m2m Trip to East London

Monday morning instead of heading into the office as usual, two women from work, Alisha and Chloe, picked me up on the way to the airport. One great thing about flying in South Africa – they don’t care if you board with your toiletries in a Ziploc bag or not! We took short ~1.5 hr commuter flight to East London, a city which lies on the Indian Ocean in the Eastern Cape province. After landing in a dumpy little airport and procuring our rental car, off we went. To do what, you ask? Well unfortunately, Chloe (an evaluation and operations research specialist in the m2m M&E department) is leaving in a few days to start grad school back in the states. Before Chloe leaves, there is a lot of work to be done orienting Alisha (another relatively new m2m employee, working as an international M&E systems manager) to a bunch of the ongoing M&E projects, many of which are centered in East London. And along with that I fit in somewhere in the mix too...

Anyway, to make M&E orientation matters even more interesting, there is a very large and important M&E report due to Johnson and Johnson by the end of the month, completion of which still requires all of the actual data collecting. Ok, let me back up. m2m has a group of sites in the Eastern Cape (10 total) that combined are called the “Innovation Center.” These 10 sites serve as an ideal place for m2m to focus its operations research, as the urban location, high HIV prevalence rate, and relatively improved literacy rate in the area simplify the logistics of working with this population. As m2m wants to improve the quality of its services and test out new ways of educating mothers and tracking clientele, it uses the IC sites to run tests and try new practices before rolling out changes in all 500+ sites. Johnson and Johnson funds 7 of these IC sites (in addition to 8 other sites throughout South Africa) and is invested in the research done there. The upcoming J&J report must give feedback not only on the basic services of all 15 J&J sites, but also on an ongoing IC study trying to test the effectiveness of contacting clients via phone and home visits after birth in effort to improve the rate of 6 week infant PCR testing (to see if the baby is HIV+), as opposed to only interacting with clients as when they choose to seek out m2m in clinic sites. There are, unfortunately, myriad complications with this seemingly simple, yet very important, task. To start, clients must give permission to be contacted via phone and home visit – and for some people who have not disclosed to their friends/neighbors/children/partner, the idea of having a mentor mother (who is often well known for her role in the community) seek them out at home is unacceptable. Beyond that issue, many women do not have the same phone number and/or address 6+ weeks after birth compared to the contact info they initially give the mentor mothers – they may not have the money to maintain their cell phone number, they may move (and poor people especially are obviously very migrant), they may live in an informal settlement and not have an address, they may lie about their contact info so as not to be bothered by the mentor mother, they may leave the city and return home to rural areas to have their babies where there is more family support, etc., etc. There are also a ton of logistical issues in even asking the mentor mothers to do this sort of follow-up, as they must have m2m give them advances on airtime and money to take taxis/minibuses to homes. Truly, the list of complications goes on and on (and again, is so daunting!).

As for where I fit in, I’m going to spend the next few weeks helping with the Johnson and Johnson report, particularly with data collection...which is why I went to East London, as I myself only found out on Monday. Haha, what I have learned recently is that when someone mentions on Friday they’ll be picking you up to go to the airport Monday morning, then you say ‘ok’ and go with the flow. No, in all seriousness, I’m very excited to be helping out with this project and I’m more than happy to travel, experiencing South Africa beyond Cape Town and learning more about m2m operations at the site level. So back to our trip...

I don’t know much about East London, but it didn’t seem anything like Cape Town. From what I could tell driving around, there were much fewer white people and the city streets themselves appeared more run down with lots of swamped sidewalks and street-side craziness. The weather was beautiful and warm, and the beach looked very enticing, but sadly we never make it down to the water’s edge. Leaving the airport, we drove into the city of East London, to a major maternity hospital called Frere where we met our local m2m study coordinator, Nzwaki. What a great woman! She was so open and kind and helpful. After lunch together, Nzwaki took us to a few sites to introduce us to the mentor mothers and show us all the logbooks so we could familiarize ourselves with the data collection tools and talk about any foreseen issues with Chloe and the mentor mothers before we actually begin data abstraction.

