Author: cld220

8/13/19- Clinics, Training and Market Shopping

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Today we left the hotel at 8:30 bright and early, ready for whatever the day throws at us!

Once we got to World Hope, Rohan and Jordan immediately left to visit three clinics—Mabunbuka, Mateboi and Gbendembu. The team sent Jordan to ask CHOs and nurses about preeclampsia and the monthly CHW meeting times each clinic has. We sent Rohan, Ukweli’s quality control guy, to look at how each clinic is storing their test strips. Since we’ve been in Makeni, he’s been running experiments on how the combined humidity and temperature of the region effects each assay of the test strip. From his testing so far, our test strips have had no problems! The original assay color has remained the same after about an hour of exposure.

 

The other four remaining Ukweli team members stayed behind at World Hope to work on training with Hassan. Hassan has done an incredible job so far comprehending and learning the UTI and preeclampsia information. We are all starting to feel very confident in his abilities to train other CHWs, and he is super eager to start training at clinics. He’s been telling us every day now that he is meant to be in the field and not in a conference room. We hope to soon grant his wishes and put him into the field, however we are still waiting on the approval of our marketing license :(. Praying it gets approved by August 20th!

Teaching Hassan in the World Hope Conference room.

 

Later in the day, Zach, Naakesh, Sage and I went to the market to get supplies for the training sessions Hassan will hold. We got 300 blue pens which will be given to each CHW who purchases a box of test strips. This will hopefully incentivize CHWs to record the number of people who screened positive or negative for a UTI and/or preeclampsia on our data chart print out. We then bought 5 large ledgers to give to PHUs so they can also record information about the people they are screening. We also purchased 15 cups that Hassan can utilize in the role play part of his training session. We plan on having CHWs practice on each other with these urinary cups before they get certified to screen people in their community.

 

Zach is a big fan of the quotes they put on the cars and buses. “Son of man” is just one of his favs.

The busy market roads

This bumper sticker describes how it feels to be in the conference room all day.

 

When we got back from the market we continued training with Hassan. He absolutely nailed it and we had a really good discussion about how he would present it differently in front of a PHU vs. a CHW. He even did part of the training without the reference guide. Tomorrow we will continue on with more of the training and hopefully get more updates on the status of our marketing license!

8/6/2019- Visiting 3 Clinics

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Today we got up bright and early to visit three clinics. We were joined by the sickle cell team and maternal mortality documentary team. They wanted to come with us to observe how we conduct interviews as well as see what the clinics in Makeni are like.

Yesterday we found out that World Hope is no longer funding Community Health Workers (CHWs) stipends. After hearing this news, we decided that we needed to visit a few clinics to see how the program is functioning despite no stipends being paid to the health workers. We also wanted to see how much of an understanding nurses and Community Health Officers (CHOs) had of preeclampsia.

 

The first clinic we went to was called Kageaneh. We spoke to the female CHO about the CHW program and about the number of cases of preeclampsia she sees. She currently has 11 CHWs working at her clinic and all of them are being paid a stipend for their work. She believes that they are being paid by the government. We asked her about supplies and she told us that they have not received a shipment of supplies since February, which is one of their biggest challenges for providing quality care. When we informed her our strips now screen for preeclampsia, she seemed excited about it but she said that she has not had any cases of preeclampsia at her clinic. She was extremely familiar with the condition and knew the difference between eclampsia and preeclampsia. She also had a blood pressure cuff to test for hypertension.

The second clinic we went to was Kamabai. We met with a male CHO who didn’t seem to be as informed about his clinic as the Kageaneh clinic CHO. He wasn’t sure if his CHWs were being paid a stipend and he wasn’t sure who was paying their stipends if they were receiving one. I was surprised at his lack of information because the Kamabai clinic is one of the newest, biggest and nicest clinics in Makeni. He later told us that he hasn’t had any cases of preeclampsia. He said if a woman has preeclampsia they are immediately referred to a district hospital and so most cases of the condition are dealt with at the hospital.

Kamabai Clinic

This is a catchment map of the communities and villages that the Kamabai clinic serves.

 

The third clinic we visited was in Binkolo. The CHO we met said that he currently manages the care of 15 surrounding communities. He told us that the CHWs he manages are receiving a stipend that the government pays for. He informed us that they currently screening pregnant women for preeclampsia with a protein assay, blood pressure cuff and physical examination. When we informed him that our strip can screen for both UTIs and preeclampsia he was happy and said that combined screening tests are efficient and would help his work.

Some of the Ukweli, Sickle Cell and Documentary team members.

 

Later in the day we met with our translator, Hasson, to talk about an employee contract with Ukweli. We wanted to make sure he understands that his contract focuses on the milestones and accomplishes he makes during the months we employ him. It was interesting to watch how Khanjan negotiates and comes to an understanding with Hassan about his job duties and making money to keep the venture self-sustaining.

