Download - Ford Program Recs

Fall 2013Client Contact: Dennis Haraszko

International Development in PracticeFord Family Program Development Advisory Team

Dougie Barnard, Ali Searle, Katie Suarez, and Sally Xie

mHEALTH: DANDORA Utilizing Mobile Technology to Improve Maternal and Child Healthcare in Dandora, Kenya

Table of ContentsExecutive Summary.................................................................................................................3

Context and Goals...................................................................................................................5

Key Objectives.........................................................................................................................6

Project Evaluations..................................................................................................................7TABLE 1: Evaluation of mHealth Projects....................................................................................................................... 8

Mobile Alliance for Maternal Action (MAMA)................................................................................................................8Wazazi Nipendeni.................................................................................................................................................................... 10FrontlineSMS..............................................................................................................................................................................12Uganda Health Information Network (UHIN).............................................................................................................13CommCare................................................................................................................................................................................... 15

Recommendation..................................................................................................................17

Budget...................................................................................................................................19

Timeline................................................................................................................................21

Future Directions...................................................................................................................23

Conclusion.............................................................................................................................24

Appendices............................................................................................................................25Appendix A: How MAMA Messages Work..................................................................................................................... 25Appendix B: Comparison of the Five Projects on Cost Effectiveness..................................................................25Appendix C: Comparison of the Five Projects on Ease of Implementation......................................................26Appendix D: Comparison of the Five Projects on Proven Benefit and Impact...............................................26Appendix E: Comparison of the Five Projects on Ease of Scalability.................................................................27Appendix F: Comparison of the Five Projects on Relevance to Local Context...............................................27Appendix G: Sample Timeline for the Implementation of CommCare..............................................................28

Development Advisory Team.................................................................................................29

References.............................................................................................................................30

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Executive SummaryThe Ford Family Program, in conjunction with the Holy Cross Parish,

established the Brother Andre Dispensary in 2011 to meet the medical needs of the people of Dandora, a large slum outside of Nairobi, and the primary dump site for the capital’s waste. The Brother Andre Dispensary is currently an outpatient facility, which consults with 70 to 100 individuals a day. In 2013 the Ford Program conducted a maternal health assessment, in which it analyzed the existing maternal health care services available in Dandora. This assessment exposed, among the few health centers in Dandora currently providing maternal health care, a lack of community outreach and a corresponding lack of accessibility and knowledge of care options by women and children. While the existing maternal health facilities provided basic brochures on issues around pregnancy, such as breastfeeding; this was generally the extent of community outreach. Few pregnant women and mothers turned to the centers for care by an educated medical professional (Scott 2013).

In order to address the exposed gap in the provided maternal health services, and combat the high rate of maternal and infant mortality, the Ford Program is in the process of adding a maternal ward to the Brother Andre Dispensary. Acknowledging the power of technology as a means to interact with women at a distance and low cost, the Ford Program is interested in adopting a mHealth platform. Our team was solicited to (1) Research; (2) Evaluate; (3) Identify; and, (4) Develop a recommendation for an mHealth strategy for the Ford Program’s efforts in Dandora.

We first conducted comprehensive research of various mHealth projects, ultimately focusing on five that we found to be the most successful and applicable to the Brother Andre Dispensary. These were divided into two comprehensive groups, (1) direct SMS messaging platforms for mothers; and, (2) mobile health tools for community health workers

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(CHWs). Specifically, we evaluated three direct messaging platforms - Mobile Alliance for Maternal Action (MAMA), Wazazi Nipendeni, and FrontlineSMS; and two mobile technology tools for CHWs - Uganda Health Information Network (UHIN) and CommCare. Each of these projects was evaluated relatively by five considerations provided by the Ford Program - (1) cost effectiveness; (2) ease of implementation; (3) proven benefit and impact; (4) ease of scalability; and, (5) relevance to local context, which were then analyzed as a whole. Based on previous assessments highlighting the need for community outreach and increased knowledge of and access to services, as well as these individual evaluations, our team concluded that focusing first on a CHW-centric project would enable the Ford Program to most effectively address the immediate needs in Dandora and improve maternal health outcomes. The successful implementation of such will ideally result in a network of mothers that can support additional implementation in the future of a direct message campaign for new and expectant mothers.

Our analysis identified two platforms, CommCare and MAMA, capable of most effectively and efficiently addressing the maternal health issues in Dandora. We recommend that the Ford Program first utilize CommCare to strengthen the services provided by CHWs, namely data collection, case and CHW management, and the improvement of care. CommCare was found by numerous studies (Svoronos 2010, Mitchel 2012, Mohamed 2013) to effectively standardize support and improve the ease of data collection. The recent implementation of CommCare by Pathfinder in Nairobi under the mHMtaani campaign, primarily concerned with HIV/AIDS, provides evidence of the platform’s success in a context similar to that of the Brother Andre Dispensary.

CommCare also excels in regard to cost effectiveness. The Ford Program, with less than 50 CHWs (potential mobile users) would fall within the Community package, thus the required software, as well as technical

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and developmental staff support for the first year, would be provided free of charge. If in the future, the Dispensary grows beyond the scope of the basic package, it has flexibility to expand at little cost. A final benefit to CommCare, which concerns both cost and ease of implementation, is that CommCare does not require the use of smart phones. The platform has the flexibility to be run on any java-enabled phone, which are available at very low cost and are already familiar technology to many potential users. In summary, we primarily recommend the implementation of CommCare, a mobile technology for CHWs, which has been shown to be cost effective, easy to implement, impactful, scalable, and relevant to local context.

Evidence suggests that only upon the successful establishment of a network of mothers and awareness of available maternal health services, possible via implementation of CommCare, would the Ford Program benefit from pursuing a direct mobile messaging campaign for mothers. Based primarily on relevance to local context, ease of implementation, and cost effectiveness, we recommend that if such a stage is reached, MAMA may be an ideal mobile platform for the Ford Program to additionally implement. MAMA provides new and expectant mothers with two messages per week, from their fifth week of pregnancy through their child’s first year, covering topics such as breastfeeding, appointment reminders, postpartum family planning and tips to avoid mother-to-child HIV transmission.

In conclusion, based on the overarching need for community outreach and provision of services, we recommend the Ford Program first implement CommCare, a relevant and evidence-supported tool providing CHWs with easier data collection, better management, and improved care. Upon successful implementation of CommCare, we suggest the Ford Program then consider adopting MAMA, which would build on the established network with the community to directly provide new and expectant mothers with encouragement and information. Through the adoption of this collaborative mHealth strategy, the Ford Family Program can meet needs

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and improve provision of maternal services in Dandora, ultimately improving health outcomes.

