Archives June 2013

Dr. Junior Bazile and Henry Makungwa

Dr. Junior Bazile is a Haitian physician who received a medical degree in Haiti and obtained a master’s degree in public health from the University of Alabama at Birmingham under a Fulbright Scholarship. After several years working in Haiti and in Burundi, he is now working with Partners In Health in Malawi as the clinical director and community health director.

Henry Peter Makungwa is Malawian, and is currently the manager of the Village Health Worker program, overseeing all activities related to the household chart. He has been extensively trained in agriculture extension and holds a certificate in that field. After many years working with NGOs in the field, he joined PIH/APZU in 2008 and is one of the pioneers of the household chart program in Malawi.

In 2007, Abwenzi Pa Za Umoyo (APZU), the sister organization of Partners In Health (PIH) in Malawi, began a community health worker program to support HIV care in the remote, rural district of Neno. The program was designed to complement and be integrated with a Ministry of Health national HIV care program. The addition of community health workers allows HIV care and treatment to reach Malawians living in remote areas where geography makes it exceedingly difficult for them to access care.

In this setting, community health workers provide a critical link between the community and the local health facility. They visit patients between medical appointments, ensuring medications are taken as prescribed, answering questions, and monitoring for medical and social complications that might hinder a patient’s successful treatment. They also refer and accompany patients to a health facility when necessary.

During their regular visits, community health workers (CHW) collect data on a paper household chart, developed by PIH/APZU and the Ministry of Health. Data about all members of the community are collected on the chart, aggregated by site supervisors, and entered into a database. The resulting data give PIH/APZU a rich window into the lives of the people we serve. The information allows managers and supervisors to identify people suffering from inadequate housing, food shortages, a lack of potable water, or to find communities where a lack of information and cultural barriers are preventing pregnant women from attending antenatal appointments.

But these uses of the household chart are only possible with quality data. Challenges with the quality of CHW-collected data have been well documented in settings of poverty. In Neno, informal assessments had already indicated that household chart data were of poor quality, which prevented PIH/APZU from using the information. Since CHWs knew the data they were collecting were not being used or even analyzed, they tended not to pay attention to securing complete and correct data. In addition, the staff responsible for aggregating household chart data saw the task as an unwelcome addition to their existing workloads, which led to inconsistent data quality checks and further reduced the usability of the data.

In order to assess the quality of household chart data, PIH partnered with researchers at Harvard’s Department of Global Health and Social Medicine to apply Lot Quality Assurance Sampling (LQAS). LQAS is a classification technique originally used in manufacturing to evaluate the quality of, for example, a batch (or ‘lot’) of T-shirts that a factory produces. LQAS allows the manufacturer to take a sample of T-shirts and determine if the quality of the lot is acceptable. PIH uses the same approach with household chart data—staff examine only a few household charts from a health center (the ‘lot’) and determine whether the summary data quality from dozens of CHWs is statistically good enough to produce reliable results.

In July 2011 we did a baseline LQAS assessment of data quality, using five ‘clusters’ each made up of several different health posts. The results were sobering. Four out of five clusters had poor CHW data quality. From those results, we knew intervention was needed, and which health posts needed it most. We also knew where data quality was acceptable, with one cluster acting as a positive example where we could identify what was working well and extract best practices.

Based on this initial assessment, we implemented several measures to improve data quality. Responsibility for data aggregation was given to the site supervisors at each health center, who were eager to help with the improvement effort. Other staff members were assigned the specific role of implementing quality improvement measures based on the results of the LQAS assessments, which would ensure that patients got the services they need.

The resulting improvement was overwhelming. Three months after the baseline assessment that showed 80% of clusters with poor quality, we had turned the proportion on its head. Now, 80% of clusters showed good data quality. And by March 2012, all five clusters showed good data quality. The data that were previously so fraught with quality issues could now be used to improve the quality services at PIH/APZU facilities.

By using LQAS to identify data quality issues, and then intervening to improve data quality, we made the household chart a usable, practical tool for monitoring and improving the health of our patients. By accurately measuring trends in the community and tailoring our services to meet the needs of the rural poor, PIH/APZU is better positioned to appropriately address the burden of disease. These services break our patients out of the cycle of poverty and disease that in some cases has plagued them for generations.

Learn more about PIH at www.PIH.org.

