~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

If you missed our last three blog posts in this series on human centered design, you can learn about what human centered design is here, read a case example of how we build empathy with health works in Nepal, and see how we’ve used prototyping to test a new monitoring and evaluation dashboard in Benin.

Our final post is going to explore the concept that your project is never complete; even after you launch, it’s important to continue to get feedback. In this post we’ll share an example of how we’ve iterated on our software based on feedback from health workers and ministry officials in Benin.

*A health worker sorts through paper records. Source: VaxTrac.com*

The Problem
The World Health Organization (WHO) and the Benin Ministry of Health issue a country-wide immunization schedule that recommends when children should receive their immunizations, beginning from the moment they are born and lasting through the first year of life. Health workers in urban clinics manage hundreds of children’s schedules using paper records. Keeping track of which children are due for which vaccine during any given vaccination session is a time-consuming task.

Parents of these children lead busy lives and often live far from the clinic. It takes hours out of their day to bring their child to vaccination sessions. While parents value vaccines, health workers don’t always communicate clearly to parents about when to come back to the clinic for the child’s next vaccination. A direct consequence of this is that children often miss their appointments.

Our Solution: Callback List 1.0
Clinics that use VaxTrac to record childhood immunization data have an advantage: as long as children are registered in the VaxTrac system, the system can automatically generate a list of children that are due for upcoming appointments. This can save health workers from several hours of paperwork each week.

Our team of software engineers saw this as an opportunity and developed a basic callback list. The first version of the callback list pulled a list of children that were due for an upcoming appointment along with basic information, such as date of birth, village and contact information. But health workers weren’t using it. We wanted to know why.

Back to the Drawing Board: Stay Responsive to User Needs through Iteration
Technology is meant to change over time. VaxTrac’s software engineers like to remind our team that the software is never finished; it’s constantly evolving and adapting to user needs.

When we began developing our mobile (Android)-based system, we brought health workers together to get their feedback on what they wanted from a callback list feature. We used a number of human centered design methods to elicit feedback, such as prototyping [link to prototype blog], brainstorming lists of what they do during vaccination sessions, and breaking into groups to sketch out what they wanted the callback list to look like.

*Meredith leads a focus group with health workers. Source: VaxTrac*

We asked them to create the callback list over again from scratch. We asked guided questions: Is any of the information available on the callback list useful? If so, what is it used for? What other information should it include? How would they like to see the callback list organized? What rules should the callback list follow? How long should a child stay on the list?

Having health workers sketch their answers to these questions helped all of us think through these abstract questions together.

We found key insights:

Health workers were using the callback list, but not in the way that we had originally intended. Instead of using it to contact the parents of children who were due for upcoming vaccinations, they used it to track down children who had missed an appointment.
Phone numbers change often so we needed to make it easier for them to update parents’ contact information.
In order to be more useful, the callback list would need to be interactive, allowing health workers to sort the information in a variety of ways.

Hearing the health workers’ perspectives helped us rethink the purpose of the callback list and how to redesign it.

Build, Do, Learn, Repeat: VaxTrac’s Philosophy on Iteration
Build: Our software engineers took our learnings from the user feedback session and went to work on building a new and improved callback list. In addition to the callback list, we created a defaulter list, providing health workers with a list of patients that have missed their appointment. We also made both lists sortable by any category (village, date of birth, sex, date of appointment, etc.) And lastly, we made it easier to update contact information.

Do: After our software engineers updated the callback and defaulter lists, we made sure health workers received adequate training on how to use it. Our Benin-based team visited clinics for additional training.

*VaxTrac staff training health workers. Source: VaxTrac*

Learn: After a few months of using the new callback list, we held a focus group with health workers to learn more about what they thought of the different VaxTrac features, including the callback list. We learned that health workers would like to be able to sort by the mother’s name in addition to sorting by the other categories. We also learned that health workers would like a way for the callback list to help them contact parents of children who are due for upcoming vaccination sessions.

Repeat: Each time we add new features and users, we get new perspectives. All of the feedback that we’ve gotten from health workers have helped us make our callback list and defaulter list more user-friendly. But we’re not done yet! We are currently conducting a study to assess the possibility of incorporating an appointment reminder feature to the callback and defaults lists, so health workers can use the system to contact parents directly, possibly through SMS or Interactive Voice Response (IVR).

Once we learn everything we can, our cycle will repeat again.

The more we iterate, the stronger our product becomes because it’s based on feedback from the people who use our system. While it can be daunting to go back to the drawing board, adding iteration into your project plan from the beginning can save you time and resources down the line.

We’ve embraced the philosophy that our software is never finished. And we can’t wait to see how far it’ll take us.

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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources[link: http://www.designkit.org/resources/1.

