Global Health Travel Blog

UNC Gillings students share their global field experiences around the world.

Month: July 2018

Exciting month in Uganda!

It has been an exciting month for the Sayana Press team in Uganda – and, tangentially, an exciting month for me!

The PATH vehicle parked in the staff quarters at Kityeyera Health Center IV, Mayuge district.

The PATH vehicle parked in the staff quarters at Kityeyera Health Center IV, Mayuge district.

After successfully launching a nationwide scale up of the provider-injected Sayana Press drug in 2016, the PATH team has been focusing on introducing self-injection. After several months observing self-injection in four target districts, the team set out to conduct an evaluation with the goals of, 1) finding out whether self-injection is working for women in rural areas and 2) learning which variation is most cost-effective.

I joined the team as they were wrapping up their first phase of the evaluation: interviewing the providers who were training women to self-inject. In the second half of my internship, we were busy preparing to launch the second half of the evaluation: interviewing users themselves. Throughout both phases, the team also facilitated monitoring visits at each site to support the field teams. It turns out, starting when I did was a perfect time! I was able to observe the launches of both phases as well as join the team in the field for monitoring visits and jump in on some trainings.

Kirsten holds a case of Sayana Press to be delivered to field sites in Mayuge district.

Holding a case of Sayana Press to be delivered to field sites in Mayuge district.

The PATH vehicle loaded up with cases of Sayana Press for delivery.

The PATH vehicle loaded up with cases of Sayana Press for delivery.

One of the trainings was conducted in July. I joined the team’s Scale-Up Manager, Edson Twesigye, to travel to Mayuge district in Eastern Uganda to orient new providers to the program and “train the trainers” in self-injection. We visited two facilities, Kityeyera Health Center IV: a bustling, district-level referral clinic/hospital, and Muggi Health Center III, a sleepier, more rural center still serving a fairly large population. Observing how Edson facilitated the training sessions offered a lot of insight into PATH’s training methodology, and I enjoyed the chance to also facilitate my own sessions as well. I spoke to the groups about the procedure for using the self-injection register, a reporting tool developed by the team to ensure accurate data collection. The team had found in other sessions that the register was sometimes confusing for providers and was being filled improperly, particularly a few vital questions. I enjoyed the chance to discuss their challenges with them and we were able to clarify several key points. This exercise was an informative opportunity to improve my understanding of data collection tools, especially as we focused on data entry at the point of service delivery.

Conducting a training session with self-injection providers. (From left: Kirsten Miner, Violet Asiimwe, Lydia Namuganza, and Jaliya Nabirye.)

Conducting a training session with self-injection providers. (From left: Kirsten Miner, Violet Asiimwe, Lydia Namuganza, and Jaliya Nabirye.)

A key component of training is reviewing and practicing the self-injection procedure with each training team. Self-injection is a 10-step process which is led by a “job aid” – a series of pictures, each with a corresponding instruction, that guides a user through prep up to completion of the injection. There are four critical steps: mixing the solution by shaking the vial, activating the device, pinching the skin at the injection site (abdomen or thigh) to make a “tent”, and then pressing the reservoir slowly to inject the drug. It was exciting and illuminating to watch the training team in action!

Research Assistant Violet Asiimwe makes a model using a condom and salt which is used to simulate an injection site for a training.

Research Assistant Violet Asiimwe makes a model using a condom and salt which is used to simulate an injection site for a training.

After returning to Kampala from Mayuge I joined the team in completing our remaining duties to prepare for Phase II of the evaluation: client survey administration. This training offered even further opportunities for observation, learning and practice. Overall, I had an amazing internship with the PATH team in Uganda. I look forward to following the Sayana Press project further and delving into the results of the evaluations!

-Kirsten

 

Too Good to be True

A retiree immigrant shopping at the organic market near downtown.

A retiree immigrant shopping at the organic market near downtown.

