forward, as we'll be documenting our successes, challenges, and lessons learned so we can refactor our intervention to better solve for pregnant women in our catchment area. This gets to the heart of the PDSA discussion that you, Dr. Bettina and I were having (https://openideo.com/challenge/zero-to-five/ideas/our-village-raising-our-children#c-0b4ac5cb7c30eab756e8d88b3104f22a).

Photo of Stan Jarzabek
Team

Hi Duncan: great idea! What you propose would be an important component in a project we have in mind on detecting and monitoring malnutrition among pregnant women and newborns, and to monitor child growth & development (according to the WHO recommended milestones or other similar validated guidelines): https://openideo.com/challenge/zero-to-five/ideas/using-mobile-phones-to-identify-cases-of-malnutrition-and-slow-child-growth-development-in-hard-to-rich-low-income-communities
Would you be open to discuss possible synergies between our projects? Nepal is one of the possible settings for our project, I visited Kathmandu University in December last year, people there are keen to establish research along the lines of healthcare technologies. I would love to see you in our team.
best wishes
Stan

Photo of Duncan Maru
Team

Great! I do think that mobile applications are key here.

Photo of Laura Schwecherl
Team

Stan,

The use of mobile technologies within group pediatric care sessions could be really powerful. (Independent use may, in the short-term, be less sustainable.) How do you foresee using mobile applications most successfully in a group setting? We could see how it best fits into our model going forward!

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Congrats on this post being today's Featured Contribution!

Photo of Laura Schwecherl
Team

Thanks!