Another trip to East London and other m2m news

You might be thinking all I do is experience the beautiful scenery that Southern Africa has to offer, but that’s not entirely true, I promise! Work has actually been quite time consuming of late – but it’s rewarding and exciting to feel like I’m finally making a meaningful contribution to the M&E department, as opposed to just being the new fellow.

One overarching theme we are focusing on is developing new ways to routinely collect outcome data from sites in an attempt to have a better understanding of the impact our efforts have, and also to monitor data quality at the site level. (FYI, outcome data is different from the routine output data we collect on a monthly basis, and it’s much harder to produce. Outputs are essentially just numbers produced (e.g. number of new clients, number of m2m one-on-one interactions, number of support groups, etc.) whereas outcomes show our achievements and the effect our program has on people (e.g. % of clients on ARVs, % of clients who have disclosed, etc.) With better data collection, we hope to provide feedback not only to site staff about their services and impact, but also to provide programmatic feedback to m2m senior management staff so we can address problem areas and improve upon m2m practices. Basically, we’re trying to do what would sound quite logical and obvious – USE DATA to inform decision making, prove to outsiders we do good work, and motivate staff – but in practice it’s a bit more difficult than that. We already have a ton of data out there in the logbooks kept at each site, but accessing it is a whole other story when dealing with limited resources, the absence of electronic databases, and often less-than-ideal English literacy and numeracy rates at the site level.

Related to accessing logbook data, I’ve been helping develop and pilot a new tool (FYI in m2m lingo “tool” = Excel spreadsheet) aiming to track program quality at the site level. The basic idea is someone could go to a site with their laptop, spend a few hours getting some data out of the logbook, and then use spreadsheet calculations to project site statistics on outcome data. The logbook abstraction process I was previously involved in for the J&J report involved collecting data on individuals and then analyzing trends; this program quality assessment tool is meant to be a much faster way of collecting population level data (as opposed to individual client data). This tool has also been developed such that we can get a feel not only for program quality and impact, but also for level of potential client follow up needs at each site. Active Client Follow Up (ACFU) is a big term on the m2m radar right now, as we explore ways to contact clients beyond when they come to see us at clinics, in order to improve service delivery and increase the % of women who take up a certain behaviour (e.g. take ARVs starting at 28 weeks, have their baby tested at 6 weeks post birth, etc.). Ok, sorry for all the explanations, it just seemed like some context was necessary...

The other week I spent the whole afternoon by myself at a site in Cape Town piloting this Program Quality tool, trying to work out the kinks and see how long it took, how difficult it was, etc. I really must say, I LOVE working at the site level, and once again, I am so grateful my M&E position allows me to do so relatively frequently. It is always so refreshing to hang out with the Mentor Mothers and Site Coordinator and be reminded of how your efforts contribute to something so meaningful in the end. I really can’t say it enough – I am so happy to be taking part in the work that m2m does!

Part of my site visit work involved asking the site staff about whether they would be interested in doing ACFU work, and whether there would even be a need or interest in their opinion. (ACFU work is not entirely simple when dealing with an HIV+ population – you can’t just assume that everyone will want to receive phone calls or home visits, since they may not have disclosed and don’t want to be associated with m2m outside the privacy of the clinic.) It’s always so interesting to get to talk to these women. They were very enthusiastic about sharing their experiences with me and kept saying how nice it was for me to be there using their data, because it made them feel like it was actually important. This is yet more evidence that better data use is a must for m2m, in terms of motivating staff and giving them a better understanding of the number of people they help and the impact they have. There’s a big disconnect between telling someone to record the numbers and getting them interested in WHY they’re recording the numbers, and closing that gap will obviously help improve upon data quality too. When I asked the site staff about whether they would be interested in ACFU (such as being given airtime to call their clients and remind them to come in and have their babies tested), much to my surprise they told me they already keep in touch with their clients on their own. As they described going well beyond the work that they were hired to do, giving their numbers out and making themselves available to their clients 24hrs/day and calling clients on their own, they expressed how much they really cared about their jobs. Very inspiring!

A few days later, the DSITS M&E team (consisting of Monica, Alisha, Ilan (a Pfizer Fellow here until March) and me) hopped on a plane to East London. Monica also brought Angela, her 5 month old baby, who served as an entertaining team mascot. She was very cute and an incredibly well-behaved baby, I must say! We had 3 days blocked out to meet with Nzawki (the woman I did all the J&J data abstraction with), get updated on the Early Infant Diagnosis study that is wrapping up at the East London Innovation Center, talk through the study and decide how we want to analyze and present the data, pilot the Program Quality Assessment Tool, pilot more Data Quality Assessment Tools, go through all the results from the Johnson&Johnson report and share the results with the East London Provincial Managers (PMs are local program managers in charge of about 10 sites each, making sure the site staff have adequate support, maintain good records, don’t run into problems with facility staff, etc.) and get their opinions on the results, discuss how to use the lessons learned from the J&J data abstraction process to integrate data use into m2m programs, and finally to meet with an IT specialist about helping to revamp our routine monitoring database (the one that collects the monthly output data from each site and compiles it into monthly country level reports)…needless to say, 3 days was not nearly enough time to accomplish all of this, despite the fact that we worked nearly every waking hour of the trip!

