Today was similar to yesterday in that it was mainly transcribing. Grace, Kayla, and Noah met Alieu at World Hope and began the transcription process. Noah and Kayla rotated with each other while Grace worked on a document regarding finances. Noah and Grace had spoken with Hassan and the logistics manager at World Hope to get Hassan’s bike situation settled.

Matt Samara and Wara went to Magbenteh Community Hospital with the cervical cancer team from World Hope. They got 12 interviews for Part A of our cervical cancer study. When they returned to World Hope, they continued inputting the demographics of the 200 interviews into the Excel sheet. The team continued transcribing with Wara and Alieu and have almost transcribed all the interviews!

Our time in Sierra Leone is coming to an end as we are leaving Friday but, so far, the Ukweli team has accomplished a lot both for Ukweli and the cervical cancer study. But each member has also learned a lot from our time here; we have grown a lot as a team and have developed communication and leadership skills.

Noah Grace and Alieu went into the community  and completed an additional set of 18 interviews to make up for the ones lost yesterday to the broken recorder. This concluded the interview process and now

The rest of the team stayed at World Hope with Wara and did a large quantity of transcriptions while analyzing the data.

Once Noah, Grace, and Alieu returned to World Hope, our lovely Alieu and Wara had revealed that they made an African dish for us: foofoo! They worked together to make us this dish and we all shared it as a team; it was an amazing experience and we are grateful they shared their culture with us.

  

This week has been highly educational and productive for the Ukweli team. The team members went into both rural and urban communities within Makeni and were grateful enough to have sit down interviews with around 200 women. The women of the communities shared their experiences and knowledge of cervical cancer, its causes, HPV, and the incoming HPV vaccine.

 

As of now, around 130 interviews have been translated into English and transcribed. The team is working diligently to complete the remaining transcriptions. However, there will need to be an additional number of interviews recorded, around 30, as one of the audio recorders stopped working as the files were being uploaded, and yesterday’s work got deleted.

 

The team has seen substantial strides in their ability to efficiently finish the vast amount of work needing to be done– their ability to work together has improved dramatically throughout their time in Sierra Leone. Conducting these interviews has allowed the team to really learn about the Sierra Leone culture and appreciate the beautiful geography within each community. The team also continues to express gratitude for the support of their translators, Alieu and Wara, as these interviews would not have been possible without their assistance. They are giving us their best efforts and are just as passionate about this research as we are, and this doesn’t go unnoticed.

 

Grace, Samara, Matt, and Noah woke up early to meet with their translators, Wara and Allieu, who would help the team conduct interviews today. They set the goal of 50 interviews for the afternoon after which the rest of the day would be spent transcribing the interviews.. Kayla arrived this morning after completing her summer internship; the team happily greeted her and caught her up on the plan for the day. She would spend the rest of the day traveling with other teams to PHUs to see Ukweli operations.

 

The interviewers showed the team a good location to begin the interviews. They split up with Samara, Matt, and Wara going into the neighborhood on one side of the road and Noah, Grace, and Allieu going into the neighborhood on the other side of the road. Both groups went along the smaller streets of the communities on their respective sides of the road, approaching women and informing them about the study to see if they would like to participate and consent to voice recording. The team saw a great variety of responses among the women of this community, and the data seems of excellent quality. By the end of the afternoon, the groups had a combined total of 46 interviews done! Right before dinner, each group sat down with their respective translator to translate and transcribe the interviews. This is a tedious process, and it can take about an hour to transcribe just two or three interviews. It is important to transcribe every word as closely as possible to what was said in order to make sure the data is accurate. After dinner, Grace and Noah invited their translator to come to the hotel to help them translate the interviews. They were awake until almost 1 AM. Matt and Samara went to bed early because their translator was scheduled to arrive early the next morning to help them. 