Community Engagement, Economic Burden, Healthcare Workforce, Innovation, Research

Part II-Prototypes Bring Ideation to Life

Marie Onakomaiya · April 7, 2016

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Welcome to the second installment of our blog series on human centered design. In our introductory post we broke down what human centered design means for designers and implementers of international development projects. Our most recent post gave a case example of how we’re building empathy with health workers in Nepal. This post will share a case example of how we’re prototyping different iterations of a monitoring and evaluation (M&E) dashboard for our staff in Benin.

Once you have worked with your project partners to determine what you want to design or test, the most effective way to get useful feedback from the people you’re designing for is to prototype what you want to test.

*Sam facilitating the feedback session on VaxTrac monitor*

Prototyping allows you to get feedback on something concrete rather than abstract. It is the difference between asking someone to describe their perfect cup of coffee versus giving them three different cups of coffee to critique. They will have a better grasp of what you are trying to design, and you will get more specific and useful feedback.

Prototyping also gives you the flexibility to test a variety of unique ideas without spending the resources on a project that might not work the first time.

The Problem
Our team in Benin needed a new, more efficient way to monitor our project. As we trained new health workers to use VaxTrac and added an entirely new health zone to our scope of work, our field team had to process more data than ever before.

Each field supervisor had devised his own method of monitoring how health workers use the tablets, what bugs occur in the software, and how to compare tablet-based reporting to paper-based reporting. Meanwhile, back in DC, our Learn team stayed busy exporting data from CommCare reports and spending a lot of time converting data into a more useful format.

It quickly became clear that we needed a more efficient way of tracking data so that our field-based team could spend less time entering data into spreadsheets and more time responding to health worker needs, prioritizing resources and tracking progress over time.

Prototyping Solutions to Test the Best Ideas
To solve this problem, we have been working with our team to design a monitoring tool that will allow our field supervisors to monitor the project more easily. After a series of feedback sessions interspersed with a variety of paper monitoring tool prototypes, we decided the best solution would be to design a web-based data dashboard that can automatically populate with data from CommCare, such as when a form is submitted, the time it takes to complete a form, when a child is fully immunized, among other pieces of data. We are also working to incorporate additional pieces of data such as, data use, battery level of the tablet and the last time the tablet had an internet connection.

In order to get feedback from our team in Benin, we designed a live prototype of a monitoring and evaluation (M&E) dashboard:

Our DC staff brought the prototype to our Benin staff during a trip to Benin a couple weeks ago. We held a focus group and asked our team questions about the types of data they want to monitor on the dashboard, how data should be grouped, how data should be displayed and how they would use the dashboard.

By providing a concrete example of an M&E dashboard, we were able to elicit specific and useful feedback from our team in Benin. The designing of the dashboard is an ongoing project. We will continue to get feedback and iterate on our designs until we come up with a solution that meets everyone’s needs.

Check out the final post in our series about human centered design, where we’ll give examples of how we keep iterating on our projects even after we implement.

________________________________________

To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources.

Community Engagement, Economic Development, Healthcare Workforce, Innovation, Organizations, Research

Part I- To Get Inspired, Build Empathy into Your Project Plan

Marie Onakomaiya · April 1, 2016

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Build Empathy First
In our first blog post about human centered design, we talked about building empathy for design thinking. But what does “empathy” really mean, and how does it translate into research methodology?

To have empathy is to understand another’s perspective. If your goal is to build empathy with the community you’re designing for, it’s important to budget time, space and resources to talk to a variety of project stakeholders about the challenge you’d like to solve before the project starts. While it’s difficult to convince donors to spend money on an extended R&D phase, giving communities a voice at the onset of your project can save your organization time and money by allowing stakeholders to voice their opinions and be active participants in the design process.

The methods we use to build empathy are reminiscent of the research methods found in academic settings. Human centered design is especially akin to the philosophy of community based participatory research (CBPR), which also recognizes that when given a voice, communities are best equipped to identify sustainable solutions to challenges they face. Like CBPR and more traditional qualitative research methods, human centered design relies on interviews, focus groups, observations, surveys, card sorts, among other interactive methods, such as role plays, immersion and community mapping to elicit feedback from stakeholders.

Let’s dive into the case example of how we are building empathy with health workers in Nepal to improve our user interface and workflow.

The Problem
The clinics we work with in Nepal are fundamentally different than the clinics we work with in Benin. In Benin, the clinics are urban and busy. There are vaccination sessions almost every day. Caregivers bring their children to the clinics for vaccinations.

By contrast, the clinics we work with in Nepal are rural. The population is dispersed. As a result, vaccinations only happen a few days a month. There may be one or two sessions that take place at the main clinic, but there are usually also a number of outreach sessions, in which the health workers walk several hours to sub-health posts within their catchment areas. Since the population is small, only a few children come to each session.

Building Empathy through Brainstorming and Workflow Cards
There are a number of methods we could use to get into the mindset of the health worker. The key is to remember that health workers are the experts. They understand their job better than anyone else. Our job is to listen, build empathy for what they experience in their jobs and translate that into our software design.

