I-TECH builds local ownership and sustainability through collaborations throughout Zimbabwe. Under the CDC and PEPFAR awards, I-TECH has formed and leads two consortia – ZAZIC and ZimPAAC.
Voluntary medical male circumcision (VMMC) safely reduces the risk of female-to-male HIV transmission by up to 60%. Few men have any post-operative VMMC complication. However, current practice in Zimbabwe and throughout most of sub-Saharan Africa requires VMMC patients to return for multiple, in-person post-operative visits. With low complication rates, and severe healthcare worker shortages, these required visits are a burden for providers and patients — threatening achievement of critical HIV prevention targets. A two-way texting model studied by University of Washington researchers in Zimbabwe offers a new way to address this barrier by reducing provider workload while also safeguarding patient safety.
“These visits can be a barrier to male circumcision uptake and expansion in countries with severe health care worker shortages, as well as negatively impacting patients who needlessly pay for transport, miss work, and wait for unnecessary reviews,” said Principal Investigator Caryl Feldacker, PhD, MPH, at the International Training and Education Center for Health (I-TECH) in the University of Washington Department of Global Health.
The study included 721 VMMC patients in two locations in urban Zimbabwe. In the study, patients communicated directly with a health care worker through interactive text messaging for the critical 13 days post-VMMC, rather than returning for required in-person visits. By giving men the option to heal safely at home, or return to care when desired or if complications arose, the method dramatically reduced in-person visits by 85%. Texting also reduced follow-up costs by about one-third while improving the quality of care.
As compared to routine in-person care, the study yielded twice the number of reported complications. “This increased identification and reporting is a positive result that is likely attributable to improved counseling and men’s engagement in care. Through texting, men were empowered to observe their healing and report potential issues promptly, before they worsened,” said Feldacker.
Currently, most text-based health care efforts blast pre-defined messages to many people simultaneously, removing patients’ ability to communicate back with health care workers. In contrast, two-way texting between providers and patients provides interactive care, and the short time frame heightened participation: in the study, 93% of men responded to texts. Both providers and clients reported confidence in the texting option, feeling safe and highly recommending it for scale.
“With the current system, Zimbabwe could perform millions of unnecessary follow-up visits over the coming five years. The workload burden for health care workers and time lost for patients who are healing without complication is a significant burden for health care workers and clients alike,” said Feldacker. “Potential gains in efficiency and reduced costs through using two-way messaging are large.”
With funding from the U.S. Centers for Disease Control and Prevention (CDC), and in partnership with the Society for Family Health, the model will soon be tested in urban South Africa. The new, field-based research will further test two-way texting in a different geographical and patient context to better inform the model for adaptation and widespread scale-up.
Feldacker added that “while our findings are grounded in studies on male circumcision, our results are largely attributable to the methods rather than to a specific disease or condition.
“With minimal adaptation,” she continued, “two-way texting could streamline other post-operative care contexts or be re-configured for other similarly acute, episodic conditions where continuity of care within a short period is critical for patients, such as short-course TB treatment, post-operative healing, post-natal care or early childhood illnesses — diarrhea, pneumonia, malaria — laying the foundation for generalizing to other diseases and contexts.”
For more on the study, see the paper pre-published in the Journal of Acquired Immune Deficiency Syndromes (JAIDS):
The study was led by Caryl Feldacker, and co-investigators are Vernon Murenje (International Training and Education Center for Health (I-TECH), Harare, Zimbabwe); Mufuta Tshimanga (Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe); Scott Barnhart, Isaac Holeman, and Joseph B. Babigumira (Department of Global Health, University of Washington); Sinokuthemba Xaba (Ministry of Health and Child Care, Harare, Zimbabwe); and technology partner Medic Mobile (Nairobi, Kenya).
The Zimbabwe 2wT study was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW010583.
Jan Flowers
Jan Flowers, MS, is a Clinical Faculty member and Research Scientist in the University of Washington School of Nursing, and is faculty co-lead of the Digital Initiatives Group at I-TECH (DIGI). Her area of focus is on innovative strategies and technologies for healthcare systems strengthening in resource constrained settings through appropriate electronic collection and use of quality health data for evidence-based decision making.
She has led informatics organizations and teams for over 20 years, focused on technology policy and law, health information systems evaluation and maturity modeling, open source communities of practice building, health technology engineering and implementation, patient centered technologies and mHealth, and standards-based interoperability for improved care at the point of service, surveillance, and program monitoring.
Ms. Flowers serves on the board of directors for both OpenMRS and OpenELIS Foundations, and the founder of the OpenHIE LIS Community of Practice, which develops and shares common standards and best practices amongst the open-source LIS community. She holds an MS in Health Law & Policy from the University of California San Francisco jointly with UC Hastings Law School, and a BS in Psychology from the University of Washington.