The team learned a lot today in terms of efficiency and planning accordingly. The cell phone service shut down during the day and the groups that split could not contact one another. Next time, they agreed to create a meeting spot in a landmark location to check in if they were lost. They also programmed the coordinates of the World Hope office on their phones in case they needed to walk back to the office from the communities. After dozens of interviews, the team learned what methods of communication (including phrasing of questions) are more effective than others. For instance, each team found that the women were confused when they were asked about vaccines. They noted this and rather said “injection” or “marklate” (Krio terminology) in addition to the term “vaccine”. The women were more receptive to this diction and the answers reflected as such. In other words, the team affirmed that they must be good listeners, adaptable and personable.

Today we began conducting interviews for Cervical Cancer Research. Samara, Matt, Noah, and Grace arrived at the World Hope International Makeni Field Office and met with the translator, Suiluman. The consent form, demographic survey, and interview guide was discussed so Suiluman was better informed about what and why we are asking such questions. The team walked to a nearby village where the mock interviews began. The purpose of the mock interviews was for each interviewer to practice their interview style, ascertain which questions needed to be reworded, and probing questions that could be useful for deeper insights within a semi-structured interview. Each member conducted two interviews– the first set of four interviews was within one community, and the second set of four interviews were conducted further down the road within another neighboring community. 

 

Once the interviews were complete, we walked back to World Hope to work with Suiluman and transcribe the interviews verbatim. Individually, each member worked with Suiluman to translate and transcribe two interviews each. This was a very time-consuming process that we will collectively work on in order to improve the efficiency of transcribing. Once the interviews were transcribed, they were analyzed and placed into an Nvivo where cross tabulation can be performed. 

Hassan, our distribution manager, arrived to World Hope and had discussed how he went about his onboarding and training processes throughout the day. Today, Hassan focused on Class A pharmacies and conducted a training at a previously onboarded PHU. His week will be filled in regards to training and onboarding.

Tomorrow, two translators will be joining the team and we will be conducting a total of ~200 interviews in a variety of communities and/or villages within Makeni. We also have our teammate, Kayla Miller, joining us in Sierra Leone tomorrow!

 

Today, Samara and Matt went to Panlap Community Health Center. There was a great turnout of women from the local community to be screened. This was the largest group they had seen. Some women waited almost an hour to be screened. During each screening, Nurse Janet was able to complete three or more consultations. Samara and her team are hopeful that they will have enough interviews for the cervical cancer study. And for some good news, the Sierra Leone Ethics and Scientific Review Committee and Lehigh’s IRB gave the team approval to start the interviews! After the team heard the good news, they went to the printing store in town and printed the consent forms, surveys, and interview guides. They are hoping to interview women tomorrow! 

Grace and Noah spent majority of the day at the World Hope office familiarizing with the Cervical Cancer Study so that they are more than prepared for the beginning of interviews tomorrow. This consisted of reading over the submitted IRB and discussing the interview questions. Going over the process of interviewing was highly beneficial. Additionally, Grace had updated the Ukweli website and created a team email so that all data collected by Hassan may directly to one place. During this time, Hassan was sent to preform for sales and engagements with new and existing clients. Once Hassan returned to WHI, the team discussed how the day went and how to move forward. We decided that tomorrow Hassan should aim to onboard pharmacies and utilize the log book we created and printed for him, as it is a could way to retain data.

 

Grace and Noah focused on formal documentation of Ukweli’ strategies, team members’ roles and responsibilities, and forming a communications log. They went to the World Hope Office and stayed there most of the day. The potential Ukweli strategies going forward included the positives and negatives of each route, as well as the possible outcomes of each strategy. Additionally, they created a new set of questions to ask at PHUs in order to gather more information about the practices of payment for health services within Sierra Leone– although services such as maternal healthcare and care for children under the age of 5 is guaranteed to be free within this country, the reality is that the service itself may be free but the cost of materials isn’t. For example, a clinic may perform a screening service for free, but the device used may need to be paid for in order to perform that service. The communications log was formed to allow the Ukweli-Lehigh team and World Hope International team the ability to view all Ukweli-related communications between the Ukweli-Lehigh team and Distribution Managers within one document– this is necessary to provide oversight and accountability within the venture’s operations.