Dr Rani Pal is a Consultant Diabetologist from the Horton General Hospital in Banbury, Oxfordshire.  Dr Pal and colleagues have developed several new initiatives to improve the care of patients with diabetes, including the “Diabetes in Primary Schools Oxfordshire” programme which won the team the “Diabetes Team of the Year” award at the BMJ awards in May 2013.  Here she reflects on another project and some challenges in taking a new direction towards self-care in diabetes.

OX-DOTS seeks to discover the key to self-service, self-control, self-care of diabetes health…..

Dr Rani Pal and colleagues at the BMJ Awards 2013

The Opt-out clause

One young person said to me: “Expectations to be fit, happy and healthy places undue pressure on young people, who can then become demoralised and demotivated. The question of perfection should not be there, because of added pressure.  There is already a ‘Constant pressure’ of not living up to standards, personal differences are to be expected. It’s your life and sometimes it takes a severe illness to jolt you into it.”

Young people are living with demands in society with the added problem that poorly controlled diabetes adversely affects concentration difficulties and alterations in mood or behaviour.

I gathered that the vast amount of printed literature and information on websites/ media sources is still an opt-out – of not paying attention to it? Or perhaps sources are not enticing or attractive enough to capture the patients’ interest.

Why Target Diabetes?

Around 3.1million people (7.4% UK population) and 347million worldwide have diabetes (T1DM, T2DM).   This is predicted to rise to 4.6million (9.5% UK population) by 2030; diabetes morbidity requires ‘a lifelong package
of care’ and remains a considerable burden for Health Services. Simple lifestyle measures (healthy diet, regular physical activity) can potentially prevent/delay the onset of Type 2 Diabetes, but Type 1 diabetes is not preventable.  Diabetes will be the 7th leading cause of death by 2030. Up to 24,000 people with diabetes are dying in England each year from avoidable causes: in those aged 15 to 34 years, compared to those without diabetes, a nine-fold increase is seen among Type 1 (1 in 360), and six-fold increase amongst T2DM (1 in 520); The 2010 National Diabetes Inpatient Audit accounts for 15% of inpatient bed days, where one third of patients experienced at least one medication error.

Why target Children and Young Adults?

Of 29,000 UK children with T1DM, around 40% are primary school age-group: a rising incidence (4% per year) and doubling for each decade is seen, with many under 5 years. A significant number of teenagers are developing secondary
complications of nephropathy and retinopathy before the age of 20years. Minimising these health effects depends on continuously accruing knowledge and retaining a positive attitude to self-health needs.

Targeted resources used to uplift health knowledge in all members of society.

Diabetes (insulin-dependent) in Children and Young Adults is different from other health conditions as it requires 24 hours close attention from carers, continuous dynamic interaction and dialogue, understanding, discussion and problem solving of specific issues, and motivating self- responsibility for life health management. To partake in all aspects of a normal life, children depend on everyone being informed – at home, during school, social or leisure
activities. Parents, friends and relatives, school staff and public all have a role to support them to retain optimum health and glucose control, so that their well-being prevents future health complications which are linked to diabetes, namely eye and kidney disease.

Although there is an array of copious electronic-information and many national and international websites relaying diabetes health information, we want to identify which channels of dialogue are used most frequently by young people with diabetes to empower self-education and management of their diabetes condition.

Questions and challenges

• What is the most effective way to impact on a change of culture and attitude for the present generation?
• How can we examine self-training methods and a variety of information sources and communications?
• What are the most likely sources of Electronic information that young people with diabetes, their families and friends are most likely to utilise?
• What other channels of dialogue and interaction can be used to empower self-education and management of health condition?
• Progressive e-tools – are they the young persons’ choice?
• Can they relate to these as they grow and develop, to progress on their life-long self-education?
• With your experience, are you able take up the chalice of self-care or propose how to develop this for young people with diabetes?

NHS Directive for Self-care

In 2006, the DOH published a white paper, “Our health, our care, our say: a new direction for community services” . It outlines a vision for healthcare as, “meeting people’s aspirations for independence and greater control over their lives, making services flexible and responsive to individual needs”. “Self care is about people taking responsibility for their own health and well being”. “Self management is about people making the most of their lives by coping with difficulties and making the most of what they have”.

OX-DOTS wants to know your views, suggestions, difficult aspirations, campaigns and solutions!