Overall, we had a really good accomplished day!

August 15th, 2018 Last day in Makeni

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Today we got to sleep in a little, which was very nice for all of us because of how early we had to be at the hospital yesterday!

When we got to World Hope, we spoke with a woman who works for early child development programs. She is the supervisor of 10 mother support groups, which is a group of women (about 15 members) who meet to advise and educate each other on health related topics. She says she visits these groups monthly to provide sensitization on different topics such as nutrition and disease prevention. She also gives refresher trainings to these women to ensure they understand the information presented. She told us that the CHWs select who is in the mother support group and the community members appoint who should serve as the leader of the group.

We are thinking that to get pregnant women to understand the importance of disease screening, we should target mother support groups. Women, especially pregnant women, will trust their community members way more than us or any ad. They will also be much more receptive to learning about UTI screening if it comes from someone they know and trust.

We are thinking of teaching the mother support leaders about the signs and symptoms of a UTI. Then, they can go to their group members and educate them.

After interviewing, we finalized all of our concept of operation documents. We organized them all into a single folder with the most update versions.

Later, we went to radio Mankneh and AMZA radio to see if they would be willing to run a health program on Ukweli. Radio is a good way to engage with community members in Makeni, so we are considering purchasing a time slot for an hour to help sensitize and introduce our venture. Both stations charge the same hour and 30 min rates, however radio Mankneh is a more community based program and is the oldest station in Sierra Leone. They also broadcast in 5 different local languages, rather than other stations which is just english and creole.

August 14th, 2018 Makeni Regional Hospital

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Today we woke up early to meet with the medical superintendent of Makeni Regional Hospital. We started the conversation telling him about our venture and how we are looking to expand it. His main concerns were about how effective CHWs will be in reading the color change. He was telling us that many may be colorblind or that the change is not drastic enough to detect. He told us that at the hospital, over treatment is very common. He suggested that we need to continuously compare our strips against the gold standard to ensure it is producing accurate results.

He told us that hepatitis B is slowly becoming an epidemic in Sierra Leone, and so a rapid diagnostic test (RDT) would be extremely helpful. Hepatitis B can be active or latent, so a test that can tell you what stage it is in would be even more helpful to ensure proper treatment.

Another rising infection is curable STIs, such as chlamydia, gonorrhea and syphilis. They are seeing a lot of pregnant women, who are screening positive for syphilis late in their pregnancy. They all had originally screened negative a few months before. A nurse at the hospital figured out that the diagnostic they are using for syphilis has a 90% chance of a false positive for pregnant women in their last month of pregnancy. Also, a 90% chance of a false positive when the patient has malaria. We are not sure why they use this test when malaria is so prevalent. This leads to many people being diagnosed and treated for something they don’t actually have.

He emphasized the importance of sensitization and proper marketing of Ukweli so people become familiar with the brand and understand how it will help them. He gave us suggestions of radio stations and different healthcare stakeholders.

pictured: The Medical Superintendent

We then went to the hospital laboratory to see the different RDTs they use. They seemed to only use a 10 parameter strip, rather than specific parameter strips like ours.

After visiting the hospital, we went back to World Hope to finalize our training and employee documents. Tomorrow is our last day in Makeni 🙁

Pictured: the laboratory services sheet

August 13th, 2018 Visiting Kalangba and M’bunduuka

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Today we set out early to visit Kalangba, a much more rural clinic than the ones we have previously visited. We first spoke to a nurse in charge who has been working at the clinic since 2008. She told us that her clinic has a major shortage of medication, also that they hardly do any outreach programs with the catchment villages because of the far distance the clinic is to the neighboring communities. She stated that the closest village is 15 miles away. Women often deliver babies on the way to traveling to the clinic because they don’t know the age of gestation, and only start to go to the clinic when they are in pain. The clinic delivers about 20 babies a month, and the most popular month is January (during the dry season). She currently manages 24 CHWs and gives refresher trainings to them every 3 months to make sure they are performing the correct job duties. She was very pleased with our venture and thought of it as a way to motivate CHWs to do work.

pictured: the nurse in charge

Later, we met with 4 CHWS. Three of them have been working since 2013, and the other since 2017. They all said they have trouble convincing community members that they are there to help and serve them. A lot don’t understand the reason for visitations and are shy to revel symptoms. The most common illnesses they see are malaria, pneumonia, diarrhea and malnutrition. All of them have to pay for their own phone calls to clinics for patients and hospitals, and wanted to have access to the freeline service. When we told them about our venture, they said sensitization and community engagement will be crucial to gain peoples trust and willingness to get screened.

pictured: the four CHWs

After, we drove to M’bunduuka to talk to CHWs. However when we got there, the CHO told us that they all left because we took too long to travel to meet them. Our interview at Kalangba took too long unfortunately.