 

The Distribution Manager, Hassan, met the team at WHI this morning and we instructed him that today was a sales day for him. So, he set out to go sell boxes of test strips and to engage with PHUs in general. When he arrived back, he discussed that each of the PHUs he visited were agreeable to buying Ukweli test strip boxes, but he will have to revisit them within the next few days to conduct Ukweli training with more nurses and community health workers (CHWs) upon his return.

 

Samara and Matt traveled to Garden City Hospital with Nurses Janet and Miata. As before, Janet conducted the pre-screening counseling while Miata performed the screening procedure as well as the post-screening counseling. While waiting for patients to arrive, Miata also introduced Samara and Matt to the head doctor of the hospital. Afterwards, Samara observed seven patients being screened and Matt sat in on the pre-screening counseling. The team then returned to the World Hope office where they met with Edwin to discuss his opinions on the interview questions. He expressed his concerns about some wording and perception issues– the team edited the questions accordingly. The Ukweli-Lehigh team hopes that the interviewing will be able to begin next week.

Noah and Matt went with Hassan, Naakesh, and two other teams to visit several PHUs around Makeni: Tambiama CHP, Panlap CHC, and New Hope Hospital. They had a list of questions prepared to ask nurses and other staff at these health facilities to get insight on their duties, operations, and their knowledge and use of Ukweli test strips. Each interviewed person would receive two packets of biscuits as gratitude for their participation. At Tambiama, a public facility supported by funding from UKAid and other organizations, Noah and Matt were introduced to a State and Road Community Health Nurse. Nurses of her type are usually stationed temporarily at health facilities in rural areas and highways, but she has been at this location since 2018. While she has screened with Ukweli test strips before, she has not done so for the past 3 months due to the Nurse-in-Charge being absent for health reasons. The nurse also stated that their Ukweli strips were given away for free to pregnant women due to their expectation of free healthcare.

 

 

 

After visiting Tambiama, Noah and Matt traveled with the group to Panlap Community Health Center (CHC). This facility was recently upgraded from a Community Health Post (CHP) to a CHC, indicating it grew to a greater capacity facility, although they still did not have an in-house lab and had to send samples to larger facilities for analysis. Noah and Matt interviewed a community health officer (CHO) who explained that they now only used the free two-parameter glucose and protein test strips provided by the government instead of the Ukweli test strips, which they called “World Hope strips.” They indicated that the government strips were preferable because Ukweli test strips were given away for free to pregnant women despite being bought by the workers out of their own pockets. 

 

 

The third location visited was the New Hope Hospital, a larger private hospital. There, the team interviewed another Community Health Officer who has been working at the hospital for 2 years. He said that they did receive Ukweli test strips and that screening is performed by a lab technician. However, there are not many pregnant women in the area and no maternity clinic at the hospital. 

 

 

 

Today, Grace and Samara went with the World Hope International Cervical Cancer Research Team to observe some screenings at Branda Medical Centre LTD. Grace and Samara traveled to this facility with the community mobilizer and got to observe how he engaged the community in order to increase the number of women getting screened. He parked the WHI truck in the middle of a village and ,with his microphone, began announcing that women from 25-49 should come to the nearby hospital to get screened and treated for cervical cancer free of charge. The confidence and enthusiasm of the mobilizer really drew the attention of the community and was truly inspiring to watch. 

The next stop was Branda. At first arrival, Samara and Grace were introduced to some of the staff, including the doctor in charge and the woman who ran the facility. A WHI team member, Janet, then gave Samara and Grace a tour of the hospital which contained a variety of wards. There was a female and male ward along with a children’s ward and maternity ward. There was also a triage center and housing for the hospital’s matron. Once the introductions and tour was complete, it was time to wait for patients to come in for a cervical cancer screening. There was a little bit of waiting but then a few women came in for the free screening. Samara and Grace took turns observing the interactions between the staff and the patients, noting how the nurses were comforting the patients. The screenings took about five minutes and were very educational to observe. Overall, the experience was highly beneficial and intriguing. 

The Ukweli Team regrouped at World Hope and conducted a meeting with our distribution managers, Hassan and Jawara, to try and critique operations to increase sales. This conversation took a lot of brainstorming and gave us a new outlook on how Ukweli needs to begin to function. 

