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Mobile telemedicine for Community Health Worker HIV Care: A pilot study in Nairobi, Kenya. Jennifer Cohn, MD MPH University of Pennsylvania School of Medicine. Background. Scale up vs HCW shortage Use of CHW for HIV care WHO Task Shifting Report (2007) Evidence of health systems benefit
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Mobile telemedicine for Community Health Worker HIV Care: A pilot study in Nairobi, Kenya Jennifer Cohn, MD MPH University of Pennsylvania School of Medicine
Background • Scale up vs HCW shortage • Use of CHW for HIV care • WHO Task Shifting Report (2007) • Evidence of health systems benefit • Evidence of clinical benefit • Country guidelines • Challenges • Poor clinical support of CHWs in field • Poor linkage of CHIS to formal HIS WHO. Task shifting, 2007 Celletti et al., AIDS 2010 Decroo et al, JAIDS 2010 MSF Khayelitsha programme report, 2011
Background: Kenya • HIV • 1.6 million HIV • 540,000 on ART • Changing guidelines • Health workforce shortage • Nurses 1.18 per 1000 • Doctors 0.14 per 1000 • Kenya Community Health Strategy • Developed 2006, roll-out 2009 • Level 1 of the health system • Aid in delivery of Kenya EHP • Supports CHWs in a variety of tasks, links to an RN supervisor • Link CHIS to HIS • Interim reviews
The Pilot Study • Goals • Support CHW clinical-decision making • Link CHIS to HIS • Innovation • Branched logic surveys • Easy-to-use interface • Real-time upload to server • Aims • Assess ability of CHWs to learn and use mHealth application • Assess function and connectivity of server • Assess patient outcomes (earlier return to clinic, clinician action). • Setting • Nairobi, Kenya • Mbagathi District Hospital • Subjects • 17 CHWs • Convenience sampling
The Pilot Study: Methods • CHW activities • 1st line ART initiation • 2nd line ART initiation • Defaulters • Post-hospitalization • Clinician request • Training • Standard 4 hour, didactic and role play • 2 Facilitators • Use for 6 weeks
The Pilot Study: Methods • CHW activities • 1st line ART initiation • 2nd line ART initiation • Defaulters • Post-hospitalization • Clinician request • Training • Standard 4 hour, didactic and role play • 2 Facilitators • Use for 6 weeks
Evaluation Tools • Ability to learn and use technology • Role play • Time 0, 3 and 6 weeks • Satisfaction • Survey (Likert scale) • Time 0 and 6 weeks • Server function • Server downtimes • Failed uploads • Patient outcomes • Red flags • Chart review
Results: CHW Demographics and Server Function • Server Functioning • Downtime: 1 episode lasting 33 hours • Survey transmission • 78 total • 16 (20.5%) uploaded >24 hours • 6 (7.7%) uploaded greater than 48 hours
Results: Chart Review • Charts reviewed • 28 reviewed • 34 not found • 28 mismatched name/chart number • Results • 20 (71%) red flags (earlier visits) • 6 (20%) CHW-instructed earlier visits • Key indicators: • Cough >2 weeks • Adherence
Discussion • Technology • Minimal training requirements • Quickly attained and maintained • Good connection and server functionality • Acceptance and satisfaction • Clinical significance • High numbers of red flags • CHWs identify critical issues clinicians may not • Limitations and next steps • Small sample size, short follow-up period • Inability to locate many charts • Next steps: Push technology to link to clinicians
Thank You • University of Pennsylvania • Penn CFAR • Greg Bisson, MD MSCE • Nairobi, Kenya • KhouShong MPH • DonataMuthoni • Josephine Mwagiru • IT team • Debbie Theobald • Adam Kundishora