FYI, at each m2m site, mentor mothers must fill out notebooks on all the antenatal and postnatal clients they see that day, and then they must take those books and transfer all of the info for the known HIV+ women into what is called the logbook. Instead of being organized by date, the logbook is then organized by client, so under each client you can enter numerous appointments and update her info as she progresses in the program. What Alisha, Nzwaki, and I will be doing is now creating electronic databases for the logbook data. (We also have to do the same for special logbooks which are tracking the baby PCR follow-up study.)

I’m sure you’re wondering why this work requires headquarter M&E staff to fly to East London, but this data abstraction is far more complicated than one might expect. For one thing, mentor mothers are not given computers (nor would many even be trained to use one) so the logbooks are all updated by hand and must not leave the sites. The process of recording each pregnant woman seen, and then transferring the info for all HIV+ women into a separate book and keeping track of each woman over many months is time intensive and fairly complex (it definitely took me a good while before I had completely oriented myself to the logbooks, so I can imagine mentor mothers must feel somewhat overwhelmed being required to do this work). Of course human error and data omission comes into play, be it because mentor mothers don’t understand something or clients don’t give accurate information/don’t know their own statistics (e.g. CD4 test date and results). Or in some cases, the M&E logbook design itself causes problems. For example, we now know it must be clarified that mentor mothers are not to fill out the box on infant feeding practice until after birth because right now many are interpreting that field as the planned infant feeding practice (which of course may vary from what occurs after birth). We also learned that “complimentary” doesn’t mean anything to many women whose first language is not English, so the logbook shouldn’t have a box to mark for “complimentary feeding,” but rather something more simple like “breast milk plus other foods.” It’s always quite the reality check to be in those settings and realize how much we as technology savvy, educated Americans take for granted. And just to add another dimension of confusion, the logbooks were newly revised and some women are had a few issues adjusting to the new ones, not to mention that some mentor mothers went back and transferred all their old client data to the new books while others did not, thus affecting the number of “new” clients seen at different sites over the past few months. Now we subsequently have to go through and interpret each client entry and filter based on dates and AN/PN status to ensure we control the data used for the J&J report. Suffice it to say, data abstraction over the next few weeks (especially with a tight deadline) is going to be challenging.

Monday afternoon as we drove through a township to get to another clinic site, we encountered a lot of road destruction (large concrete blocks, tree trunks, scrap metal, trash, rocks, etc. strewn all about some streets), likely coinciding with the unrest arising from the recent nation-wide strikes...though sadly I can’t see why destroying your own township would be helpful in expressing your frustration towards the government. Luckily we still managed to weave our way through the rubble and make it to the clinic, where we met with more mentor mothers. Everyone was surprisingly friendly and embracive, making me very conscious of the fact that Americans are not generally comfortable with being touchy and open in work settings. I was greeted with hugs by everyone even though obviously no one knew me, and then they all had a good laugh at the fact that they thought Morgan was a man’s name, haha.

Anyway, after the day wrapped up on Monday, Alisha and I drove Chloe back to the airport (she had to get home since this is her last week in South Africa, but the two of us stayed on to start the data abstraction process on Tuesday) and then settled in at our very lovely B&B where they also served us a tasty dinner of bobotie (a Cape Malay casserole dish made of minced beef flavored with curry and other spices, dried fruits, and an egg custard topping – yum!). m2m knows how to treat people well on work trips! Tuesday morning Alisha and I met Nzwaki at the maternity hospital and went through the report outline and then spent the day working at a smaller clinic, beginning the long process of data abstraction. At the end of the day we drafted up the schedule for completing data abstraction for the 10 sites in East London, 2 in the Western Cape, and 5 in Port Elizabeth...which means Nzwaki and I have a lot of travelling to do over the next two weeks!