I do not want to exaggerate when I say this, but visiting San Miguel de Allende (San Miguel), Mexico, for the first time was magical. This small city is the second colonial city that I am visiting for my practicum about the impact of Western retiree immigration in Latin American cities. San Miguel has a deep history tied to the Mexican revolution, silver trade, and powerful Spanish families, but it’s fascinating how the words of American writer Stirling Dickinson were what attracted Westerners to this baroque city: “There was enough light for me to see the Parish church sticking out of the mist. I thought ‘My God, what a sight! What a place!’ I said to myself at that moment, ‘I’m going to stay here.’”

I share this brief overview of San Miguel’s charm because it illustrates how easy it is to overlook the concerns of the city and the surrounding communities. Look beyond the beautiful architecture and breathtaking views of the highlands and it becomes clear that the city has been operating for outsiders for a couple of decades. While the locals have either been forced to move to the outskirts of the city or leave the area altogether, the economy has largely catered to American and Canadian retirees who desire the amenities and culinary taste of their home countries while wanting that performative element of a more colorful culture. Of course, because of the retiree’s persistence and economic power, they are also the reason why San Miguel has the largest concentration of non-governmental organizations in Mexico, working to solve or mitigate problems related to natural preservation, animal abandonment, children’s vision, water quality, and over a hundred more issues.

Preparing for drone footage over San Miguel de Allende. (Photo credit: Erika Munshi).

Preparing for drone footage over San Miguel de Allende. (Photo credit: Erika Munshi).

Through my qualitative research in San Miguel I have gathered that the presence of retiree immigrants has morphed the social determinants of health for the community in a manner that benefits some while harming others. If you ask any key stakeholder in San Miguel what they think about retiree migration and the effects on the community, they will likely say that the retirees have been the best thing to happen to San Miguel because they have created jobs, have demanded better services, instituted a culture of volunteerism, and have helped San Miguel become one of the most desirable cities to visit in the world. These stakeholders might be government officials, real estate agents, or geriatric specialists, but they often also own other commercial businesses catered to retirees and tourists in general. If you ask people who operate outside of these circles (like a store owner in a predominantly low-income Mexican neighborhood), you will hear how difficult it is to afford living in San Miguel with stagnant wages. Those jobs that the retirees created, like housekeeping and gardening, do not pay enough to maintain families. There are families who owned homes in the center of town for generations and have been offered thousands of dollars to move elsewhere, and so they do, but they move to the outskirts of the city that may or may not have reliable municipal services. With the city’s water quality concerns of high fluoride and arsenic levels—especially in the outskirts of the city where the government must ship well water for distribution—you’re seeing teenagers experiencing early onset osteoporosis and children with developmental delays, among other health concerns.

The iconic Parroquia de San Miguel Arcangel in downtown.

The iconic Parroquia de San Miguel Arcangel in downtown.

I feel like there is more to this story than we have the capacity to capture in this exploratory project, and with only one week left in San Miguel, I am hoping there is enough time to properly share the story of the community.

-Karla

Lessons from the Field

My last day at the MAZA office in Tamale. (L-R) Rufal Abdul-Nashiri (Nash), Accounts Officer; Me; Genevieve P. Nyewieh(MzGee), Community Relations Manager; and Isaac K. A. Awuni, Driver Relations Manager.

My last day at the MAZA office in Tamale. (L-R) Rufal Abdul-Nashiri (Nash), Accounts Officer; Me; Genevieve P. Nyewieh(MzGee), Community Relations Manager; and Isaac K. A. Awuni, Driver Relations Manager.

Hello everyone!

It’s been quite the adventure since my last post. I went back into the field for the questionnaire portion of our field assessment. This part of the project was more interactive, which I enjoyed. For this blog post, I wanted to share with you two main lessons I learned in the field and working with MAZA overall.

Lesson 1. Leave your expectations and fantasies out the door before you enter any new community, venture, job, anywhere.