Of course it was great to see Nzwaki again, and I’m really excited about the fact that we’ll be working together more, as Monica, Nzwaki, and I are going to be the 3 primary people wrapping up the Early Infant Diagnosis Study. I’ve written about this before, but just a quick reminder: the Innovation Center is a new concept that consists of 10 sites in East London where we can pilot new program tactics and evaluate their impact before doing a large-scale roll-out at all 579 m2m sites; the EID study is the first IC study, involving ACFU work. A lot of women drop out of the PMTCT continuum after they give birth, but it’s incredibly important for them to follow-up and get their babies tested because if the baby is HIV+ then early ARV treatment makes a huge difference in the baby’s outcome. Also, all babies should be initiated on cotrimoxizole prophylaxis at 6wks of age while breast feeding. (CTX is an important antibiotic because it’s effective in preventing a certain type of opportunistic pneumonia infection that is the leading cause of death in babies that contract HIV; WHO guidelines say all HIV-exposed babies should be on cotrimoxazole until HIV transmission has been ruled out and the baby is no longer breastfeeding.) The EID study was designed to determine whether improves testing uptake. This involved providing mothers with an actual test date (babies should be tested for HIV at age 6wks; the date given to mothers was predicted based on their expected delivery data; it was reasoned that providing mothers with an actual date might help them better remember/focus on testing), and having mentor mothers make calls and in some cases home visits to follow-up with clients and remind them about testing. We also want to analyze whether such services are sustainable for m2m (a lot of extra cost and manpower are required to organize airtime distribution and client tracking, etc.).

The trip was incredibly interesting. One morning I went out to another site by myself with a PM to again pilot the Program Quality Assessment Tool after I had made some revisions to it based on my experience the week before. Once again, it was so great to get to chat with the site staff, and so inspiring to really hear first hand how much they care about their work. I had actually been to that particular site before with Nzwaki when we were doing the data collection for the J&J report in August, so I shared with the site staff how successful the report had been. (J&J was very impressed with m2m’s work and signed on to not only continue funding 15 sites across the Eastern and Western Cape but also to fund new sites in South Africa, Swaziland, and beyond.) When I thanked them for working hard to keep good records, since it really does make a difference allowing us to prove our impact to donors and subsequently sustain funding to help even more people have the opportunity to access m2m services, they were truly so thrilled, cheering enthusiastically.

We sometimes walk a delicate line when we visit sites to do M&E work, because site staff often get nervous and feel like they’re being critiqued, when really we often just want to learn from them what they find difficult about the record-keeping tools, etc. so we can improve our services. It’s hard not to feel a little out of place as a young, white, American in an African clinic, and I’m sure my appearance and accent do not make it any easier for site staff to feel at ease, but I’m try to just be comfortable and friendly, and at the end of each visit I always feel so grateful for how kind all the women are. It sounds so cliché, and I know I’ve already said a million times, but every time I go to a site I am reminded of what amazing work m2m really does. Once again, the women at this site I visited in East London told me they already follow up with clients on their own. They actually seemed surprised at the fact that I was surprised they already did this (if that makes any sense), as they kept stressing “but it’s so important, and we want to help people, we have to!” When I asked if they minded using their own airtime out of pocket to do this, they said of course they didn’t mind because it was their duty to help other women. Being around these type of women, I feel nothing but admiration. That’s par t of what I love about m2m – it’s not solely about PMTCT; it’s also about women’s empowerment – taking young women who, generally speaking, do not have significant skills and are not good candidates for employment, and making them feel valued and providing them with the chance to do meaningful work in the community.

I learned so much from Monica as we went over the nuances of the Baby Study to date, and I am grateful for the opportunity to participate in this kind of research. It’s so different from lab work, but I think it’s incredibly valuable for me to have an appreciation for these types of studies and to realize the logistical challenges behind making them happen. I’m really looking forward to working with Monica on this further. As an M.D. herself with years of experience practicing in war zones and doing epidemiology work accross Africa, she’s a particularly fitting mentor for me to have. Anyway, I won’t get into to all of the roadblocks we’re encountering with the seemingly simple Baby Study, as I’m sure I’ll more to say about that later as we really delve into the analysis and reporting later this month, but suffice it to say it’s not as easy as it sounds to conduct a meaningful study with this population in this setting.

Ok, enough rambling about m2m stuff for now. All in all it was a great trip to East London! I've really enjoyed work these past few weeks and am looking forward to more to come...