We still proceeded to interview the CHO, who has been working at this clinic for 3 years. He was promoted about a year ago, and still has not received any change in his payroll.

He says he could be working in the city making a lot more (due to his education), but he cares deeply about the health and wellbeing of his community. He says most of the nurses in the clinic are not even on payroll.

pictured: the outside of the clinic

He told us that there is currently no outreach programs because of the lack of mobility. Because of no outreach programs and far reaching distances, very few people come to his clinic. He aims to have 22 people visit a month, but he’s only been getting about 15. He currently advises 12 CHWs and 1 peer supervisor. He hasn’t given a CHW training or skills refresher in over a year, and so some of the CHWs are not performing their job duties correctly and referring patients. He says he can’t give the training because of the lack of resources to teach and transport people.

One of the challenges the clinic faces is a lack of supplies. In the labor and delivery room, he said they don’t have forceps or scissors or any type of delivery kit. He said that almost all women come in to the clinic to give birth because if they give birth at home, the government fines them.

Overall, he really liked the idea of our venture and will pass on the message to his CHWs the next time they meet (25th of every month).

pictured: the CHO

August 12th, 2018 Visiting Rokonta

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Today we visited Rokonta community health clinic and spoke to a CHO and 3 CHWs. The CHO has been working at the clinic for the past 6 years and lives on site. She told us that right now the clinic is very slow because of the rainy season. People don’t want to visit the clinic because of how hard it is to travel and the conditions of the roads. She currently travels to Makeni weekly to report what’s been happening in her clinic, also to voice the concerns and challenges of the 12 CHWs she manages.

pictured: The CHO

The clinic does not have a lab, however they still screen for HIV, Malaria, and UTIs. They cannot do complicated diseases such as typhoid, they must refer for that. She raised some concerns about our venture when we told her that CHWs will be charging women 1000 leones for a strip. She stated that women will likely not pay because of the free healthcare that lactating mothers receive. We must do a lot of community engagement and sensitization in order for women to understand the importance of being screened.

Most of the conversation with the CHWs was dominated by the CHO. When we asked the CHWs anything, she always intervened and spoke over them. However, we did get a little bit of information from them. Two of them have been working since 2016 and the other since 2013. The challenges they face are late stipends, lack of supplies for first aid/malaria treatment and reluctance of their community members to come to the clinic.

Pictured: The three CHWs

When we got back from the clinic, Khanjan treated us with Indian food from Freetown and it was delicious!

August 10th, 2018 Visiting 3 Pharmacies

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Today we walked to three class A pharmacies by the main Makeni market to discuss how they screen and refer women. The first pharmacy we went to was marked “noncompliant” by our field fellow Gabi. We decided to go anyway to get a sense of why they were marked this way. A man greeted us and told us that his pharmacy does a lot of screening for women, particularly pregnancy and UTI tests. He says that women (usually rural) walk in groups to his pharmacy, and that they stop there on their way to the market to pick up supplies. His pharmacy screens women there, and then depending on the results, treats them with either amoxicillin or ciprofloxacin. He employs a lab technician to do the screening and interpretation of results. They also do more advanced screening such as HIV, diabetes and typhoid. He has no refrigeration for any of his drugs and all of them are imported from either China, India or the UK. He stated that most never complete the entire dosage of antibiotics because once they feel better they see no need to complete the rest. We all were alarmed by this, because of antibiotic resistance and how dangerous it can be.

The next clinic we went to was called “Poormans Pharmacy.” It was much larger and employed more people. The owner wants to sell our product and seemed to be very interested in Ukweli. His pharmacy also screens women on the spot and provides them with medication. More advanced cases are referred to health clinics/hospitals.

pictured: owner of Poorman’s Pharmacy

The third clinic was not at all interested in carrying our product. He stated that his pharmacy does not screen women due to contamination. His pharmacy is too small to screen women and he does not feel comfortable doing so. He only supplies the treatment medications.

Visiting all three ultimately gave us good insights on how the referral process works and the accessibility to UTI treatments. Our venture can only exist in type A pharmacies that have a lab space for screening.

August 9th, 2018 Doris and Yoni

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Today we visited a community health post (CHP) in Doris. We met with a nurse in charge and 2 CHWs. The nurse in charge had been working in healthcare for 20 years, and was promoted to nurse in charge about 2 years ago. The CHWs had both been working since 2015. It was really important for us to visit this post because they have the highest number of people infected with a UTI within their provence. We had happened to visit on the day that all pregnant women in the surrounding communities come in for a check up. There were 6 pregnant women in the waiting room and the nurse in charge showed us that he had just screened two of them for a UTI and both came back positive. Our translator, Hassan, explained to us that he thinks the high rates of UTIs is due to the large amounts of stagnant water in the area.