Context and GoalsThe Ford Program’s request that we research mobile health

technology strategies adaptable for maternal healthcare in Dandora reflects new trends in global health. The twenty-first century saw an enormous rise in mobile subscriptions in the developing world. In 2000, 5.5 per hundred people had a mobile subscription; but by 2009, 67.6 per hundred people had mobile subscriptions in developing countries. In conjunction with an increase in mobile subscriptions, interest in utilizing mobile technology to inform and distribute health care services has grown. Innovative and dedicated global health organizations such as Care International, the Rockefeller Foundation, the mHealth Alliance, and the United Nations Foundation have created a multitude of projects exploring the potential of mobile health (mHealth) technology in a variety of settings. The Ford Program’s recent needs assessment indicated that community health care has much to gain from harnessing mobile phone technology (Scott 2013).

Dandora, an Eastern suburb of Nairobi, Kenya, has an estimated population of 200,000 people. A large slum area, and Nairobi’s principal dumping site, Dandora is host to a multitude of health issues. The dumpsite deposits over 2,000 tons of waste daily, exposing nearby residents, criminals, and scavenging children to a myriad of health ailments. According to a report from the United Nations Environmental Program, 50% of children living in the areas surrounding the dumpsite have respiratory ailments and toxic blood lead levels. Additionally, reports from Community Health Workers (CHWs) include elevated cases of cancer, anemia, hypertension, frailty, kidney problems, nervous system disorders, and miscarriages (Africa Science News). It is within this context of structural issues that the Ford Program established the Brother Andre

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Medical Dispensary to provide medical treatment for the poor and most in need in Dandora.

The Ford Program believes that the community health issue of paramount concern, that must be addressed, is the issue of maternal and infant health. In response to the findings by the Dandora Law and Human Development Project, which used organizational mapping to conduct a baseline survey of social, economic, and political conditions in Dandora, the Ford Program is planning to soon erect a new maternity ward. The greatest contributing factor in the decision to build a new maternity ward is the lack of maternal health services at public hospitals in Dandora. This is further compounded with a lack of knowledge and accessibility to services that is rampant among the poor squatter community.

Assessment of maternal health services in Dandora revealed that the majority of women were unaware of the various outreach programs already available, elucidating the need for a salient campaign, and alluding to the potential aptness of a versatile mHealth platform. A needs assessment in the summer of 2013 found that many women believed there to be no options for maternal health services at the five hospitals in Dandora (Scott 2013). A lack of resources and CHWs contributes to women’s lack of awareness of the existence of maternal services. It is clear that, while some services for maternal and child health may exist, women within Dandora are generally either not aware of them, or not capable of accessing them (Scott 2013). Only a fraction of the community’s women attend even a single visit with a doctor or CHW before giving birth, and an even smaller fraction make it to a hospital for a safe delivery. Through the erection of a new maternity ward, the Ford Program hopes to bridge this gap by providing maternal and child health services that effectively reach the mothers. In response to the successful impact of recent mHealth initiatives worldwide, the Ford Program hopes that, by harnessing mobile technology for use by its new

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maternal health ward in Dandora, it can improve and better promulgate maternal health services at the community level.

Key ObjectivesThe Ford Family Program hopes to investigate several potential

models that use mobile technology, in a variety of ways, to improve maternal health outcomes. Ultimately, it hopes to implement similar strategies in Dandora, to support and improve the services available at the new maternity ward it is planning to construct. In order to address these fundamental goals, the Ford Program established the following objectives for our team:

1. Research models that use mobile technology to improve the provision of maternal healthcare to women in resource-poor settings in East Africa.

2. Evaluate 4-5 potential models on specific criteria, including cost effectiveness, ease of implementation, proven benefit/impact, ease of scalability, and relevance to local context.

3. Identify the strategy we most expected to succeed, and4. Develop a budget, work plan, and timeline to address the

resources involved in implementing a similar initiative in Dandora.

Project EvaluationsCollectively we evaluated a multitude of different mHealth projects

and platforms, and then narrowed our research down to five bright spots, or key successes. We found that mHealth could be segmented into two primary subgroups: (1) direct messaging platforms to mothers; and, (2) mobile tools for community health workers (CHWs). We compared and contrasted these two subgroups, evaluating individual examples of each, to

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determine which platform would be the most applicable, and likely to be successful, in the context of the Brother Andre Dispensary.

Though both direct messaging and mobile health tools are important, we found that at the outset it would be most advantageous for the Ford Program to adopt and implement a mobile tool that can be used by CHWs. This conclusion was based primarily on the findings highlighted in Ashley Scott’s Maternal Health Facility Assessment Report. The report found that the majority of women living in Dandora where ignorant or unaware of the various maternal health services that were available, and thus, often sought out the counsel and advice of local midwives, or traditional birth attendants (TBAs) as opposed to trained medical experts such as doctors and CHWs. In conjunction, the report found an overarching lack of outreach across all five of the evaluated medical centers. While hospitals and dispensaries offered brochures on limited topics, such as breastfeeding, these were generally the summation of maternal outreach by the health facilities (Scott 2013). Thus, based on the voids of maternal health services, highlighted by Scott, we came to the conclusion that as the Brother Andre Dispensary is first implementing mHealth, it would be the most worthwhile to implement an mHealth tool for CHWs, enabling them to develop a network among the local community. Such a platform would afford CHWs with the opportunity to conduct greater outreach, effectively raising awareness around the countless issues related to maternal health. In the more distant future, once a mobile tool for CHWs has been implemented, and a network of trust established with mothers and community members, it may be possible for the Ford Program to complement it by also phasing in a direct messaging campaign for mothers.

Cognizant of our team’s overarching conclusion that the Ford Program should initially pursue the implementation of a mobile health tool for CHWs, we researched and evaluated five bright spots, projects across both subgroups, that could be adapted to address the maternal health needs

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of the community in Dandora. The five key projects that we evaluated in depth are summarized below. Each of the five projects was considered in light of five key metrics, supplied by the Ford Program: (1) cost effectiveness; (2) ease of implementation; (3) proven impact or benefit; (4) ease of scalability; and, (5) relevance to local context. The projects were ultimately evaluated relative to each other on a scale of one to five, one referring to the organization that most effectively and successfully fulfilled each of the objectives or considerations (and five referring to the least successful). Our findings are summarized in TABLE 1, and discussed in further detail below.

TABLE 1: Evaluation of mHealth Projects

Direct SMS to Mothers Mobile Tools for CHWs

Considerations MAMA Wazazi Nipendeni

Frontline SMS

UHIN CommCare

Cost Effectiveness 2 5 3 4 1

Ease of Implementation 2 1 4 5 2

Proven Benefit/Impact 3 2 3 5 1

Ease of Scalability 4 2 5 3 1

Relevance to Local Context 1 4 1 5 1

Cumulative Grade 12 14 16 22 6

Mobile Alliance for Maternal Action (MAMA)

MAMA is a direct messaging program, which empowers mothers with the knowledge to combat high rates of infant and maternal mortality.