I realized my first day in the field that my idea of what it would be was very much glorified. I had received words of advice and told what to expect from my preceptor, Nana, but that didn’t prepare me for the actual act of being in the field. For many years, before embarking on this MPH journey, I had created a fantasy of what working in the “field” in public health would be like, and this was not it. It was tedious, and I thought to myself: “maybe I’m not built for this.” But then days 2 and 3 came and I got to learn the communities I was in and it seemed a little less like work every day. I was built for this after all, and it was only when I had set aside my expectations that I began to enjoy it.

Lesson 2. Be aware of what your presence in a new community may represent, of the privilege you have to be working in that community, and its implications.

Be cautious entering into a community you’re not a part of – whether your work requires physical interaction with others or not. The first part of my field work required little interactions with community members outside of MAZA drivers, and that’s when I felt most out of place. I didn’t speak much because my work at the time didn’t require it and I didn’t speak any of the languages, and that’s what made me stick out the most. And though the community members were welcoming of our field assessment as they were familiar with the MAZA team members I was with, there were moments where I couldn’t help but feel intrusive. I had to make conscious effort of my presence in each community to gain perspective and for a more enriching experience.

Me riding a motorbike for the first time with the help of Genevieve. Motorbikes are a common mode of transport in Tamale, and it was only right that I learn to ride one while there.

Me riding a motorbike for the first time with the help of Genevieve. Motorbikes are a common mode of transport in Tamale, and it was only right that I learn to ride one while there.

For the past few weeks, I’ve been back in Accra working on the not so adventurous things like completing a literature review, analyzing data, and writing. I look forward to seeing how this project makes an impact on MAZA’s program in northern Ghana.

Thank you all for the opportunity to share my experiences with you.

Best,

Edith

Greetings from Malawi, the warm heart of Africa

We have a new blogger, Aninda Sen, a master of public health student working with the UNC Water Institute and World Vision in Malawi and Kenya this summer! He’s checking in from Malawi!

As I have discovered first hand, this country is fully deserved of that title, as you cannot walk down the streets for 5 mins without someone waving to you while shouting “Hello” or as they say it here “Muli bwanji”. The country is beautiful, and its people are warm and welcoming to all, and in recent times, there has been great leadership shown in access to safe water, sanitation and hygiene. And this is where I will be working for the first half of this summer.

Wanted to throw a picture in there. That’s me (right) and my friend Natsumi (left) at Sandram, Lilongwe. She is another one of the interns from UNC working on this project.

That’s me (right) and my friend, Natsumi (left), at Sandram, Lilongwe. She is another one of the interns from UNC working on this project.

I am currently in Malawi working on my summer practicum with 2 other students on a project which is part of the long-standing successful partnership between the UNC Water Institute and World Vision Malawi. As part of the assessment team working on the functionality of solar powered water pumps in rural Malawi, I am collecting data in order to understand the sustainability and effectiveness of solar pumps, as well as testing water samples from various water points in order to determine the safety standards and any health risks involved to those who depend on this water for their daily activities. My work also involves gauging the impact of the improved access to safe water on the economic development of these rural communities. The vast majority of my data is collected through the use of electronic surveys and interviews with the local people and water committee members living in the villages served by solar pumps. This has allowed me work with the team trying to understand the future potential of such large-scale projects in areas where water has traditionally been difficult to come by. It has also given me the opportunity to interact with the people who are directly being affected by these water systems. And to be honest, that is the most rewarding part of my work. Everyone I come across in these small communities has such useful information to provide when it comes to evaluating the effectiveness of the water pumps. Coming from a developing country myself, where electricity is not always available throughout the year, this has allowed me to begin exploring the possibilities provided by clean, sustainable energy sources such as solar power. Also, the villagers cook a mean pot of psima with “mileage” chicken, so that’s a bonus that accompanies all the traveling.

The work often takes me off the beaten path, to some hard to reach communities, and that is my opportunity to get to explore the country a bit more closely. I am a trigger-happy cameraman, which means all the travel has exposed me to some dramatic scenery and breath-taking African sunsets. I am only 4 weeks into my work, and I feel like time is flying by way too fast for me to take all of this in. We have been to the villages of Langa and Sandram, and every community offers the opportunity to learn something new about the WASH system, and how it is being managed for a bright and sustainable future.

