Opportunity Health Ambassadors Hearty Gardens Impact SMS Med Adam Jutha Gladys Manzur Joel Lugones Leena Patel Hans Peng 2012 Triangle Global Health Case Competition UNC Team 4 Prevention of Cardiovascular Disease (CVD) Risk Factors in Kenya ENGAGE. EDUCATE. EMPOWER. 1
2012 Triangle Global Health Case Competition. Prevention of Cardiovascular Disease (CVD) Risk Factors in Kenya. ENGAGE. EDUCATE. EMPOWER. UNC Team 4. Adam Jutha Gladys Manzur Joel Lugones Leena Patel Hans Peng. Executive Summary. - PowerPoint PPT Presentation
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Adam JuthaGladys ManzurJoel LugonesLeena PatelHans Peng
2012 Triangle Global Health Case Competition
UNC Team 4
Prevention of Cardiovascular Disease (CVD) Risk Factors in KenyaENGAGE. EDUCATE. EMPOWER.
1
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med2
Executive Summary
Recommendation: Develop public health prevention programs and strategies to target Kenyans under age 45 in urban areas
Impact: $12.3MM grant from Gates Foundation will initiate sustainable programs for the prevention of CVD risk factors in Kenya
ENGAGESMS MED
EDUCATEHEALTH
AMBASSADORS
EMPOWERHEARTY
GARDENSOPPORTUNIT
Y
• Under 45 years• Urban Areas• Risk factor:
obesity
• Widespread mobile use• Effective
health education channel
• Personal community approach to care• Culturally
sensitive• Low-cost
training
• Sustainable, fresh and healthy alternatives• Local job
creation
Objective: Prevent and manage cardiovascular disease (CVD) risk factors in Kenya
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med3
Agenda
• Urban areas and <45 yrs• Leading factor: obesity
Opportunity
• SMS Med• Financial Cost: $4.5MM Engage
• Health Ambassadors• Financial Cost: $1.3MMEducate
• Hearty Gardens• Financial Cost: $6.5MMEmpower
• Total Financial Cost: $12.3MMImpact
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
1965 1975 1985 1995 2005 2015
9.5 13.5
19.7 27.4
35.6
46.4
Kenya’s population (M)
2.6%
As Kenya’s population grows, CVDs are expected to increase unless public health programs are expanded
3.5%
Kenya’s population growth rate, average
Kenya’s population has steadily increased
The growth rate will likely slow down in the coming years
1966-1975 1976-1985 1986-1995 1996-2005 2006-2015
3.64%
3.78% 3.0
9% 2.62%
2.68%
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med5
Annual deaths from CVD are projected to increase 86%, reaching 80,000 deaths by 2030
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Lay Health Advisors (LHA) model shows proven results in curbing health issues factors in culture driven communities
4 year program 2 year program 2.5 month pilot program 1.5 year program100 Advisors 200 advisors 500 advisors 50 yearsTreating Malaria Hypertension Heart disease &
strokeInfant mortality
• Immunization• Family health
planning• Medication access• Referrals to
physicians
• Monitor blood pressure
• Modify diet, physical activities
• Check blood pressure• Monitor symptoms of
stroke & heart attack• promote healthy
living
• Mental health counselors for black mothers
Diagnosed: 85%Treated: 91%Mortality: -49%
Decreased average
systolic BP from
140 - 108mm Hg
Reduction in hospitalization for
stroke, heart attack: 9%
Initiate primary care: 98%Mortality: -23%
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med17
Training represents the highest cost in this relatively inexpensive program
Year 1 Years 2 through 4
Total
$1,021
$91
$1,293
Costs for Health Ambassador’s Pro-
gram in USD (’000s)
Health Workshops
7%Training Costs for 400 Ambassadors
93%
Workshop and Training Costs
Opportunity Health Ambassadors
Hearty Gardens ImpactSMS Med18
Agenda
• Urban areas and <45 yrs• Leading factor: obesity
Opportunity
• SMS Med• Financial Cost: $4.5MM Engage
• Health Ambassadors• Financial Cost: $1.3MMEducate
• Hearty Gardens• Financial Cost: $6.5MMEmpower
• Total Financial Cost: $12.3MMImpact
Opportunity Health Ambassadors
Hearty Gardens ImpactSMS Med19
Accessibility to healthy alternatives should complement educational programs to allow for lifestyle modifications
Education Healthy Alternative
s
Educational programs through SMS Med and Health Ambassadors provide awareness for people to try new alternatives
Accessibility to healthy food alternatives enable people to practice new habits
Opportunity Health Ambassadors
Hearty Gardens ImpactSMS Med20
Urban food gardens (including “Hearty Gardens”) provide access to fresh and affordable produce
Fresh, organic produce
Improved access to food alternatives
Targets at risk urban population
Community Empowerment
Decreased risk of CVD
MicroGardens use Woolly
Pocket system
Opportunity Health Ambassadors
Hearty Gardens ImpactSMS Med21
“Hearty Gardens” can use Woolly Pockets, innovative and cost-effective technology, to enhance urban gardening
The Woolly Pocket SystemA Modular Gardening System
Space efficiency ideal for urban areas
33% less space required to grow crops
Requires 50% less water.