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MAMA’s culturally sensitive messages have gained positive recognition (Rao 2011, Labrique 2013), as the easily adaptable MAMA platform has been implemented across sixty-eight countries, and by over two hundred organizations. These evidence-based and personalized messages are sent twice a week to mothers, from their fifth week of pregnancy, through their child’s first year (“Who We Are.” MAMA). Since its launch in 2011, 377,971 mothers have used the MAMA SMS service. MAMA measures the success of their program by the number of women registered for SMS, and the subsequent attendance to recommended checkups. Underscoring MAMA’s focus on providing new and expectant mothers with culturally specific evidence-based messages.

MAMA’s SMS-based messaging platform, launched by Former Secretary of State Hillary Clinton, offers mothers personalized messages of encouragement, warning, and reminders (Appendix A). The messages are developed based on UNICEF and WHO guidelines, and vary based on the date of birth of the child (“FAQ.” MAMA). Sent in local languages, the SMS cover a myriad of topics, and can be broken down into core and topic based questions. Core messages cover weeks 5-42 of pregnancy and the first year of the baby’s life. These messages cover a myriad of topics including HIV testing, preparing for birth, breastfeeding, infant illness, postnatal care, and vaccinations. While topic based messages, address specific issues, such as the prevention of mother-to-child HIV transmission and post-partum family planning (“Mobile Messages.” MAMA). Thus, MAMA is well known for its comprehensive set of evidence based, and context specific messages.

MAMA requires only limited technology, underscoring the ease of implementation and minimal implementation costs associated with the program. The lack of new technology facilitates implementation; the Ford Program would only need to request the messages, then could download, adapt, and share. Additionally, as all phones are able to receive SMS, the end-user faces no costs, and the primary associated cost that the Ford

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Program would face would be SMS fees. Though costs for implementation are limited to SMS, these can be high as mothers receive two messages a week. Thus, the greatest threat to scalability of the MAMA program lies with high costs associated with SMS. This threat to scalability has been illustrated in South Africa, where due to high SMS costs, MAMA has only been implemented in Hillbrow and Johannesburg (“Learn More.” MAMA). Thus, we would recommend that the Ford Program pursue an implementation campaign, similar to Cell Life, which circumvented the associated costs by partnering with a local telephone provider (Cell Life’s, MAMA).

Overall, MAMA’s personalized and evidence based messaging campaign would provide the Ford Program with an easy to implement context-specific platform. In particular, MAMA’s culturally sensitive focus, and easy adaptability, would provide the Ford Program with the ability to address concerns specific to the community of Dandora, such as the dumpsite. Additionally, the low associated costs of the project, limited solely to a centralized computer and SMS costs, which could be negated through the forming of a partnership; make MAMA a cost effective and easy to implement platform for mHealth for the Ford Program.

Wazazi Nipendeni

This is a national, partner-driven multi-media ad campaign in Tanzania designed to empower women and members of the community by providing free healthcare information and access to support. The free SMS services integrate all stages of the maternal health continuum, including ANC, malaria prevention, HIV testing and PMTCT, danger signs, individual birth planning, safe delivery, nutrition, and postpartum care.

Wazazi Nipendeni’s SMS-technology, because supported through various key technological partners including Text to Change and the Tanzanian national government, has very few implementation fees and

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reaches an astounding number of pregnant women, mothers, and community members. However, an addition to the SMS-technology itself, a key aspect of the program is the multi-media national advertising campaign, which “has proven to be critical in building awareness of the messaging service, with registration rates reaching four times their average when there is a full media presence, versus without” (MAMA Spotlight 2013). This campaign, including radio jingles, television ads, billboards, and posters that publicize the short-code to enroll, represents costs and responsibilities outside the scope of the Ford Program’s current means, and therefore renders it the lowest achieving project in terms of cost of effectiveness.

Aside from the expensive advertising campaign, Wazazi Nipendeni utilizes some of the simplest technology on the market, especially for the end-user, making it one of the easiest projects to implement. Because end-users will be using their own phones, virtually no orientation or training is necessary. While Wazazi Nipendeni “found significant value in pre-testing the messages at different stages of the development process”, no major change in direction or content was required, indicating that there were no gaping service weaknesses or technological flaws. Furthermore, the project leveraged its partnerships in content design; significant content was adopted from MAMA and the WHO, minimizing the amount of original content that was generated. Taken as a whole, these lessons indicated that Wazazi Nipendeni excels in ease of implementation.

Though still in its infancy, Wazazi Nipendeni boasts overwhelming evidence of reach. Within eight months of its November 2012 launch, the project achieved national scale, confirmed by its subscriber base of over 180,000 Tanzanians (a number which is predicted to reach over 300,000 by the end of the year). With an average enrollment of 7,000 new registrants every week, it continues to expand with extraordinary momentum, indicating its enormous potential and ease in terms of scalability. While

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these numbers hint to impact, their overall effect on the end-user remains unclear; it is yet to be determined whether users are experiencing improved health outcomes as a result of the service. Despite this gap in statistical data, anecdotal data indicates strong improvements. One pregnant mother of three acknowledged that, before receiving tests explaining that breast milk is all the baby needs, she had been unaware of this information and had given her newborns water and porridge. Now, she exclusively breast-feeds her five-month infant. Eliza, a first-time mother, similarly praised, “I was happy to receive the Wazazi Nipendeni information. I found the text messages on my phone very useful during each period of my pregnancy. I liked the helpful tips, including the importance of attending clinics regularly. I learned about the need for testing and prevention. I feel that it benefited me to know these things. I was able to go and deliver my baby safely… this service also assisted my husband to better understand what I was going through during my pregnancy, so he could be of greater assistance to me” (mHealth 2013). Furthermore, health workers recognize an increase for knowledge and heavier demand for medicines and services by patients who are enrolled in the campaign. The overwhelming subscription data in addition to strong anecdotal data indicate that Wazazi Nipendeni has a relatively strong impact compared to other projects, however further data on user outcomes is necessary to strengthen its evidence.

Addressing potential problems in terms of gender gaps in literacy and phone use, cultural suitability, illiteracy, language barriers, and local practice, Wazazi Nipendeni places strong emphasis on ensuring relevance to local context. In particular, they create a free service and a simple registration system in which users can indicate their interest (pregnant woman, mother, supporter, or general interest) as well as their stage in the process (i.e. indicating the age of the fetus or baby) so the project can target them with the most pertinent information. Additionally, developers

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spent considerable time working with MAMA, the WHO, and local and medical experts to ensure their content is on par. With a commitment to “walking a mile in their shoes”, Wazazi Nipendeni excels in adapting its messages to local relevance. However, because the national ad campaign is such an integral part of the project, its relevance is somewhat undermined in a region such as Dandora, where the average person may not have access to a radio or television.