Our team of interns recently went to Lake Malawi for the weekend to take a small break from all the field work, and it was one of the best holiday destinations I have ever been to. Beautiful scenery, amazing beaches and crystal-clear water, to go with the amazing food.

Sunset upon Lake Malawi.

Sunset upon Lake Malawi.

The time I have spent so far in Malawi has been very helpful in helping me become a more well informed public health practitioner. I cannot wait to see what the next few weeks have in store for me. I will be sure to keep you all updated. Till then, have a nice day, or as they say here “Mukhale ndi tsiku labwino”.

-Aninda

Farewell, Malawi

Patient education related to HIV preventive behaviors and stigma.

Patient education related to HIV preventive behaviors and stigma.

The second part of my time in Malawi was meant to be spent working on the second objective of my practicum experience, which is to help to create an interim report (“results brief”) for the partners, funders and key policymakers, using the study’s protocol information and the data collected thus far. Since mid-January 2018, the study team has been gathering data from participants who were referred to and/or enrolled in the national Prevention of Mother-to-Child Transmission of HIV (PMTCT) Program between July 2016 and June 2017 at 11 different facilities in Lilongwe district. The plan was for me then to work with the Head of the Analysis and Manuscript Writing Unit of the UNC Project-Malawi, to analyze the data and produce the report. The study’s timeline projected that all data in Lilongwe would be collected by May, and that after a couple weeks the study team would move north to enroll participants from the Mzimba South District. I would then work on the interim report and perhaps spend one of my last weeks with the study team up north.

UNC project employee on a documents and samples drop/collection in the Area 25 Health Clinic.

UNC project employee on a documents and samples drop/collection in the Area 25 Health Clinic.

After a slight delay, the study moved to the Mzuzu Health Center, a five-hour drive from Lilongwe. Unfortunately, two weeks later, half of the team had to come back to Lilongwe because as we crosschecked information and started data cleaning for the statistical analysis, we discovered that there was some missing data. There had been issues related to data collection and recording methods, and we would need to return to some sites. The study design proposed the collection of retrospective data on each woman and her infant from PMTCT enrollment through the child’s second birthday, but several logistical difficulties have delayed the team’s efforts. The challenges include reduced time to access the electronic medical record system and the lack of electrical power in the facility. Furthermore, in Area 25, the biggest site in Lilongwe, 307 Mother-Infant Pairs (MIPs) were sampled for the study’s nested cohort, but about a third of those could not even be contacted or traced because their location information was not enough to enable my colleagues to find them.

Educational messages on the walls of the Area 25 Health Clinic ARV waiting area.

Educational messages on the walls of the Area 25 Health Clinic ARV waiting area.

Educational messages on the walls of the Area 25 Health Clinic ARV waiting area.

Educational messages on the walls of the Area 25 Health Clinic ARV waiting area.

Front view of the Area 25 Health Clinic ARV waiting area.

Front view of the Area 25 Health Clinic ARV waiting area.

While that is being sorted, I have been continuing to support the research team with data entry and management tasks, such as quality control, tabulation of information and the improvement of different control tools used for the study. Towards the completion of my second practicum objective I have been working on analyzing some of the data with STATA and summarizing information from our study protocol to be relevant to our audience. You can see the first two pages of the draft results brief below. The report is formatted according to pre-determined design guidelines.

As my departure approaches, I can say that the last two months have been extremely significant to me. I have been able to combine my previous professional experience and my MPH knowledge and skills, and have a positive impact in very meaningful and interesting work. I now very much look forward to being back home (my heart is in Chapel Hill/Carrboro) to complete the program and to work with an amazing Capstone team for the next academic year!

My deepest thanks to the UNC Project-Malawi SOAR PMTCT study for hosting me, to the amazing Health Behavior faculty and staff who have been so supportive, and of course to the Research, Innovation and Global Solutions team who helped make the trip and stay here easier. I look forward to sharing more details about the study and my work during Practicum Day!

See you! Tiwonana!

-Rigo