We are starting with the goal of understanding health workers’ workflows in different situations. In other words, what do health workers do to prepare for a vaccination session? What happens during a session? What happens after?

Our DC-based team started by brainstorming objects, people and actions involved in a vaccination session. We scoured the internet for images to represent everything that we came up with. We put together sample workflow cards and brought it to our project partners in Nepal.

*Draft Workflow Cards (Source: vaxtrac.com)*

Seeing the sample workflow cards inspired our in-country partners Amakomaya to continue the brainstorm. They looked at our cards and told us what images worked and which images did not convey the right meaning. They grabbed a marker and started brainstorming their own list. We sketched images together.

We designed an interactive activity with health workers to use the workflow cards to get a better understanding of the different workflows they use during vaccination sessions. We are currently working to add Amakomaya’s feedback into an updated version of the workflow cards, which we will test out with a group of health workers early this year.
Using cards with simple images on them is a great way to get health workers talking about how they do their work. Cards are tangible objects that health workers can put in their hands and arrange in different ways. It gives the group a visual to refer to when someone has a question. It allows our team and health workers to identify gaps in the work flow as well as pain points.

We hope that by understanding current workflows and processes, we can understand the challenges that health workers face in their daily jobs and iterate our software so that it improves their workflow.

Check out our next post in our series about human centered design next week, where we’ll give examples of how we’ve been prototyping a monitoring and evaluation dashboard with our team in Benin.
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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources

Community Engagement, Research, mHealth, Innovation

How to Incorporate Design Thinking into your ICT4D Projects: A Blog Series

Marie Onakomaiya · March 24, 2016

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on the VaxTrac blog

2015 was a year abuzz with talk about human centered design in the international development community. Words like “human centered” and “design thinking” may sound like international development buzzwords on par with “sustainability” and “capacity building” (thanks Devex), but behind the words are tangible methods you can use to elicit feedback from the people your project serves and use their insights to build better, smarter solutions.

If we break down the jargon, human centered design means to listen to the people that you are building a program for – before, during and after implementation. You listen to them because they are the experts. If you are designing an app for health workers to register patient data, you listen to health workers because they are experts on their workflow and needs. If you are designing an educational SMS system for youth, youth are experts in understanding what they want to know and how they want to discover that information. Simply put, human centered design is a series of methods implementers can use to engage with users throughout a project’s lifespan.

The human centered design process walks us through methods we can use during three key phases

Inspiration: defining the problem, the audience, understanding facilitators and barriers
Ideation: brainstorming ideas, testing out prototypes, finding the best solution
Implementation: choosing the best idea and implementing it, while still getting feedback and iterating

While human centered design is typically thought about in terms of technology projects, in recent years, the concept has been applied more broadly to solve complex global health challenges. In an interview with WIRED magazine, Melinda Gates, Co-Chair and Trustee of the Bill and Melinda Gates Foundation, described human centered design as “meeting people where they are and really taking their needs and feedback into account.” It sounds intuitive that we would want to understand the needs of the people we serve, but we often lack the tools and resources to do this well.

We are writing a three-part blog series to share our own experiences designing a mobile vaccine registry system for health workers. Our blog series will give case examples of the methods we used at various stages of the human design process. The first post will focus on how we are building empathy with health workers in Nepal to improve our user interface and workflow. The second post will look at how we’ve been prototyping a monitoring and evaluation dashboard with our team in Benin. Lastly, our final post will emphasize the importance of iterating after implementation by sharing our experience customizing our software, based on user feedback in Benin and Nepal.
We hope you will be able to use our experience to incorporate human centered design into your own projects.

To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources

Economic Burden, Infectious Diseases, Innovation, Non-Communicable Diseases, Research, Vaccination, Children

Recent Therapeutic Advancements in Combating Dengue and Glioma

Marie Onakomaiya · December 28, 2015

~Written by Kate Lee, MPH (Contact: kate@recombine.com)

Sanofi-Pasteur's Dengvaxia has been approved for the prevention of the four subtypes of dengue in children over 9 years old and adults under 45 years old. Photo Credit: European Pharmaceutical Review — *Sanofi-Pasteur's Dengvaxia has been approved for the prevention of the four subtypes of dengue in children over 9 years old and adults under 45 years old. Photo Credit:* *European Pharmaceutical Review*

Infectious and chronic diseases are some of the top priorities in global health. Abundant funding, both from the government and private sector, is poured into therapeutics research to help decrease morbidity and mortality from both types of diseases. For example, recent news has highlighted two promising therapies with the potential to alleviate the global burden of two diseases: dengue fever, an infectious disease, and glioblastoma, a chronic disease.