Overall, the model comprises a promising initiative with important strategies such as user-specific content, integrated partnerships, ongoing monitoring, and broad content. However, resources and costs associated with the project’s crucial national advertising campaign render it infeasible and overambitious for the Ford Program’s current goals in Dandora.

FrontlineSMS

This is an open SMS platform, with the flexibility to be adapted by the end-user, which can be used to track maternal and child health indicators. The Ford Family Program recently began implementing FrontlineSMS in Uganda, in conjunction with the Village Health Team. FrontlineSMS is exceedingly easy to implement, organizations need only to download, plug in, and use. Another benefit to implementation is the myriad of services that FrontlineSMS can provide, illustrated by the various organizations that currently utilize FrontlineSMS. For example, FrontlineSMS is being used to send market prices in El Salvador, security alerts in Afghanistan, and run a rural healthcare network for 250,000 people in Malawi (Banks 2009). However, messages are capped at 160 characters, limiting the scope and depth of the maternal health message.

FrontlineSMS is a particularly low cost option, as the software is free to download, and the software has the flexibility to be run on GSM modems (a USB modem that uses a SIM card), in addition to mobile phones. In general, there are more GSM options than smart phones, and GSM modems

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are much cheaper than comparative smart phones. The use of GSM networks, are not only cheaper and easier to use than mobile phones, but has the functionality to send messages offline, via GSM networks. However, this cost-saving feature requires organizations to partner with local wireless providers. In Kenya, this would likely entail a partnership with one of the three major providers - Safaricom, Airtel, and Orange.

Despite the low costs and ease of implementation associated with FrontlineSMS, the program is known to have received mixed accounts of impact and effectiveness. A pilot project in the Philippines used FrontlineSMS to inform customers of the cost of various medicines, affording customers with the information to easily compare prices, without extensive independent investigations. A survey of users found conflicting opinions as to the benefits of the platform. While some users felt the system improved the sharing of information, promoting long-term benefits to both consumers and patients. Others, particularly people in remote areas, found the information was difficult to understand. Additionally, the study highlighted a number of limitations to the FrontlineSMS system, including (1) difficulty navigating between languages, as one natural language query is not applicable to the other settings when location or language changed; (2) the character limitation for the message (messages are limited to 160 characters) forced the program's information to be shortened; and, (3) the system does not include a spell correcting service, and thus cannot help reduce the misspelling of complex drug names (Nisperos 2011).

A recent study that was conducted in Kenya, a pilot project using mobile technology in community based livestock disease surveillance, highlighted a number of the challenges and limitations to FrontlineSMS listed above. These include issues with the reliability of mobile phone networks, electricity, and mobile literacy, all of which would be issue that would also affect the end users of the Ford Program’s mobile platform, new and expectant mothers in Dandora. The study also revealed problems with

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underreporting, due to fear of implications and lack of understanding. Although this study did not concern mobile health, it provides a number of important takeaways for the Ford Program, particularly the lessons of reliability, coverage, and underreporting.

Uganda Health Information Network (UHIN)

The UHIN is a pilot project of AED-SATELLIFE’s Center for Health Information Technology, a U.S.-based nonprofit organization, which serves an estimated 130,000 health professionals globally. Launched in 2003, the UHIN aims to improve health outcomes by equipping CHWs with critical health information through the use of PDAs (“Connecting Health Clinics”). The UHIN uses PDAs to serve many functions, including equipping CHWs with up-to-date health information and national health guidelines. The UHIN believes that creating a network of PDAs, wireless access points (WAPs), and cellular telephony has the capacity to transform health services and create new forms of health information delivery. Since 2003, 175 remote health facilities, serving more than 1.5 million people, have sent and received health information using PDAs ("Health Management Information Systems"). Though limited research suggests proven benefits of the UHIN, the UHIN contains lessons important for maternal health care. Namely, that the use of PDAs has promising potential to transform health services through applications, communication of health records and patient information, and as an educational tool for CHWs to receive up to date health information. One of the greatest benefits of mobile health technology is its cost effectiveness. This has proven to be true in evaluative reports of the Uganda Health Information Network, which found a “24% savings per unit of spending over the traditional manual data collection and transmission approaches, a figure likely to increase as additional paper forms are converted” (AED-SATELLIFE). Though this is a positive finding, it is the

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only evidence of UHIN’s cost effectiveness, and it was reported by the organization itself. Though specific costs to get UHIN up and running are not listed, they are known to include establishing a network with a central server, wireless access points, and mobile phone provider, in addition to purchasing smart phones; all of which are costly. Thus, the cost effectiveness must be questioned due to lack of evidence and costs not mentioned. There is significant reason to believe that initial start up costs for the UHIN are quite high. For instance, Canada’s Fund for Africa contributed $761,000 Canadian dollars to the development of this information network (Kirunda, 39). One PDA costs about $150 US dollars and the wireless access point is estimated to be $600 US dollars (Kirunda, 39). When analyzed more broadly, the UHIN is burdened by start up costs, and once implemented has signs of cost effectiveness. Similarly, self provided reports show the implementation of the UHIN to be fairly easy. One article states “the project was able to evidence health workers comfort with the use of PDAs as a result of their demand for additional content and services” (Outcome Mapping). For this particular organization, SATELLIFE, what constitute “evidence” is merely self-reports, which for obvious reasons contain biases. Other signs of easy implementation include reports that CHWs easily adapted to using PDAs, and those that had difficulties received basic training, making the transition fairly easy. Nearly all of the reports around the implementation of the UHIN focus on the PDAs, which raises questions about the implementation of the information network (i.e. wireless access points, central server, etc.). Although it has been shown that the UHIN has provided health workers at remote sites with critical health information not previously available to them, hard evidence of UHIN’s success is limited. There is little to no evidence that health information accessed by CHWs through their PDAs improved health outcomes. The limited evidence about UHIN’s “success” includes self-reported feedback of using PDAs. For example, an

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impact assessment found that, “Over 50% of health workers surveyed rated handheld-accessed information useful at all stages of patient care” (AED-SATELLIFE).

Under the direction and leadership of the Ugandan government the UHIN has plans of going to scale, but resource and technological issues pose challenges for the national scale up. In 2010, seven years after the project began, the UHIN was handed over to the Uganda Ministry of Health to roll out onto a national scale. Since its inception in 2003, the UHIN project has trained over 700 health workers in five rural districts. However, the project has a long way to go before achieving national scale. Obstacles include funding and the organization of an information network with numerous wireless access points, central servers, etc.

