South Sudan: Health eVillages Technology in Healthcare Program

Project Goal:
 
The intention of this program is threefold: 1) To familiarize staff at the only national referral and teaching hospital in South Sudan with digital reference, data collection, and decision support tools 2) To get an accurate estimate of the scope and cost for building a Center of Excellence in Juba, and 3) To get an accurate estimate of maternal morbidity and mortality in Juba Teaching Hospital, which presumably represents the most high risk obstetric cases in Central Equatoria.

Project Objectives during this reporting period:

1. Ongoing support of all health workers in Respectful Health Care
2. Ongoing support of all target health workers in use of mobile tablets with Health eVillages suite
3. Improved Data Tracking in Maternal Mortality
4. Improved service delivery
5. Improved Patient Satisfaction

Summary of RMF/WCF-sponsored activities carried out during the reporting period under each project objective:

1. Observed health workers in the context of Respectful Health Care
2. Remained available for troubleshooting and advanced tips/tools for target health workers in use of mobile tablets with Health eVillages suite
3. Ongoing Data Tracking in Maternal Mortality
4. Qualitative interviews with health workers completed for month #2
5. Patient Satisfaction survey administered to month #2 sample

Results and/or accomplishments achieved during this reporting period:
 
Observe health workers in the context of Respectful Health Care
Remain available for troubleshooting and advanced tips/tools for target health workers to use mobile tablets with Health eVillages suite
 
Improved Data Tracking in Maternal Mortality
After earning approval from the Ministry of Health Ethics Committee, RMF completed designing the instruments to accurately record maternal morbidity and mortality at Juba Teaching Hospital in an unprecedented study with both a quantitative and qualitative research design. The data collection tool has been refined and data collectors and interviewers have been identified. Under the supervision of the department chair for the OB/Gyn Unit, Dr. Kuma, a thorough review of all existing documents was done to attempt an estimate of baseline mortality over the past year to serve as a comparison.
 
Improved Service Delivery and Improved Patient Satisfaction
 
Patient Satisfaction (PSAT)
Samplings of 20 patients with different admissions diagnoses and from different wards were surveyed by the Master Trainers before discharge during month 2. Included in the sample were women in labor, repeat elective cesareans, hyperemesis gravidarum, fibroids, preterm labor, gastroenteritis, umbilical hernia, and septic infection patients. There were several consistent themes across all wards:
 

1. No access to free or subsidized medications and lab tests
2. Lack of cleanliness in units
3. Not enough staff for the volume of patients
4. Disrespect from health workers
5. Long wait times
6. Language barriers/communication issues

Of the 20 patients surveyed, only 4 of them said a health worker used a tablet for patient education or medical reference while they were being cared for, 2 of them said they did not recall, and 17 said a tablet was not used directly as part of their care, and 1 did not answer.
 
This leaves a definite gap showing we need to focus the next month on encouraging health workers to use the tablets not only for their own reference, but interactively with patients for education purposes.
 
15 said they would recommend Juba Teaching Hospital to friends and family. However, some of this may be due to lack of alternative medical services or cultural norms that would prevent them from admitting otherwise to the interviewer.
 
11 patients said their medical diagnosis and plan of care was explained ot them well, 5 said it was somewhat explained and 4 said it was not explained at all.
 
Health Worker Survey (HWS)
 
74% of health workers report using the tablet to aid their work at least 3-5 times days per week with 37% of them saying they use it every day. The remaining 26% report using it at least once or twice a week.
 
This leaves a gap for us to encourage increased use among participants. One reason that contributed to the slight decrease from the prior month is that one participant was admitted to the hospital (not JTH) for health issues and her device was not deployed to  another user since she has since returned to work.
 
The most popular features used:

Omnio —  Disease/diagnostic tools: 100% of health workers have used this
                Drug reference tools: 100% of health workers report having used this
                Calculators: 26% of health workers report using this
                Textbook reference: 26% health workers used this feature
 
Videos — 100% of health workers used videos on the tablets in the past month

Impact this project has on the community (who is benefiting and how):
 
The primary beneficiaries of this program are the health workers at Juba Teaching Hospital and their patients. The direct impact has been that hundreds of patients have received better and more timely care as information needed to triage, diagnose, and properly treat them is more readily available. This is especially true for the nurses who often serve as the frontline for patient care as doctors are spread very thin. An indirect benefit is that the health workers have expressed and increase in self-efficacy, which significantly adds to the morale and job satisfaction necessary for worker retention. This is in direct alignment with RMF’s value proposition of Respectful Health Care.
 
One new development we saw over the course of month 2 is that observations were made that the objective and evidence-based material available have actually served to improve staff relationships. An example of this was highlighted by one of the participants who described that when a doctor and a nurse have differing opinions regarding patient diagnosis or management, the nurse used to always have to concede to the doctor. This left her 1) feeling bad 2) reinforcing the hierarchy 3) discouraging her form taking a stand or voicing her opinion in the future 4) sometimes led to worse patient outcomes. This was true even when the doctor was a new graduate intern and the nurse was experienced. With the tablets, the information used for decision-making is presenting in a way that does not force cultural gender, or hierarchical norms to be included in the decision-making thereby ensuring it is non-threatening and the proper choice is made.

Some suggestions and feedback from health workers:
 
What is the best thing about having the eLibrary device available to you?
 
“For difficult cases when the doctor is not available, it helps in directing you what to do”
“We are empowered with more information…and now we can discuss evidence with doctors.”
“The diseases, drug reference and videos are available all the time for patient care.”
“It is a refresher of things we may have forgotten and is available instantly so it is good for use with and without the patient.”
“I can access information very fast so it saves time and lives.”
“It is so much easier to find out information about diseases and drug dosages compared to before.”
“It is helpful when a mother is admitted and a doctor is not around so we can look things up for reference.”
“It helps me so much with patient education because it gives ideas how to explain things.”
 
Do you have any suggestions or observations to improve the program?
 
“Sometimes it seems that using the devices worries the patients.”
“This should be translated into Arabic.”
“We need to add more videos on complicated labor (breech, shoulder dystocia, etc…), these videos are all normal, so we need more training on abnormal labor.”
“The period of 3 months is not enough. We need these devices at least for 6 months to really see how much to use them.”
“We need more videos.”
“We need this in Arabic.”
“Sometimes we show it to other staff and they are interested. We need enough devices for all the staff.”
“Please add some more months other than just 3.”
“Medical and surgical videos should be added.”
“Please add cancer drugs.”
“Training should be longer so for those who are not used to the device we can learn more.”
“Sometimes it is hard to charge the device. I am getting used to it.”
 
Real use success examples:

1. Two eclamptic patients survived because the midwife was able to access information on prevention of seizures and management of the cases. One was discharged while the other survived but remains on the ward as she is now blind due to the hypertension. The health worker has been able to use the eLibrary to assist with decision-making when the doctor is not available.
2. A patient was admitted with tuberculosis and HIV; the nurse was able to use the drug reference to find the correct drugs, and the dosage tool to calculate the correct dose of medications for the patient.
3. A mother was admitted with malaria. The midwife was unsure how much quinine to give the patient but with the tablet, was able to figure out the IV drip rate and the medication dosage.
4. A woman came in for HIV testing and was found to be HIV+. The midwife used the disease reference in order to appropriately council her not only on HIV transmission and treatment, but also on family planning methods.
5. On the gynecology ward, a nurse used the tablet to assist with the diagnosis and management of sepsis, then use the drug reference and calculator to confirm that she remembered the right drug required and the right dosage.