 

Day 2:

The Ukweli Team spent the day visiting peripheral health units (PHUs) to interview PHU staff directly. Noah went to Makama Community Health Post and interviewed Sister Mariama, the Nurse in Charge (NIC) at Makama CHP. The questions asked during the interview focused on obtaining firsthand accounts of the challenges related to UTIs and preeclampsia. The discussions sought to tease apart any potential difficulties that can be addressed in terms of the distribution of Ukweli test strips– although the feedback given was overwhelmingly positive, the insights offered by PHU staff appeared to be relatively uniform from PHU to PHU. For example, each PHU only buys one to two boxes of Ukweli test strips at a time because of the extreme lack of financial resources.

 

After visiting Makama CHP, Noah met with Grace at World Hope International’s Sierra Leone Field Office– the two traveled to Stocco Dots Center for another interview of the clinic’s doctor, Edwin. The answers were relatively similar to the answers obtained from Sister Mariama, but we learned that most PHUs have one day of the week dedicated to antenatal care (i.e., antenatal day). As a result, Ukweli screenings are only conducted one day out of the week at most PHUs.

 

Afterwards, Grace & Noah walked with the Ukweli Distribution Manager, Hassan, to view the Bombali District Medical Officer’s building. Hassan brought to our attention that the adjacent PHU, Primary Health Clinic, was hesitant to participate as an Ukweli-equipped PHU due to concerns related to payment for a service that is supposed to be free of charge. However, the team patiently discussed the purpose of the cost recovery model; that is, in order for the test strips to reliably be available at all PHUs, the cost must be recovered for the purchase of more test strips. In particular, the idea of the test strips is to make screening accessible to all without pregnant women having the burden of traveling long distances to a clinic with the ability to conduct further screening.

 

After further discussion, the Nurse in Charge at Primary Health Clinic appeared more receptive to participating as an Ukweli PHU, but she would like re-verification of our project’s permission to operate within the district– this is because a new District Medical Officer (DMO) was recently appointed for Bombali District, and PHUs are required to strictly adhere to the wishes of their respective DMO. Therefore, the team is currently attempting to arrange a meeting with the Bombali DMO to alleviate any concerns that Primary Health Clinic and other PHUs may have going forward.

 

In the afternoon, Grace went to Gladys Koroma Memorial Hospital and met with the nurse who oversaw outpatient care and antenatal care, Fatimah. Grace interviewed her and obtained essential information about the difficulties within a hospital. Fatimah expressed that pregnant women often do not go to get help given they either do not want to pay or they are used to having children and getting taken care of at home so, why should they start now? She also suggested that we should maybe utilize WhatsApp as a way to receive data from PHUs in regards to the results of the test strips. Grace also learned that some private health units do community engagement to try to convince women to come into the units and get tested and treated. This was very beneficial to learn about. 

 

Samara and Matt visited the Magbenteh Community Hospital in Makeni. They were introduced to the Human Resources officer, the hospital manager, and other staff, all who were very friendly and hospitable . Afterwards, the staff then showed them the room in which the cervical screening and treatment occurs. The staff described the full screening and consultation process and walked them through how the patients are treated for cervical cancer if they screened positive. The staff said many women are very open to the treatment if they screen positive, but some have to ask their husbands for permission. This has not been a huge barrier to the program; in fact, they reported that when men are counseled with the women, they are very willing to give their permission as head of the household for the wife to be screened.

Minuet demonstrated the thermal ablation instrument. The rod heats up to 100 degrees Celsius in five second and applies to the lesions on the cervix for 40 seconds to ablate the cancerous tissue. The procedure is virtually painless and no local anesthetic is applied.

Samara shadowed Minuet while screening a patient. Samara observed the consolation and screening process. The patient was nervous at first but Minuet was kind and comforting during the entire process. The vinegar was applied to the cervix and the nurse waiting one minute before she examined the cervix. After her exam, the patient left and Matt and Samara were taken back to the World Hope office to continue revising the IRB informed consent document.