After 20 years of research, Sanofi, a French pharmaceutical company, developed Dengvaxia, a vaccine to prevent dengue. Mexico is the first country to approve the vaccine for use in children over the age of nine and adults under the age of 45. A clinical trial last year found the vaccine to have an effectiveness of 60.8% against four strains of the virus[1]. Sanofi bypassed European and US regulations and sought regulatory approval for Dengvaxia in dengue-endemic countries. According to their press release, the vaccine, “will be priced at a fair, affordable, equitable, and sustainable price... and may be distributed for free in certain countries”[2].

Dengue is a febrile viral illness that is spread via the bite of an infected mosquito, and is endemic to tropical and sub-tropical climates. According to the World Health Organization (WHO), about 400 million people globally are infected with the dengue virus each year. Prevention has been limited to effective mosquito control and appropriate medical care[3]. These measures are often either ineffectively implemented, or there are limited, or no available medical resources in the community. Dengvaxia has the potential to reduce the burden of dengue, especially in developing countries that are particularly hard-hit with the disease. Future research could be directed towards making the vaccine more effective in children, as severe forms of dengue are the leading cause of illness and death in children in Asian and Latin American countries[3].

As one tropical virus is being prevented, another virus is being used to combat brain cancer. Researchers at Harvard and Yale have teamed up to use vesicular stomatitis virus (VSV) and Lassa virus, to search for and destroy cancer cells in mice[4]. Lassa is a febrile illness, usually transmitted by rodents, and is endemic to tropical and subtropical regions of the world[5]. VSV has been studied for many years and is generally effective in killing cancer cells; it becomes deadly to the patient when it reaches the brain[4,6]. Interestingly, including Lassa virus appears to make VSV safe for cancer therapy in the brain.

Researchers created a Lassa-VSV chimera, an organism that includes the genetic codes of two different organisms, to target glioma, one of the deadliest forms of brain cancer, which accounts for more than 80% of primary malignant brain tumors[7]. Glioblastoma is the most common form of glioma and is associated with poor survival, making this chimeric treatment a potential life saver for many patients. The next step in the treatment development process is primate research to evaluate safety. This is still a long way from the initiation of human trials, and eventual market, but promising nevertheless, for the millions of people globally who are affected by brain cancer.

Dengvaxia and the Lassa-VSV chimera represent recent advancements in therapeutics with potentially significant global impact for brain cancer and dengue respectively - diseases that affect populations in many nations.

References:

1. Sanofi's Dengvaxia, World's First Dengue Vaccine, Approved For Use In Mexico. International Business Times. http://www.ibtimes.com/sanofis-dengvaxia-worlds-first-dengue-vaccine-approved-use-mexico-2219515. Published December 10, 2015. Accessed December 20, 2015.

2. World’s First Dengue Vaccine Approved After 20 Years of Research. Bloomberg Business. http://www.bloomberg.com/news/articles/2015-12-09/world-s-first-dengue-vaccine-approved-after-20-years-of-research. Published December 9, 2015. Accessed December 20, 2015.

3. Dengue and severe dengue. World Health Organization. http://www.who.int/mediacentre/factsheets/fs117/en/. Updated May 2015. Accessed December 20, 2015.

4. Using a deadly virus to kill cancer: Scientists experiment with new treatment. The Washington Post. https://www.washingtonpost.com/national/health-science/using-a-deadly-virus-to-kill-cancer-scientists-experiment-with-new-treatment/2015/12/07/7d30bc5a-9785-11e5-8917-653b65c809eb_story.html. Published December 7, 2015. Accessed December 20, 2015.

5. Lassa fever. World Health Organization. http://www.who.int/mediacentre/factsheets/fs179/en/. Updated March 13, 2015. Accessed December 20, 2015.

6. Viral Therapy in Treating Patient with Liver Cancer. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01628640. Updated July 2015. Accessed December 20, 2015.

7. Schwartzbaum J A, Fisher J L, Aldape K D, Wrensch M. Epidemiology and molecular pathology of glioma. Nature Clinical Practice Neurology (2006) 2, 494-503. doi:10.1038/ncpneuro0289

Vaccination, Innovation, Research, Infectious Diseases, Health Insurance

Will We Witness the End of HIV in Our Lifetime?

Marie Onakomaiya · December 1, 2015

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

December 1st of every year is designated as World AIDS Day, a day devoted to increasing knowledge and awareness about the impact of HIV/AIDS around the world. This year is no different, and over the last few months and years some exciting things have been happening regarding HIV/AIDS.