With over 175 health facilities, the UHIN is a national project in conjunction with the Ministry of Health. Contrastingly, the Ford Program’s work in Dandora is small scale and context specific. Additionally, the UHIN project has operated in rural areas and thus would need to be reworked to operate in an urban setting like Dandora. The aims and scope of the UHIN project are towards a national health information network, which makes it a poor fit for Dandora.

CommCare

This is a cloud based mobile platform that aims at empowering mobile CHWs, through the provision of electronic job aid and data collection, with the ability to ultimately achieve better health outcomes in the community. CommCare is one produce of the for-profit company Dimagi, which creates other platforms that help organizations in different ways, such as CommConnect and CommTrack. CommCare, which is primarily used by CHWS, can be used in conjunction with CommConnect, which similar to FrontlineSMS helps organizations directly reach clients directly via SMS.

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CommCare offers a low cost option for the Ford Program, providing basic services for up to 50 mobile phone users, 50 CHWs, free of charge. These services include, but are not limited to - CommCare Exchange, data export, standard reports, outbound messaging, rules engine, data security and privacy, user groups, and community support. Dimagi's four end services and technologies - CommCare, CommConnect, CommTrack, and Implementation services - interact with each other, affording users an interactive and multifunctional service platform. However, while CommCare is free, the service of CommConnect comes at a cost. To help organizations estimate the cost of implementing CommConnect, CommCare has created an intuitive and easy to use Total Cost of Ownership Model. Through providing basic numbers, such as the number of CHWs, additional staff and office needs, benchmark for total cost per CHWs, and expected health benefits; organizations can receive an estimation of total costs, explore permutations, and plan budgets for the next 5 years.

As the Ford Program currently has fewer than 50 CHWs, CommCare is a cost effective option. Additionally, as needs may change in the future, CommCare can easily be scaled up at a reasonable low cost. In the future, as the requirements of the Ford Program would grow, CommCare has the option to scale up to 250, 500, 1000, and up to unlimited users (CommCare is in the process of changing the prices for the various options, so prices are currently unavailable). No matter the scale of CommCare, the program has the flexibility to be run on the Cloud, a virtual machine (e.g. Google Earth or Amazon), or on a private server, which are both associated with low costs.

In addition to being a cost effective option, CommCare is relatively easy to implement, as it is compatible with both smart and non-smart phones. Thus, the costs associated with the purchase of phones for CHWs are relatively low. Implementation is made easy through the provision of an online instruction guide, which covers all facets of implementation, from platform set up, to project planning, to project management; as well as a

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myriad of training materials, such as 20 Steps for Phone Preparation, Phone2Phone Installation Guide, which organizations can easily download and use to directly train CHWs. In addition, qualified organizations are eligible to receive CommCare's technology support and extensive implementation tools for the first year free of charge. However, while the technology itself is basic and should be relatively familiar to CHWs, it does require CHWs training to use new application. This is different from the other platforms we recommended. Furthermore, cloud-storage may be a barrier to implementing this new system as opposed to the old paper and pen system.

CommCare empowers CHWs with the resources and knowledge to inform mothers remotely, and more efficiently collect and analyze data. This is done through the supply of audio, image, video, GPS, and barcode information during CHWs visits, and can be collated on either your computer or on Google Earth. CommCare has been shown to improve accessibility to people, the quality of visits, and accuracy and efficiency of the collection of data through simple and easy to understand messages. Research has shown that CommCare increased the timeliness of visits by 85%, adherence to protocol by 20%, and the knowledge base of CHWs by 22%. Additionally, it has detected fake data with 80% sensitivity and 90% specificity (DeRenzi 2012).

For example, a researcher tested two projects that incorporate CommCare in ASHA, a program in India, which uses CHWs to educate and persuade pregnant women to adopt and use government's new health care practices and services. This qualitative study found that through utilization of CommCare’s media function ASHA was able to inform client-counseling sessions. CommCare enabled ASHA to track clients, reach clients quickly, and deliver personalized services based on clients’ status, while saving ASHA employees time. In the clients’ perspective it was found that the

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mobile devices were viewed with a sense of authority, consequently receiving more respect and attention (Schwartz 2013).

Of particular interest to the Ford Program is Pathfinder’s current project, mHMtaani, which is being implemented in Nairobi. mHMtaani distinguishes CommCare from similar health worker-centric applications, providing evidence of the successful implementation of CommCare in Kenya, with a similar local context to the Ford Family Program. Though mHMtaani is predominantly a HIV and AIDS prevention, treatment and care program, it also provides maternal and child health services. Pathfinder first implemented CommCare in December 2012 as a decision-making and counseling tool for women and children (Pathfinder 2013). Though mHMtaani offers evidence on the efficacy of CommCare for the community of Dandora, there has yet to be much research on the cost effectiveness of the project.

In summary, CommCare would offer the Brother Andre Dispensary and the Ford Family with a cost effective, easy to implement, and culturally sensitive tool for CHWs. CommCare would empower CHWs with the tools needed to promote quality and efficiency in the collection of data. Effectively providing imperative information to new and expectant mothers, while reducing the need for in person clinical visits, which can be costly and time consuming.

Our primary conclusions from this research are derived from the cumulative grades of each project, found at the bottom of Table 1. This is the summation of the scores received by a given project in each of the five metrics considered. It is our theory that the project with the lowest overall score is the most likely to succeed in the context of the Ford Program’s efforts in Dandora. Thus, our final recommendation for the Ford Program is CommCare, which received the lowest cumulative score. In fact, the only metric it did not receive the lowest score for, ease of implementation, was a

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consideration that we believed could be easily circumvented. (Explanations on how the individual scores were determined can be found in Appendices B, C, D, E, and F).

RecommendationThe first stage in the adoption of the CommCare model for use by the

Ford Family Program at its maternal health ward in Dandora is the acquiring of the Implementation Services (CommCare PLUS) Package, which includes not only the specified software package, but additionally, twelve months of direct, on-site support from Dimagi staff. Such support would include application creation, iteration, refinement, and support by Field Engineer, training, access to community support, and direct phone and email support from Dimagi.

The Ford Family Program would solely need to adapt the Community, or most basic level, software package, which accommodates up to 50 mobile users and includes all basic features of CommCare, including the application builder, CommCare exchange, data export, standard reports, management features such as user groups, data security and privacy, and community support. Furthermore, it can be expanded to include additional features, such as CommConnect, or to a larger size, such as the Standard software plan, at any point.