Pictured are mannequins used at two regional training centers for nurses, midwives, and dental nurses in Kampong Cham and Battambang, Cambodia. I-TECH has supported the procurement of new mannequins to replace those that are old or broken, as well as new teaching tools that will expand the centers’ ability to conduct simulation training. Photo credit: Ann Downer/I-TECH.
The International Training and Education Center for Health (I-TECH) is working on a project led by FHI360, and funded by the U.S. Agency for International Development (USAID), to empower health care managers and national and provincial stakeholders to improve service quality, safety, and utilization, as well as strengthen overall health systems in Cambodia.
The project’s four objectives include:
Improving policies, guidelines and standards for streamlined quality assurance.
Increasing the efficiency and effectiveness of service delivery.
Strengthening regulatory framework, implementation, and enforcement.
Supporting pre-service public health training.
Given I-TECH’s deep experience in health workforce development, supporting the environments that enable strong health systems, and working with stakeholders at all levels, the team was a natural fit for Objectives 3 and 4.
In service of this critical work, I-TECH is supporting implementation of regulations among private and public health workers, as well as helping to lay the foundation for a sustainable accreditation program for public and private health facilities. I-TECH’s team also works with national stakeholders to develop the capacity of pre-service training institutions to deliver high-quality programs aligned with current evidence and national health priorities.
“We are excited to work with our partners to strengthen these critical components of quality health services in Cambodia,” said Jeff Lane, Principal Investigator and Assistant Professor in the Department of Global Health.
“By leveraging I-TECH’s broad experience in health policy, regulation, and workforce development,” he continued, “we can help Cambodia build an accreditation program to recognize high-performing hospitals, strengthen health professional councils to regulate health practitioners, and build sustainable pre-service training institutions that deliver competency-based education to train Cambodia’s health care workers of tomorrow.”
A young woman learning to weave a basket during the September 9-13, 2019 craft-skills training session.
Young mothers enrolled in the DREAMS program in the Zambezi region of Namibia had the opportunity to learn the traditional art of basket weaving through a series of craft-skills trainings facilitated by the International Training and Education Center for Health (I-TECH) and the Integrated Rural Development and Nature Conservation (IRDNC).
The all day, weeklong trainings taught the young women the basics of basket weaving and also empowered them to create marketable items that could lead to greater economic independence. For the trainings, I-TECH and IRDNC invited a Master Weaver to teach women about the technique, the types of natural fibers and dyes, and the necessary tools used in the craft. All of the women who participated in a training made at least one basket by the end of the week.
“Basket weaving is a traditional craft in this area and it is often a source of income for families,” explains Sharon Zambwe, Program Lead for DREAMS Zambezi. “One of the best parts about this program is that it not only teaches women the skills needed for basket weaving but it also connects them to a market for their works, and with each other for ongoing support and encouragement.”
The baskets that the young women crafted were made available for purchase during an event marking the end of their training. The event was attended by representatives from the Society of Family Health; Zambezi Regional Council; and Regional Ministries of Health & Social Services, Education, Arts & Culture, and Youth and Sport. The special event provided attendees with a background of the DREAMS program and included a keynote address from the special advisor of the Zambezi Governor’s Office who presented the future vision of the DREAMS program.
A basket woven by one of the participants at the September 9-13 craft-skills training session.
I-TECH launched the DREAMS program in the Khomas region in February 2018 and expanded the program to the Zambezi region in June 2018. Since the launch, I-TECH has enrolled over 20,000 girls and young women aged 9-24 years old in the program. DREAMS is a PEPFAR-funded initiative that aims to give girls and women the tools to be Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS). The program not only addresses the HIV epidemic through prevention and treatment, but it also focuses on the structural drivers of the epidemic, such as gender-based violence (GBV) and poverty.
“The DREAMS program has been able to provide girls and young women with the mentoring and social support needed to help encourage them to make positive and healthy decisions in their everyday lives,” says Ellen MacLachlan, DREAMS Program Director for I-TECH. “The activities in Khomas and Zambezi have had a profound impact on the girls and young women in the program. Economic strengthening activities such as the basket weaving classes can directly empower women by giving them a way to make their own money so they are less dependent on a male partner, especially one who may put her at risk of HIV.”
Since the DREAMS program first launched in the Zambezi region, it has provided social and health services (such as pre-exposure prophylaxis, or PrEP) as well as HIV/GBV prevention education to girls and young women and in August 2019, the program expanded into the field of economic empowerment by providing craft-skills trainings. Since the beginning of the service expansion, I-TECH and IRDNC have trained 82 young mothers, aged 15-24, in the art of basket weaving.