The year 2013 has become known as the “turning point” or “tipping point” in the HIV/AIDS epidemic. This describes the fact that 2.3 million people began anti-retroviral medication in 2013 while only 2.1 million new infections were diagnosed. In other words, more people are receiving treatment and fewer people are becoming infected than ever before. If we keep this accelerating HIV scale-up through 2020, UNAIDS predicts we could see the end of HIV/AIDS by 2030

*Figure 1. WHO infograph detailing the impact of expanding ART (antiretroviral therapy)*

In the United States there has been a lot of media coverage, over the last year or two, surrounding pre-exposure prophylaxis (PrEP) for use by HIV-negative people to prevent HIV infection. PrEP is daily medication regimen utilizing an HIV drug called Truvada. Studies have shown that people who take PrEP as directed were 92% less likely to contract HIV. However, although it is increasing, PrEp usage remains lower than anticipated. Some barriers include a lack of PrEP awareness in people who are most at risk for HIV, some medical provider resistance to prescribing PrEP and some inconsistent insurance coverage. Additionally, PrEP continues to suffer from an image problem. When PrEP first became available, many critics were skeptical of its effectiveness in real-world settings and thought that it would undo years of work to educate folks about the dangers of HIV/AIDS. Critics also thought that being able to take a daily drug to prevent HIV would promote promiscuity and unsafe sex. A recent study in JAMA Internal Medicine proves the critics wrong on some of their fears.

An HIV/AIDS vaccine has been on the horizon ever since the epidemic was discovered. However, as we learned more about HIV, it became apparent that developing a vaccine was going to be a challenging effort. While there continue to be many HIV vaccines at various stages of development, scientists are excited about one being developed by one of the scientists who identified HIV as the cause of AIDS, Dr. Robert Gallo. His team at the University of Maryland School of Medicine’s Institute of Human Virology is beginning human trials on a potentially groundbreaking HIV vaccine. Instead of targeting different HIV viral markers to help the immune system recognize and eliminate HIV-infected cells, Dr. Gallo and his team’s vaccine targets HIV when it enters the body to prevent it from infecting cells.

All of these promising developments relating to HIV/AIDS should not overshadow the challenges that still lie ahead. Many people do not know they have HIV because they’ve never been tested. The Berkshire town of Reading in the UK is expanding its HIV testing program by offering free tests because it has more than double the UK average of HIV-positive people. The number of HIV-positive people in Russia continues to increase and has reached almost 1 million people. Some countries are passing anti-gay legislation and there is a direct link between criminalizing laws and increased rates of HIV. These are the challenges some parts of the world face in the efforts to end the HIV/AIDS epidemic.

World AIDS Day provides a way for everyone to get involved in the fight against HIV/AIDS. It’s an annual day to think about the people who’ve lost their lives to AIDS-related illnesses and to champion efforts to prevent more people from losing their lives due to HIV/AIDS related causes. This December 1st do a little research, learn about the burden of HIV/AIDS in your community, and decide how to get involved. Together we can end HIV/AIDS in our lifetime.

Disease Outbreak, Health Systems, Infectious Diseases, Innovation, mHealth, Research

Technology is Changing the Way Infectious Diseases are Tracked

Marie Onakomaiya · November 5, 2015

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

Technology is progressively becoming a bigger part of our lives. This holds true in high-income countries and in low- and middle-income countries. By 2012, three quarters of the world’s population had gained access to mobile phones, pushing mobile communications to a new level. Of the over 6 billion mobile subscriptions in use worldwide in 2012, 5 billion of them were in developing countries. The Pew Research Center’s Spring 2014 Global Attitudes survey indicated that 84% of people owned a mobile phone in the 32 emerging and developing nations polled. Internet access is also increasing in low- and middle-income countries. The 2014 Pew Research Center survey indicated that the Internet was at least occasionally used by a median of 44% of people living in the polled countries.

The increase in Internet and mobile phone access has significant implications for how infectious diseases can be better tracked around the world. Although robust and validated traditional methods of data collection rely on established sources like governments, hospitals, environmental, or census data and thus suffer from limitations such as latency, high cost and financial barriers to care. An example of a traditional infectious disease data collection method is the US Centers for Disease Control and Prevention’s (CDC) influenza-like illness (ILI) surveillance system. This system has been the primary method of measuring national influenza activity for decades but suffers from limitations such as differences in laboratory practices, and patient populations seen by different providers, making straightforward comparisons between regions challenging. On an international scale, the WHO receives infectious disease reports from its technical institutions and organizations. However, these data are limited to areas within the WHO’s reach and may not capture outbreaks until they reach a large enough scale.

Figure 1. CDC Flu View Interactive dashboard: http://gis.cdc.gov/grasp/fluview/fluportaldashboard.html — *Figure 1. CDC Flu View Interactive dashboard: http://gis.cdc.gov/grasp/fluview/fluportaldashboard.html*

Compared to traditional global infectious diseases data collection methods, crowdsourcing data allows researchers to gather data in near real-time, as individuals are diagnosed or even before diagnosis in some instances. Furthermore, getting individuals involved in infectious disease reporting helps people become more aware of and involved in their own health. Crowdsourcing infectious disease data provides previously hard to gather information about disease dynamics such as contact patterns and the impact of the social environment. Crowd-sourced data does have some limitations, including data validation and low specificity.