The Ford Program can benefit from numerous tools associated with these features. A few that our research suggests would be particularly beneficial to incorporate into the application developed for the maternal ward in Dandora include:● Specialized visit guides offer CHWs step-by-step support in their

interactions with mothers, whether it is in the context of an introductory visit, a routine follow-up, a specialized follow-up, or a post-delivery close appointment. A controlled trial in Tanzania in 2008 demonstrated that electronic guidance significantly increased adherence to clinical

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protocols; healthcare workers using the application completed 20 percent more of the required steps than those who those who used only flip charts, memory, or other non-electronic tools. Many studies have demonstrated that the use of CommCare applications prompts CHWs to conduct more thorough sessions (Svoronos 2010, Mitchel 2012, Mohamed 2013), including longer and more comprehensive household visits, more consistent follow up, and more active identification of clients. Such electronic decision support not only enables more standardized care and better adherence to protocol, but it effectively improves the knowledge base of CHWs. A 2012 study in India found that CHWs self-report better knowledge retention as a result of CommCare use (Chittamuru 2012), and another found that four months of CommCare use resulted in increased knowledge retention of at least 3-5 danger signs from 48 percent (at baseline) to 70 percent (IntraHealth 2012). Increased adherence to protocol and knowledge base, in addition to improved confidence and comfort in information delivery has resulted in the overall provision and perception of more quality services. Partners in Health-supported CHWs in Mexico and Guatemala demonstrated improved dosing accuracy when aided by a CommCare: for 6 of 7 test questions, respondents using the mHealth tool achieved mean scores significantly higher than those using only a paper-based tool (Palazuelos et al. 2013). A 2012 study in Mozambique demonstrated improved quality of services, as proven by higher danger sign identification and referral rates, by CHWs using CommCare pregnancy support modules (World Vision 2012). The same study also reported that among surveyed pregnant women and mothers, CommCare increased confidence in the services provided to them. Similar findings report that CHWs observe more attentive and trusting clients when a CommCare application is used (Bhavsar 2012).

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● Data collection enables more efficient and secure storage than traditional pen and paper methods. A randomized control trial in India found that the use of a CommCare application, in lieu of a notebook, improved data completeness from 67 to 84 percent, reducing the average amount of time it took for the data to reach the program coordinator from 45 days to 8 hours (Medhi 2012). A CHWs surveyed by Partners in Health said of the CommCare data collection tools, “it is more practical, easier to use, and saves time” when compared to traditional paper collection (Palazuelos et al. 2013).

● Appointment reminders and alerts help ensure that CHWs will don miss or be late for scheduled appointments. A randomized control trial in 2012 found that, among 100 CommCare-using CHWs in Tanzania, the use of SMS reminders improved their timeliness to visits by 86 percent (DeRenzi 2012).

● Case monitoring provides a sense of accountability, and enables better supervision of CHW work. While there have been many accounts of CHWs filling out data merely for reporting purposes, delaying the compilation of data, or skipping scheduled visits, the CommCare application has a number of checks that improve CHW transparency and prevent such behavior. A quality control study in 2012 found that false (yet realistic) data that CHWs submitted via CommCare was identified with 90 percent specificity and 80 percent sensitivity (Birnabaum 2012). Furthermore, worker activity reports can help managers track the case accomplishments of individual CHWs.

BudgetWhile no specific budget was provided for the project, we have

identified the following as key costs associated with implementing the recommended CommCare mHealth tool for CHWs in Dandora:● Software package: Free*

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The Community Software Package offered by CommCare is available free of cost. This package serves up to 50 mobile users, and should therefore be sufficient for the Ford Family Program’s purposes for the foreseeable future, as this is 2500 percent of their current CHW staff. If, in the future, the Ford Program undergoes significant expansion and needs to upgrade to a larger software package, the next available option is the Standard Software Package, which is currently available for $100/month and services up to 250 mobile users. This package also includes a few advanced features.

● Technical/Developmental Staff Support: Free*The Implementation Services Package recommended, CommCare

Plus, is free for the first 12 months of services. After that, the Ford Family program has options of whether to continue using the same package at a fee of $25,000 per year, or to downgrade to the CommCare Basic Services package, which is free but includes only minimal assistance (community support, without direct email/phone support or the support of a field engineer) and perhaps hire local, outside technical support, which will certainly be cheaper and has the possibility of being sufficient, although would lack the rich resource network provided by Dimagi staff. It is also of note that CommCare has a strong commitment to need-based pro-bono plans (both for software and service packages). For example, just last month Dimagi announced that it would support five local organizations to explore the use of mobile technology in India. Need-based requests can be made by emailing [email protected], and could comprise a viable option if the Ford Family Program finds itself in the position of needing services it cannot afford after the first year.

● Centralized laptop: estimate $700● Java-enabled mobile phones for CHWs: estimate $40-120/phone

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CommCare does not require a smart phone, merely a JAVA system with the following basic features: 1. J2ME Connected Limited Device Configuration (CLDC) 1.1 system;

2. at least 2MB Java heap;

3. at least 1MB max jar size;

The recommended screen size is 240x320. The following phone models have been successfully tested in the field: Nokia C2-01, Nokia C2-02, Nokia ASHA 206, Nokia 109, Nokia ASHA 201.

● Additional CHWs: Going local salary, adapted to performance-based financing (PBF) model

As of a Maternal Health Facility Assessment report in June 2013, the Brother Andre Dispensary currently employs only two CHWs (Scott 2013). While this number does help the dispensary expand the scope of its services, we think that it is insufficient to successfully support the planned service expansions in regards to the maternal health ward and increased community engagement. If our recommendation is adapted, CHWs will be better equipped to deliver more efficient and better quality services. Additionally, clinic management will be able to track the work of each CHW. For these reasons, we propose that the Ford Family Program hire at least four to five CHWs committed specifically to the maternal health ward, all of who should be trained in the new CommCare application when it is developed. Because there are significant time commitments involved with learning the new technology and developing an appropriate level of comfort with it, these CHWs should be focused specifically to this project, and should be hired before it is implemented. We recommend that they should also be hired with incentivized pay, to encourage more efficient and quality-drive services. Pilot-phase evidence from a World Health Organization study in Rwanda, as well as many others, suggests that incentivizing CHWs through quantity and quality of service provided improves maternal health outcomes as reported by a

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wide variety of indicators (Mugeni 2011). Keeping track of such is possible through the recommended software.