While the craft-skills training program in Zambezi is still in its infancy, there are plans to expand the scope of the training to incorporate other crafts skills such as clay pot artistry, knitting, and needlework. In addition to expanding the scope, DREAMS Zambezi plans to partner with tourism organizations as a way for the women participating in future trainings to showcase and sell their wares.
“We have been impressed with the response from the women who have participated in the program over these past four weeks,” says Zambwe. “We can’t wait to expand this program to incorporate more skills that will benefit not only the young women and their families but the community.”
Cervical cancer is the leading cause of cancer death among women in Malawi. In response, the Ministry of Health (MOH) in Malawi developed a five-year National Cervical Cancer Control Strategy for 2016-2020. The strategy outlines comprehensive interventions, including the integration of cervical cancer screening services into HIV care.
In 2019, I-TECH supported the review and update of the National Cervical Cancer Guidelines and the accompanying monitoring and evaluation (M&E) framework in partnership with the Department of Reproductive Health and the Department of HIV/AIDS in Malawi. Training materials were developed in accordance with the updated guidelines and trainings rolled out across the country. As part of their support, the I-TECH team conducted a needs assessment to establish which sites in the Southwest Zone had received equipment for cervical cancer screening and treatment services. At that time, they found only 45 health facilities that offered these services to women. Just two years later (as of June 2021), there are at least 357 health facilities (46.1% of all HIV treatment sites in Malawi) currently providing cervical cancer screening services and 211 providing treatment services. Integration with HIV/AIDS programming has resulted in the screening of 79,171 HIV positive women (52.4% of all women screened), with 4,506 (6%) obtaining a screen positive test result and 1,584 (35% of those with a screen positive result) receiving treatment in 2020.
All women and girls (inclusive of HIV positive women) reached with cervical cancer prevention, screening, and treatment services in 2020 is illustrated in the following graph:
I-TECH also led the development of a cervical cancer Client Diagnosis and Treatment Register that is used in hospitals providing cervical cancer treatment in Malawi. This register helps to provide critical data for programmatic decision making, like confirmed cases, deaths, as well as data on cancer staging and the number of women receiving treatment.
To ensure that the strategy continues to endorse current evidence-based approaches and M&E frameworks, the team convenes regular cervical cancer partner meetings to review standard operating procedures and the M&E framework, revise monitoring tools, and conduct situational analyses. I-TECH is also part of the team providing technical guidance on development of the strategic plan for 2021-2025.
In addition to contributing to national strategy updates, I-TECH is working with MOH to ensure same-day treatment or follow-up for all pre-cancerous lesions found among women screened.
I-TECH facilitates an HIV ECHO® program, a distance-based tele-mentoring program for providers and clinics across the region. Weekly sessions provide access to brief HIV clinical updates along with an opportunity to present and receive consultation on challenging or unusual clinical care issues from a team of multi-cadre HIV experts as well as from other members of the community of practice. In response to an identified need, the program added a monthly mental health and HIV session.
In 2019, I-TECH began supporting the Medical Research Foundation to initiate a similar HIV/STI ECHO® program that will target HIV and STI care and treatment sites in Trinidad and Tobago as well as with in other countries in the region.
I-TECH began the expansion of cervical cancer screening for women living with HIV aged 25-49 in Zimbabwe in 2019. I-TECH initially identified a provisional list of 89 sites for the implementation of visual inspection with acetic acid and cerviography (VIAC). The team then recruited, trained, and deployed dedicated VIAC nurses to 29 sites. Additionally, in an effort to improve service coverage in hard to reach areas without the necessary equipment, district teams carry VIAC equipment to outreach point facilities who have booked client appointments in advance. Random samples of images from clients are anonymized and sent to a gynecologist from the University of Zimbabwe for quality assurance.
Across all facilities, 9,664 HIV-positive women aged 25-49 years have been screened for cervical cancer with 93% testing negative, 6% testing positive for lesions, and 1% having suspected cancer.
National strategies, policies, and governance define the implementation environment for health information systems (HIS) and are recognized as a foundational building block for health system goals, including universal health coverage and control of HIV and other infectious diseases. I-TECH is supporting Cameroon’s Ministry of Health (MOH) to develop a national eHealth strategic plan by September 2019. A goal of the project will be to develop governance structures and processes, which can continue onward beyond the strategic planning process under MOH leadership, for on-going strategic direction, coordination, and oversight of investments in the national HIS.
I-TECH has worked with the Ministry of Health and Wellness, Centers for Disease Control and Prevention, and other implementing partners in Botswana to develop and implement robust national health information system that enable greater efficiency and accountability and strategic use of information. I-TECH’s work on the National Data Warehouse ensures the availability of strategic information to monitor progress toward reaching epidemic control, with particular focus on Treat All, linkages to care, and HIV clinical cascade for 90-90-90 care continuum.