Internet-based applications have resulted in new crowd-sourced infectious disease tracking websites. One example is HealthMap. HealthMap is a freely available website (and mobile app) developed by Boston Children’s Hospital which brings together informal online sources of infectious disease monitoring and surveillance. HealthMap crowd-sources data from libraries, governments, international travelers, online news aggregators, eyewitness reports, expert-curated discussions, and validated official reports to generate a comprehensive worldwide view of global infectious diseases. With HealthMap you can get a worldwide view of what is happening and also sort by twelve disease categories to see what is happening within your local area.

Figure 2. HealthMap. http://www.healthmap.org/en/ — **Figure 2.** HealthMap. http://www.healthmap.org/en/

Another crowd-sourced infectious disease tracking platform was Google’s Flu Trends, and also their Dengue Trends. Google was using search pattern data to estimate incidence of influenza and dengue in various parts of the world. Google’s Flu Trends was designed to be a syndromic influenza surveillance system acting complementary to established methods, such as CDC’s surveillance. Google shut down Flu Trends after 2014 due to various concerns about the validity of the data. As an initial venture into using big data to predict infectious diseases, Flu (and Dengue) Trends have provided information that researchers can use to improve future big data efforts.

With the increase of mobile phone access around the world, organizations have started using short message service (SMS), also known as text messaging, as a method of infectious disease reporting and surveillance. Text messaging can be used for infectious disease reporting and surveillance in emergency situations where regular communication channels may have been disrupted. After a 2009 earthquake in Sichuan province, China, regular public health communication channels were damaged. The Chinese Center for Disease Control and Prevention distributed solar powered mobile phones to local health-care agencies in affected areas. The phones were pre-loaded with necessary software and one week after delivery, the number of reports being filed returned to pre-earthquake levels. Mobile phone reporting accounted for as much as 52.9% of total cases reported in the affected areas during about a two-month time period after the earthquake.

Text message infectious disease reporting and surveillance is also useful in non-emergency settings. In many malaria-endemic areas of Africa, health system infrastructure is poor which results in a communication gap between health services managers, health care workers, and patients. With the rapid expansion and affordability of mobile phone services, using text-messaging systems can improve malaria control. Text messages containing surveillance information, supply tracking information and information on patients’ proper use of antimalarial medications can be sent from malaria control managers out in the field to health system managers. Text messaging can also be sent by health workers to patients to remind them of medication adherence and for post-treatment review. Many text message based interventions exist, but there is a current lack of peer-reviewed studies to determine the true efficacy of text message based intervention programs.

Increasing global access to the Internet and mobile phones is changing the way infectious diseases are reported and how surveillance is conducted. Moving towards crowd-sourced infectious disease reporting allows for a wider geographical reach to underserved populations that may encounter outbreaks, which go undetected for a delayed period. While crowdsourcing such data does have limitations, more companies than ever are working on using big data and crowd-sourced data in a reliable way to inform the world about the presence of infectious diseases.

Built Environment, Economic Development, Government Policy, Innovation, Poverty, Water and Sanitation

Climate Change and Health, Part 1: Floods

Marie Onakomaiya · July 24, 2015

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

The Lancet recently published an article on climate change and health, extensively examining the types of health risks related to climate change as well as recommendations for policy changes, in order to address these risks (Watts et al., 2015). This article re-emphasized how complex this issue is because there are several contributing factors, and elements that can be potentially impacted (Figure 1). As there are so many aspects of this topic, for my next few blog posts I will focus on briefly highlighting some of the health risks associated with climate change. This post will focus on natural disasters, specifically looking at floods.

Figure 1: Relationship between health, climate change and greenhouse gas emission (Watts et al., 2015) — Figure 1: Relationship between health, climate change and greenhouse gas emission (Watts et al., 2015)

Since 1900, floods have left more than 88 million people homeless, $595 billion in damages, and the deaths of nearly 7 million people (Khedun & Singh, 2013). Overall, climate change will have a direct impact on human health through natural disasters, such as flooding. South Asia is especially at risk as there is already regular flooding. A change in climate can affect the onset of monsoons. For example, in Kerala, a state in southern India, the monsoon season generally begins on June 1st and ends in early September, with a standard deviation of about seven days (Mirza, 2011). However, in the last 50 years this has more than doubled with the earliest onset on May 14th, and the latest date of onset on June 18th (Mirza, 2011). While this may not seem significant, it can influence the level of preparedness in communities that are at risk. Furthermore, the frequency and intensity of rainfalls will also increase. According to climate models, monsoon intensity increases during the summer, as the air over land is warmer than air over the oceans (Mirza, 2011). Floods, that result from the monsoon weather, not only increase the risk of drowning, but also affect the quality of water, thus increasing the exposure to waterborne diseases such as dysentery and diarrhea (Mirza, 2011).