TimelineA sample timeline, adapted from CommCare, can be found in the

appendices (Appendix G). The timeline can be adapted to a range of windows (i.e. 4 month, 6 month, 12 month) depending on the program’s operational status and goals at the time of implementation. The bulk of the timeline focuses on the importance of recognizing three distinct phases of implementation:● Design and Preparation: This phase is pivotal for the project’s success,

as it sets the tone for the remainder of the process. It should therefore be given the utmost attention. Critical components include the identification of key team members (within the Ford Program, within the Broth Andre Dispensary, and within CommCare), the specification of requirements and features, the building of application prototypes, and the procurement of equipment and a logistical design plan. The Millenium Villages Team executed this phase well in its efforts in Tanzania, where it spent a four month period developing the module, meeting weekly with CHWs, and holding focus groups to explore safe pregnancy management in the community and potential design and interface challenges for the community. Community participation and on-site planning were emphasized, which “was an important component in generating ownership of the module, as well as to ensure that CommCare was suited for the CHW’s working conditions” (Svoronos 2012). D-Tree also presents successful strategies in inclusive and participatory application development. For example, they storyboarded potential features using paper drawings of phone screen before adding them into the program, allowing CHWs to provide valuable feedback about workflow, aesthetic layout, and more. Simple changes were often

28

suggested, such as using a list format rather than a grid format, and omitting client names on case lists to preserve privacy (Bogon 2009). These practices ensured community support for and comfort with the application; we recommend the Ford Program ensure similar conditions in executing this phase.

● Refinement and Iteration: This phase is where the bulk of feedback is gathered, summarized, and iterated, as pilot programs are introduced. Pilot programs should include use by a small subset of CHWs, and then use feedback to review and modify the application software, training materials, and other specific strategies. The majority of programs piloting similar CommCare applications of this type seek to train 2-8 CHWs in the application, and allow each of them the ability to use it for somewhere between two weeks and seven months. Because the Ford Program and the Brother Andre Dispensary are on the smaller side relative to other organizations unfolding similar initiatives, they would probably generate sufficient evidence by focusing on pilot programs on the lower ends of these recommendations. Specific attention should be given throughout the piloting phase to responding to feedback from the end-user. This entails focusing on CHW difficulties as the end-users of the application, as well as client difficulties, as the end-users of the maternal healthcare services provided. Technical difficulties historically observed for CHWs revolve largely around resubmitting forms that did not originally send due to network problems, and achieving a level of comfort with the application such that it becomes instinctual. While predictions and anecdotal observations indicate that clients may feel uncomfortable with questions of privacy in light of CommCare’s cloud-based data, evidence from many pilot programs reveals that this is not generally the case. In fact, many clients see the phones as better for privacy than paper records (Bogon 2009).

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● Training and Deployment: Once the pilot phase indicates that an appropriate and effective application has been developed; the Ford Program can begin implementing it on a larger scale. Important aspects of the deployment phase, are ongoing CHW training and rigorous monitoring, data collection, and analysis. Training sessions should involve both educational orientation sessions and practical use observations in the field. Preliminary orientation with the technology, assuming ample effort has been put into designing a user-friendly application, should be minimal. Similar implementation indicates that even on phones using the highest level of technology, which CHWs were not even familiar with how to turn on and off, preliminary classroom instruction on phone and application use lasted less than 2.5 hours until CHWs were proficient enough for field practice (Bogon 2009). While CHWs are reportedly comfortable with proper application use after just a couple of field trainings (Svoronos 2009), we recommend such training be conducted on an indefinite basis, until CHWs can prove successful mastery of the program on a consistent basis. Ongoing data collection should then monitor data submitted for anomalies or potential problems. Additionally, exit surveys and randomized trials should be used to determine ongoing user satisfaction and, as is the ultimate goal, ultimate improvements in maternal health outcomes. Research suggests that there is a current lack of evidence throughout mHealth initiatives of all types indicating a direct, causal relationship with improved maternal health outcomes. We recommend that the Ford Program continue its dedication to effective solutions by implementing a program that is both transparent and sufficiently well supported by empirical evidence.

Future DirectionsAs previously mentioned, our team came to the conclusion that the

Ford Program should initially pursue a mHealth platform that utilizes 30

CHWs; but, following successful implementation and expansion, we recognized the importance and value of adopting a direct messaging platform for mothers. Thus, looking to the future, after having successfully built out CommCare we would recommend that the Ford Program adopt the Mobile Alliance for Maternal Action’s SMS messaging platform. While we considered a number of different mobile messaging platforms, including Frontline SMS and Wazazi Nipendeni, we came to the consensus that MAMA would be the most practical, easiest to adapt, and effective project in Dandora.

MAMA would build upon the network of mothers, created by the CHWs, offering direct messages approved by UNICEF and the World Health Organization. MAMA entails biweekly messaging to new and expectant mothers. Mothers receive two messages per a week from their fifth week of pregnancy through their child’s first year (“Mobile Messages” MAMA). MAMA’s messages cover a variety of topics and issues, and can be segmented into core and topic based messages. Core messages cover weeks 5-42 of pregnancy and the first year of the baby’s life. These messages cover a myriad of topics including HIV testing, preparing for birth, breastfeeding, infant illness, post-natal care, and vaccinations. While topic based messages, which were developed in response to the request of mother’s, address specific issues, such as the prevention of mother-to-child HIV transmission and postpartum family planning (Cell Life’s MAMA 2013).

An additional benefit to the MAMA direct messaging campaign is the ease of implementation. The Ford Program solely needs to request messages, and is then able to download, adapt, and share the innovative messages. Thus, the second step in the Ford Program’s mHealth plan is both easy to implement and scale.

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ConclusionOverall, our recommendation to the Ford Program moving forward is

two fold. First, due to the lack of community outreach and the corresponding needs of pregnant women and mothers for awareness of and access to services (Scott 2013), we recommend the implementation of a CHW mHealth tool, with CommCare being our specific recommendation for the model most likely to succeed. At a relatively low cost, CommCare will provide the Ford Program and community health workers with the ability to better collect data, provide services, and improve overall interactions with new and expectant mothers. Following successful implementation and expansion of CommCare, we recommend the Ford Program also consider the potential implementation of MAMA in the more distant future. Building on the existing network of mothers, and affording the opportunity of direct contact with mothers, MAMA may further improve maternal health outcomes by empowering mothers themselves with the knowledge and skills to make evidence-based decisions throughout pregnancy and birth. Research suggests and we firmly support that mHealth tools such as CommCare and ultimately, perhaps MAMA as well, will make equip the Ford Program to make even greater strides in combating issues around maternal health in Dandora.

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AppendicesAppendix A: How MAMA Messages Work

Appendix B: Comparison of the Five Projects on Cost Effectiveness

Project Considerations GradeMAMA Minimal implementation costs and equipment, largest

associated costs will be SMS fees and technological support. 2

Wazazi Nipendeni

Large costs associated with the multi-media ad campaign that is beyond the scope of the Ford Program’s resources. 5

CommCare Minimal implementation costs and effectiveness, especially considering their pro-bono services, which the Ford Program would be eligible for.