The CHWs stated that their main challenges are late stipends/stipends not paid in full, no access to a freeline to call clinics and traveling far distances. The stated that they are already out of all the UTI referral tickets that Gabi (Ukweli field fellow) had given to them earlier this year. They all stated that they like working with the referral process and find it effective to track and bring people to the clinic. They discuss with their peer supervisors at the end of each month to relearn skills and talk through current health issues happening in the community.

Pictured left to right: Two CHWs, a nurse and the nurse in charge.

After, we drove to Yoni, another rural CHP. We also met with a nurse in charge and two CHWs. The nurse in charge stated that her job is challenging because most people in her community are reluctant to medication. They think that healthcare professionals are out to get their money. To get rid of this assumption, she tries to do outreach programs once a month to educate people on the importance of coming to the clinic/post.

The CHWs have both been working since 2016 and said that the challenges they face most often are criticism and neglect from community members. They said they advise members to go to the clinic for treatment, however they don’t and later regret it because their symptoms get much worse. They are also trying to change the community’s mindset by running outreach programs and visiting homes frequently.

Pictured: the two CHWs interviewed

Later in the day, a tailor who is making outfits for all of us came to take measurements and deliver some of the finished pieces. Cassidy, Sage and Isabel all received their new outfits.

Pictured: Cassidy in her new outfit! Not really her style but happy to support local business women 🙂

August 8th, 2018 Visiting Freetown

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Today was an extremely busy day. We set out early for Freetown, waking up at 6:30. The first stop was to Barefoot Women, which is an amazing organization that trains women to work in technical fields, so they can enter the workforce and make money. The main skill they teach women is how to create and manage solar power systems for their communities. They also teach vocational things to women like how to make breads and pastries from cassava (we got to try muffins and they were delicious!). The women come to learn and train at their facility for up to 9 months and then return back to their communities to sustain them through the skills they learned. Women recruited to this program are aged 25-30, and are single parents or school drop outs.

Pictured: the Barefoot Women staff

After Barefoot Women, we drove to First Step, which is a juice factory. They showed us how they produce juice concentrate and all the various machines used to get the final product. The company was stated by an Italian engineer that wanted to improve the developing world by giving people jobs and technical skills.

Pictured: the machines that process the juice. All the equipment is shipped from Italy.

After, we drove to Home Leone which resettles families out of the slums and into community based housing. The houses were extremely well built and sturdy. The venture owns 65 acres of land and plans to use it to build schools and jobs for people living in the communities.

Pictured: A housing compound that houses about 6 different families.

We later visited greenhouses constructed by the HESE program at Penn State. Most of them were growing tomatoes and Okra. Okra is strong in vitamin A, and is grow to improve the health of children in the village who have vitamin deficiencies.

After lunch, we drove to World Hope International Freetown headquarters. We were given a tour of the facility which was beautiful. A majority of our time was spent in a conference room where we presented our venture to four World Hope employees and the CEO of World Hope. It went well and they gave us feedback on how we could potentially propose our venture to the Sierra Leonean government because they cover the costs of pregnant women’s healthcare. We headed back to Makeni after our presentation.

Pictured: World Hope International Freetown headquarters

Pictured: The view from the World Hope’s balcony

August 7th, 2018 visiting Makarie CHP

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Today we visited Makarie CHP to talk to CHWs and nurses in charge. One of the CHWs had been working since 2012, and the other two since 2017. All three of them had walked around 8 miles to talk to us today. The challenges they face as a CHW are no access to the free line to make phone calls, having to assist deliveries at night with little light and transportation. When we told them about our business model, they told us that the MOH had previously tried to sell Oncho tablets for 200 Leones and it wasn’t well received. The tablets treat river blindness. No one in their villages felt the need to buy one even though it was a treatment for symptoms some were suffering with. They didn’t see the need to pay for something when they have been receiving free healthcare. This was important for us to hear because our current business model will not work if the community members feel this way. Sensitization and our training sessions are very critical for the villages we are trying to reach so they understand the importance of disease screening.

Pictured: The three CHWs we spoke to

Later, we spoke to the nurse in charge who has been working at the CHP for 10 years. She told us that they lack equipment for deliveries and vaccine storage. She told us that they do not screen at this CHP, they must go to a clinic to get screened for a UTI. This was something that we did not know, we thought CHPs were able to screen patients.

We drove back to World Hope to meet up with the Lehigh faculty, and take them to Binkolo to meet with sister Marietta. Sister Marietta had told us last week how eager she was to meet with Khanjan and the professors to discuss malnutrition and delivery equipment. After, we took them to Kambai to see the clinic because it sets the bar for clinics in Makeni. They were very impressed with the newly done construction and cleanliness of the facility.

On the way to Kambai, we stopped at some cool looking rocks! Pictured is professor Cheng and Naakesh.