Mental health issues, such as anxiety and depression, can also develop after losing property or facing a financial crisis after a flood (Khedun & Singh, 2013). Furthermore, the impacts of climate change, such as increased flooding, disproportionately influence certain populations such as marginalized communities, women, children, and the elderly (Watts et al., 2015). Thus, they suffer most of the negative health consequences associated with flooding and other disasters related to climate change (Watts et al., 2015). This highlights the complexity of the issue in terms of trying to address how to help those who are most impacted by floods.

There are several mitigation efforts that can be taken in order to reduce the impact of floods. For example, urban planners and engineers can work to ensure that forested areas are preserved and development occurs in areas where soil and vegetation conditions work best to reduce the risk of flooding. Many non-structural methods can also be implemented. For example, in some areas it may be beneficial to create zoning laws that would prohibit development in areas that are prone to flooding (Watts et al., 2015). Government officials and private officials can also work together to improve early warning systems and develop better policies for flood-insurance and emergency preparedness (Watts et al., 2015). Taking these steps can help to ensure that health issues associated with floods will not be exacerbated.

References:

Khedun, C. P., & Singh, V. P. (2013). Climate Change, Water, and Health: A Review of Regional Challenges. Water Quality, Exposure and Health, 6(1-2), 7–17. doi:10.1007/s12403-013-0107-1

Mirza, M. M. Q. (2011). Climate change, flooding in South Asia and implications. Regional Environmental Change, 11(SUPPL. 1), 95–107. doi:10.1007/s10113-010-0184-7

Watts, N., Adger, W. N., Agnolucci, P., Blackstock, J., Byass, P., Cai, W., … Costello, A. (2015). Health and climate change: policy responses to protect public health. The Lancet, 6736(15). doi:10.1016/S0140-6736(15)60854-6

Innovation, Economic Development

Global Health in a 'Restricted' Country - Breaking the Barrier of Stereotypes

Sarah Weber · June 15, 2015

~Written by Dr. Sulzhan Bali, Director of Production and HR, TWiGH (Contact: sulzhan.bali@twigh.org)

*Also published on the Duke Global Health Institute Page "Diaries from the Field Blog"

Let’s play a game. Shall we? I give a word and you think of the first word that comes to your mind.

Nigeria.

Pat yourself on the back if the word you came up with was NOT ‘scam’, ‘419’, or ‘Boko Haram’. Treat yourself to a chocolate if the word that you came up was a positive word (and if you are not Nigerian).

You see, stereotyping comes naturally to our species. Often, our outlook is dictated by the media, news, and hearsay- which although important, often gives us an incomplete singular dimension of the holistic picture. Unfortunately more often than not that singular dimension dictates our biases.

I must admit, before I arrived to Nigeria for field-work, I was afraid. Afraid of what awaited me on the other side. After hearing reactions such as “Why Nigeria out of all places?”, “stay careful in Nigeria, scamming is so common”; “Oh no! Isn’t that where Boko Haram is?”, and tales of evacuation, kidnappings, and even carjackings- I had started really wondering whether I should be excited at all? It didn’t help that my field-work country site was considered entirely restricted for safety purposes. No wonder, I was a little nervous as I disembarked the plane.

After I landed, my first experience of Nigeria was a man offering help at the airport for the cart. I didn’t have local currency yet and I needed a cart for my luggage. I remembered of the innumerable warnings by friends and family to keep my wits about and to trust no one. Did I take his help? Yes. Did he run away with my bags? No. Over the course of next 2 weeks, I would discover each and every Nigerian that I met to be warm, friendly, helpful, and yes- trustworthy!

The risk of being scammed or cheated exists in every big city and Lagos is no different. This city of 21 million people is a melting pot of cultures and like any other metropolitan city in the world is like a coin with 2 sides. My time in Lagos so far has turned my idea of Nigeria that I had upside down. Yes, there is poverty. Yes, development is an issue. So is corruption, weak health system, malaria, maternal mortality, and infant mortality. Yet, there is also will power. There is optimism. There is an incredible spirit of entrepreneurship, which I am yet to see in another part of the world. Every Nigerian is an aspirational entrepreneur, hustling to be a successful one. People have a safe job along with an entrepreneurial venture. No wonder, that in Nigeria 41% of women between 18-64 years are entrepreneurs- the highest in the world! Unfortunately, Nigeria also ranks among the worst 20 countries in the world for women entrepreneurs. Many of these entrepreneur women are small traders or market women and entrepreneurship is a by-product of necessity due to lack of opportunities in the formal sector. Yet, despite it all, there is no denying the fact that entrepreneurial energy in Nigeria is on a high. There is an impressive desire in almost all Nigerians that I have interacted with to build something of their own. Optimism and innovation have overshadowed the constraints of red tape and lack of infrastructure. Many entrepreneurs in Nigeria are in it to make an impact and facilitate social change. An apt example is EbolaAlert- an organization that I am collaborating with for my study on 'Role of Private Sector in Ebola Response in Nigeria'. EbolaAlert started as a twitter handle at the peak of Ebola Outbreak in West Africa. People across the world were getting their accurate information on the Ebola Outbreak through it. What started as an information-providing platform turned into a Global health influencer that is now launching multiple public health education campaigns across Nigeria in partnership with CDC, Unicef, MSF, and the private sector.