1

UHIN Requires expensive phones/PDAs, and other state of the art technology, in addition to technological support. 4

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Frontline Minimal implementation costs and equipment, largest associated costs will be SMS fees and technological support. 3

Appendix C: Comparison of the Five Projects on Ease of Implementation

Project Considerations GradeMAMA Very little new technology introduced to general user,

although technological support will certainly be required for server. MAMA already has developed many tools to aid implementation. The Ford Program would only need to request the messages, download, adapt if needed, and share.

2

Wazazi Nipendeni

Very little new technology introduced to the general user, although technological support will certainly be required for the server.

1

CommCare Requires CHW training for use of new application, however the technology itself is basic and should be relatively familiar. Furthermore, technology support and extensive other implementation tools are provided for the first year at no charge. Cloud-storage may be a barrier to implementing this new system as opposed to the old paper and pen system.

2

UHIN Requires extensive CHW training in not only a new application, but also an entirely new technology. 5

Frontline Very little new technology introduced to general user, although technological support will certainly be required for server, especially to maintain cloud-services. Implementation will require large-scale user recruitment.

4

Appendix D: Comparison of the Five Projects on Proven Benefit and Impact

Project Considerations Grade

MAMA Extensive evidence of reach, impact, uptake, and generally positive feedback in many different settings, however much of this is self-reporting. Has been endorsed and implemented by over a hundred organizations.

3

Wazazi Nipendeni

Overwhelming evidence of reach. Evidence of impact exists, but is limited as this project is relatively recent. However, third party organizations are in the process of greatly expanding the scope of evidence.

2

CommCare Extensive evidence of reach, impact, uptake, and generally positive feedback in dozens of different settings, in both 1

34

pilot phases and full scale. Has been endorsed and implemented by a number of internationally renowned organizations. Benefits from extensive self-reporting, but also from robust analysis by many independent evaluation parties.

UHIN Very little evidence of impact. While theory is sound, little monitoring has been done to date. Evidence is lacking by both the organization itself, and third parties. However, as the project is still in early phases, this may improve in the future.

5

Frontline Extensive evidence of reach, impact, uptake, and generally positive feedback in dozens of different settings, in both pilot and full scale. Has been endorsed and implemented by a number of internationally renowned organizations. Benefits from extensive self-reporting, but also from robust analysis by many independent evaluation parties. Somewhat discredited by frequent technical issues, and the fact that the scope must remain limited.

3

Appendix E: Comparison of the Five Projects on Ease of Scalability


MAMA Scalability is very costs, due to the high costs associated with sending SMS (in South Africa, MAMA has only been implemented in Hillbrow and Johannesburg).

4

Wazazi Nipendeni

This project is made to be implemented on a large scale. However, this requires a supplemental media campaign, which is beyond the scope and purpose of the Ford Program.

2

CommCare Has a sliding scale that makes it easy to adapt to any size. It is equally easy to shift between scales, or to add a la carte additions at a certain scale.

1

UHIN Once this program has been implemented, there are relatively few barriers to scaling it up. However, dong so may not be especially beneficial, as it is intended to promote provision of healthcare in a region serviced by a specific facility.

3

Frontline Scaling this program seems to have posed a wide range of problems, as specificity of messages make them not easily adapted to a wider audience, and technological issues seem to become increasingly frequent and debilitating as scale expands.

5

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Appendix F: Comparison of the Five Projects on Relevance to Local Context


MAMA Messages are specialized to the local community, and vary based on the stage of pregnancy. SMS are sent from the 5th week of pregnancy through the child’s first year.

1

Wazazi Nipendeni

SMS content, objectives, and impact are extremely relevant to local needs. However, the multi-media ad campaign is unrealistic for the Ford Program in Dandora, and resources where people may not have access to a TV, etc.

4

CommCare mHMtaani: US-Supported Program Empowers Community Health Workers Through Mobile Technology in Nairobi, Kenya. This is a model for Ford Family Program reference.

1

UHIN With over 175 health facilities, the UHIN is a national project in conjunction with the Ministry of Health. Contrastingly, the Ford Program’s work in Dandora is small scale and context specific.

5

Frontline Messages are specialized to the local community and context, and can be easily adapted if needed. 1

Appendix G: Sample Timeline for the Implementation of CommCare

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Development Advisory Team

My name is Dougie Barnard and I am a junior majoring in Theology and Peace Studies while minoring in International Development Studies. I am a member of the International Scholars Program and my areas of research include Christianity in East Africa and social and community development. I have spent time in Uganda the past two summers volunteering for Fields of Growth International and carrying out independent research, under the advisement of Fr. Bob Dowd, for my senior thesis. I am a two-year member of the men’s varsity tennis team and a resident of St. Edward's Hall, where I live a few doors down from Fr. Bob. In 2004 my mother lived in Kenya for 7 months while adopting a baby girl whom we named Eva. I have traveled to Kenya three times, staying in Nairobi, Nakuru and Eldoret. My name is Ali Searle. I am a senior Honors student majoring in Biology

and French. I am writing a thesis, which I conducted research for at an environmental field station in Northern Wisconsin this past summer, on the effects of increased terrestrial carbon loading on zooplankton migration strategies. Using this research, I hope to gain a better understanding of zooplankton-dependent diseases, such as Guinea Worm, in impoverished nations. In 2011, I traveled to Hoehoe, Ghana where I worked on hospital development and conducted patient interviews. In 2012, I interned with Global Health Ministries, serving as a liaison for their Haiti projects, and developing maternal health education literature to be used in clinics in various countries, including Haiti and Peru. I volunteer regularly at AIDS Ministries and St. Joseph hospital. Through GlobeMed, I have also aided in the funding and development of a grassroots AIDS/Malaria prevention

Xie. I’m a first year graduate student in Global Health program. I studied Nutrition Science with a minor in Biology at Purdue University. My undergraduate study focuses on malnutrition and food insecurity. In 2010, I conducted research and studied interaction between genotype and diet calcium intake on bone health using mice. During the summer of 2011, I volunteered in Teteh Quarshie Memorial Hospital in Ghana and worked in Pediatric and Maternal Departments. My duty includes assisting doctors and nurses on caring for malaria kids, assisting delivery and abortion operations. In this past summer, I worked as an intern of Management of Non-communicable Disease Department, WHO under Dr. Ruitai Shao. My research focuses on the screening program of cardiovascular diseases in different countries.

My name is Katie Suarez and I am a senior Economics and Political Science double major, with a minor in Catholic Social Teaching. I am currently working on a thesis on the effectiveness of International Aid in South Africa, primarily USAID with a case study on the non-profit Grassroot Soccer, an HIV prevention program. I have spent the past two summers interning/volunteering with Grassroot Soccer in Cape Town and Johannesburg, South Africa. My duties have consisted in proposal writing, program development, and establishing referral networks and partnerships across the six sites. Through my summer experiences I have become really interested in health programs, sport for development, and mobilizing an AIDS free generation.

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