Professor at the School of Information and Communication Technology (ICT) and Director of the Center for Community Technologies at Nelson Mandela Metropolitan University (NMMU), Darelle van Greunen, talks about her work of supporting community healthcare workers (CHWs) with innovative mHealth apps.
Tell us about your background and the work you’re doing at the Centre for Community Technologies.
Before developing my interest in technology and obtaining my PhD in computer science, I studied a variety of discplines including law, languages, education and media. After my studies in the late 80s I taught in township schools and then went on to work for SAP Research for eight years, which was as joint appointment between the NMMU and SAP. I then fully immersed myself in academia at NMMU, which I’m still involved in today, 20 years on.
Throughout my career I’ve worked on the ground with people that experience the daily challenges associated with lack of access to technology and by extension, the services that technology connects us to. As a result, I’m critically aware of the needs and the gaps that exist. So when I joined NMMU, I started doing research that initially focused on human-computer interaction: how people interact with technology and what makes technology attractive or unattractive to them. That set off a whole sequence of events that led me to looking at how technology can be used as an enabler to achieve certain things, instead of looking at technology as a silver bullet. And that’s how the whole concept of the Centre for Community Technologies originated.
And how does the Centre for Community Technologies function?
Essentially, the Centre’s work aims to promote the development of disadvantaged communities through the use of technologies. As Director of the Centre, I’m responsible for operations and securing of funding for the execution of applied research projects. I am also responsible for ensuring that the R&D agenda of the Centre aligns not only wuth the South African National Development Plan but also with other critical roadmaps such as the Millenium Development Goals, for example. I have an extensive team of people who work with me including a business analyst and project manager, developers, content researchers and people who coordinate educational training courses, and voice-over artists, etc. There are also a number students, both post- and -undergraduates, who work voluntarily as research interns.
Our work aligns with the vision of the university in that students should put back into the community what they get out of it. Our projects are focused on applied research, as opposed to theoretical, to allow students hands-on experience in real-life settings. Some students are trained in user testing, for example, so they learn how to get user input on a technology and then accompany me into the field where they can actually do the evaluations themselves and write up the reports on their findings.
In another example, one of my former PhD students, who is now a lecturer at the University of Pretoria, carried out surveys of the entire public healthcare landscape in South Africa as part of her PhD research, which was then used in part to develop the National Health Normative Standards Framework for Interoperability in eHealth (HNSF). I currently have a PhD candidate who wrote a School Health Assessment System that is being used by school nurses in rural Eastern Cape, and some other students have developed systems that are being used by CHWs in the rural Eastern Cape. I try and retain some of the people that have been involved in these sorts of projects because it supports continuity and the sustainability of the projects. So once they graduate a select few are employed by the Centre.
Let’s talk about the apps that have been developed by the Centre for CHWs.
Our primary focus is to provide technology that can support the entire continuum of care for patients in public health environments. But it’s important to note that we didn’t assume the needs of the people we’re trying to help and then developed a couple of apps because we thought it was a good idea. We continue to visit rural areas to engage with people and really understand their needs, the context and the challenges to addressing those needs.
Rural Eastern Cape is unique in a number of ways from other rural areas in the country because of extremely limited infrastructure and a lack of access to outlying clinics because of the rough terrain, so the only form of technology in those deep rural areas is mobile. And only once we had a thorough understanding of the ways we could support CHWs and nurses working in outlying clinics and communities, could we start developing Ncediso™ – a clinical decision support app that gives CHWs access to updated information.
We had to take into account that while these nurses and CHWs are far removed from resources, we couldn’t develop a solution that relied on airtime or data bundles because despite the fact that there is a high penetration of mobile phones, there are certain areas where connectivity still remains a challenge.
So Ncediso™ gives clinical staff and CHWs access to medical information, without the need for connectivity, when they have to do a diagnosis in the absence of a doctor. They can use the app as a look up facility, so if, for example, the patient is running a temperature and is short of breath they can input that combination of symptoms and it will return possible causes that they can use to further investigate and decide on the appropriate action to take. The content on the app has been verified by medical doctors and developed by a reputable publishing house that produces medical text books. The initial funding for the development of the app was provided by the Medical Research Council (MRC) and Department of Science and Technology (DST) Partnership, and it’s now currently being funded by the Technology Innovation Agency.
What other systems are currently being developed by the Centre?
We are developing an app in collaboration with elder care facilities in the region to capture the care of the elderly by nursing staff, carers and CHWs. Up until now, we aren’t aware of an existing app who’s user flow and data set is unique to the elderly. Data such as: what and when they ate, how much liquid they’ve taken in, whether they have taken medication, their state of mind – whether they are lonely or bored or depressed – are vital when it comes to appropriate care for the elderly. So we are working on that in an effort to improve care and services to this unique patient population.
Furthermore, we’ve developed a patient management system, called Zanempilo, that is currently being piloted by the Faculty of Health Sciences at NMMU in mobile clinics to understand what kind of information needs to be captured in remote areas in both screening and treatment health encounters.
Other projects underway that we expect to be ready by the end of 2016 include an app for mental health patients that allow them to capture their mental well-being and link them to a counsellor. We’re also developing an app that uses GPS to track and trace TB patients from the time of diagnosis through to treatment.
What role do you see CHWs playing in a modern health service?
I think that CHWs have a critical role to play in extending the reach of health services because they are embedded within the communities that typically don’t have access, and they are able to respond quickly to those who are having a health episode. And as we decant health services out of hospitals more and more to reduce the burden on those services and make provisions for community health services, CHWs also have a role in conducting first level assessment before referring patients to clinics – another way to reduce the burden and long queues that are common in public facilities.
It’s important to note that what we’ve found in carrying out our work is that there is a need to enable people to use technology to its full potential. So over and above health training, we are now adding digital skills training to give CHWs basic computer literacy skills and empower them to use mobile phones and tablets effectively, from basics that we often take for granted like how to connect to the internet all the way to how to use WhatsApp as an effective information sharing tool between nurses and CHWs.
Given what you told us, can you summarise the key factors that are essential when developing apps for CHWs working in rural areas?
First and foremost is to understand the context and the workflow of CHWs. You can only do that by working hand-in-hand with CHWs, which is the second essential ingredient to an effective CHW app. We take developers to the sites and literally spend months working with CHWs to understand their needs and challenges.
The third critical factor to include in your development strategy is that of language. You have to ensure that the terminology that is being used is familiar to CHWs. CHWs are not medically trained and the use of medical jargon isn’t appropriate. Also, where possible, consider the home language of the users you’re developing for. For example, we add text overs that provide tool tips in a different/home language.
Lastly, I’d advise developers and mHealth entrepreneurs to stay abreast of developments in rural areas. There is this notion that smartphones are uncommon in rural areas but that isn’t entirely true anymore. Smartphone penetration in the rural areas is on the increase, and it’s increasing rapidly. So it’s important to bear in mind that the technology landscape changes very quickly and, while it’s slower in outlying communities, we are missing opportunities because we are working off the assumption that it’s static in rural areas
What is next for the Centre for Community Technologies – how can the healthcare community get involved to support your work?
We pride ourselves on our ability to collaborate and I’m always looking for new partners, especially in other parts of the country so that we could test our solutions in other contexts. Another specific need we have is to partner with vendors that specialise in clinical sensors and devices such as stethoscopes and blood glucose meters to expand the basic monitoring that CHWs can conduct safely and easily and so that the data can be automatically uploaded to the patient’s EHR. This is essential work in my opinion to be able to understand and address health needs of rural populations in the immediate and short term and we would welcome any assistance in helping us achieve this.