Global health is about collaboration and coordination. It is about dialogue between sectors, organizations, and cultures. To be able to do that successfully, one has to look beyond the biases. Casting away our lens of bias requires looking beyond what we see and hear in media, news, and hearsay which is only possible with a cultural immersion and an open mind. This is why field-work is such an important component of global health. Nigeria is not perfect. No country ever is. As the biggest economy in Africa and a country all set to reap its demographic dividend, Nigeria has the means and the will to become a great nation. I recently met a few Nigerian young professionals in Lagos. These were Nigerians from across the world visiting for the Young Nigerian Leaders conference to talk about the future of Nigeria. As it happens, Nigeria's biggest assets are its people. Many of who are using lean entrepreneurship, collaboration and ideation to facilitate change in all spheres. From my vantage point, the whole world is Nigeria's oyster. Restrictions on the other hand, lie only in our mind set.

No prize for guessing which is the first word that comes in my mind when someone says Nigeria. It is 'entrepreneurship'.

Innovation, Global Health Conferences

Review of Unite for Site Global Health and Innovation Conference 2015

Marie Onakomaiya · April 7, 2015

~Written by Sarah Weber (Contact: sarahkweber@gmail.com)

I attended the Unite for Site Global Health and Innovation Conference last weekend which brought together over 2,000 global health and international development professionals, social entrepreneurs and students to exchange ideas and leading practices. One of the best parts of the conference was meeting committed global health professionals with the bonus of connecting with other TWiGH team members and viewers. The conference was held at Yale and participants had the opportunity to enjoy the quaint city of New Haven as well as the snow that fell throughout Saturday. The conference was similar to many other global health conferences I’ve attended but had a unique feel due to its social innovation edge and opportunity to hear from social entrepreneurs competing for the J.M.K. Innovation Prize. The innovation prize was established by the J.M. Kaplan Fund to provide grants to emerging social sector innovations.

The conference had some very engaging and high profile speakers. I thoroughly enjoyed listening to the key-note address by the Honorable Minister of Health of Rwanda, Agnes Binagwaho, MD. She is an energetic women who isn’t afraid to speak her mind, even on controversial topics. She spoke about how Rwanda has greatly decreased its AIDS deaths, which is the fastest decrease ever in the world. She stressed how imperative it is that women have the choice for family planning since “There is no woman crazy enough to say, I want a baby every year”. She spoke about the need to meet people where they are and to move where you are needed most (rather than nice areas with beaches or better amenities). When asked what she would do if she were the Health Minister of the United States, she said she would put parents who refused to vaccinate their children on trial! Lastly, she urged us to work together and unite since “We live in one world, not three.”

Another engaging speaker was Cal Bruns, CEO/Chief Creative Incubationist at Matchboxology who presented on “What Condom Manufacturers Could Learn from Car Designers.” He spoke about a fact that car manufacturers learned long ago, that people are more motivated to purchase a product with a benefit that they want, rather than a product to prevent something they don’t want. He proposed that the condom companies should work on creating condoms with advanced technology such as stimulating beads on the inside of the condom to increase pleasure. Then men would be motivated to use condoms for the increased sensation which would as a by-product help reduce STIs and unwanted pregnancy. It was a different look on condom promotion than I’d heard before, but totally made sense.

The Social Impact Labs, which was the catalysis feature of the conference, brought together social entrepreneurs to pitch presentations about new innovations in front of a panel of judges and the audience in competition for the innovation prize. The innovation pitches ranged from nascent ideas, grassroots projects, to initiatives already underway being backed by large public health NGOs, universities and/or private companies. We heard about innovations ranging from a sex education program in Kenya teaching farmers to spread HIV prevention messages, a movement to create greenhouses in inner-city Baltimore to bring fresh produce to areas lacking produce options, to a project that creates wells to provide safe drinking water at a low cost to prevent arsenic poisoning in Bangladesh. The winning innovation was presented by Lucy Topaloff with a company called Miraclefeet which provides high quality, low cost braces for patients with Clubfoot in India. Miraclefeet won $10,000 which will be used to help provide braces to 40+ children.

Overall it was a motivating and encouraging weekend. It’s always great to meet other public health professionals passionate about improving health and opportunities for disadvantaged populations globally. Listening to all the enthusiastic and motivated young people during the social innovation pitches drove home the idea that: great ideas + passion + commitment = opportunities. These individuals, in collaboration with their networks and connections, are turning ideas into solutions to help the less advantaged. That is inspiring!