Today was our second day in Sierra Leone, but we actually started our work today. 

Our team has two subteams: operations for Ukweli and working on research for cervical cancer. We left our hotel at 9 AM and traveled to World Hope International where we began introductions and getting settled. Excitingly, this was our first time meeting in-person with several of our WHI colleagues that have worked with us on this project for several years.

We began the morning with a meeting with our distribution manager, Hassan, and we we were able to get a clearer picture as to how operations were working on the ground. From this conversation, it came to surface that there were some things that the team didn’t realize were occurring– for example, Hassan had expressed the reason for lack of sales of our product was that several community health workers were hesitant to sell and make profit to the women they are testing because it is not a good look for them within their community if they are proving false on the quote on quote free healthcare system. On the other hand, this shows that women going into the PHU are expecting the government-promoted free healthcare system. Therefore, this is leading to a decrease in demand as the economy is severely depressed and the advertised free healthcare system isn’t truly free of cost. This issue is something the team will have to work towards solving as a decrease in demand and a constant supply will cause damage to the goal of self-sustainability of Ukweli.

 Additionally, we discovered that the actual screening wasn’t still occurring the way it was intended to be done. In the original operation system, women were getting tested both at PHUs and in the comfort of their own homes because community health workers used to go out into the communities. However, Hassan had informed us that due to lack of funding the workers no longer would travel into the communities and that usually one person, the lab technician, is usually screening the patients. This led to us realizing that one person is typically responsible for logging the data of the screening results.

The conversation then led into Hassan conveying his issues he was currently having with his motorbike that Ukweli currently provides.  This issue is something we must work on to be resolved as this causes issues with the distribution of our boxes. To begin to resolve this issue, the group discussed how to proceed with WHI’s regional manager, Sharr. The regional manager was understanding, however, he had expressed that the decision of Hassan receiving a new motorbike was not his decision and it was up to another person to approve and talk to about the cost of the bike. Therefore, we will follow up with Sharr.

Afterwards, Hassan and a WHI driver drove Ukweli and two other teams to interact with PHUs. First, we went to Rescue International Hospital and we were able to introduce ourselves to the lab technician and technician assistants who use the Ukweli test strips on a regular basis. We got a tour of the PHU and received a walkthrough of what services are provided. Next, we visited Gladys Koroma Memorial Hospital. We briefly sat inside, but, the Hospital’s doctor was busy and we scheduled to meet for another time. The same occurred with the next PHU, Makama Community Health Post. We then tried for one more PHU– the DirectAid Hospital, but it was closed due to the lateness in the day. While we were not able to speak or interview anyone, it was still beneficial to see the layout and different services that PHUs offer. After further reflection of  our conversation with Hassan and PHU visits, we generated a working list of questions for PHU representatives themselves that aim to enhance our understanding of the challenges they face pertaining to maternal health and Ukweli Test Strips.

 

 

 

Samara and Matt met with Edwin, the director the WHI Cervical Cancer Screening Program, in person finally! They met Edwin’s staff and they each introduced themselves and their role within the program. There were three nurses and one community mobilizer. One of the nurses offered to work as our translator for the next two weeks. This is very exciting for the team because the nurse has the experience and knowledge of the community to appropriately interview participants. The community mobilizer talked about their demand generation strategies. For example, he goes to communities to preform concerts and utilizes the door to door method. Additionally, he recorded a jingle for the radio and recruits celebrities to talk about the program on their social media platforms. The celebrities are trying to help break the stigma that screening is a scheme by the west to limit birth rate. He said the most successful channel for recruited women to be screened is the radio. 

 

During the month of August, the Cervical Cancer Program will be based in Makeni and traveling locally. Matt and Samara have the opportunity to shadow the nurses and community mobilizer tomorrow at a hospital. Going to the hospital will allow Matt and Samara to smooth out some logistical questions: How many women will be able to participate in the study each day? What environment will the interviews generally take place? How quickly are the women screened?  

 

Once these questions are answered and the IRB is approved, Matt and Samara can create a better plan for interviewing women.