Made from 100% recycled plastic bottles
Easy set-up and user-friendly
Opportunity Health Ambassadors
Hearty Gardens ImpactSMS Med
• Largest urban center in Kenya• Targets population of 40%
•Funded by Federal Office of Population Affairs and California Wellness Foundation and California Endowment and American Civil Liberties Union
Sex, Etc.
•Has a mobile site that has FAQs, terms, and rights information
•Part of a larger organization answer sex ed, honestly
Sex-Ed Loop
•Part of a larger organization answer sex ed, honestly
•Weekly sex ed tips•Find nearest clinics via text•Mary Beth Szydlowski, the H.I.V. education prevention specialist for Chicago schools, said that Sex-Ed Loop not only reinforces what students learn in class but can reach all teenagers, including dropouts.
•Teenagers write the texts and blogs
Healthy TXT
•Founded in Chicago in 2011, Healthy TXT™ is a physician-designed service that delivers healthy text messages to inspire, engage, and empower people to take action for health
•Educational concussion messages – along with football injury prevention, performance tips, and motivational messages from leading sports medicine physicians, trainers, and professional athletes – will be delivered once or twice a week.
•All subscribers will go through a mini concussion-training course, with a text message and an educational link delivered weekly. Upon completion, participants can take a concussion quiz, and be entered for a chance to win an iPad2. Winners will be announced on Super Bowl Sunday.
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Where else is texting being used?
• A pilot study at Nationwide Children's Hospital in Columbus, OH, found that adolescent patients with diabetes who received text messages related to their medication plan were more likely to comply with it than those who didn't.– http://www.healthy-txt.com/#info
• The Pediatric Heart Transplant Program at NewYork-Presbyterian / Morgan Stanley Children's Hospital is launching a one-year program that will use a text messaging platform to increase medication adherence in its teenage heart transplant patients.
• According to BabyCenter, a social networking site for over 10 million Moms, the mobile phone is a Mom's companion that makes juggling easier. It is also changing behavior as seen in several pilot studies from Harvard and Johns Hopkins Children's Center. Healthy behaviors can be inspired and sustained by using mobile platforms where people live, work, and play.
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Texting Case Studies
• “For better or worse, this technology is here, and sending a text to a patient’s cell phone about an upcoming appointment or a test or simply to remind them to take their meds is a great example of how we can harness new communication technology for a greater good.”
• Research has shown that up to half of patients may fail to take their daily medication properly, with forgetting being a top reason for non-adherence, so at least in some cases, a text reminder may be all that a patient needs, adds Robotham, who has encouraged the use of appropriate texting among pediatricians at Hopkins Children’s.
• one study involving children with diabetes showed improved blood glucose testing rates. These children were also more likely to share their blood glucose test readings with their doctor’s office.
• patients on immunosuppressive drugs after a liver transplant had improved medication adherence. The liver study detected measurable clinical benefits from text-messaging: Acute liver rejection episodes dropped dramatically as a result of better medication adherence.
• Chronic conditions that require daily medication, like HIV, asthma and TB, or daily testing, like diabetes, are great candidates for “SMS therapy,” Robotham says.
• “Texting is an even more popular mode of communication outside the United States, and especially so in developing countries, where most of the TB cases are, so I could see this being a great new way to reach those hard-to-reach patients,” Jain says.
• “Why wouldn’t it?” she says. “A patient can read a text instantly and respond unobtrusively, it doesn’t require Internet access or picking up the phone in the middle of class or an important meeting. Sometimes, I call patients and I get no response, but when I text, I get a response immediately.”
• “It won’t be a silver bullet but it could certainly be a nice little tool in an arsenal of many other tools,” Robotham says.
• By asking questions about glucose testing, meal boluses and frequency of high and low glucoses, Dyer said she saw an increase in teens taking their medications.
• After three months of sending text reminders she reported that they were three times less likely to miss a dose. • "This form of communication allows for real-time health management which is extremely valuable for patients that
suffer from a chronic illness like diabetes," said Dyer.• The study, which was conducted by Mt. Sinai Medical Center's Pediatric Gastroenterology Department in 2008, found
that as a result of receiving regular text alerts liver transplant patients were more likely to have higher adherence rates. The number of rejections dramatically decreased from 12 episodes the previous year to only two during the study 33
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Football Injury Prevention Texting Program
“Texting is an effective way to reach teens and adults where they are today, on their mobile phones,” says Dr. Vishal Mehta, a Chicago area sports medicine orthopedic surgeon, as well as the medical advisor and co-founder of Healthy TXT, the organization behind the public service venture. “Harvard University and John Hopkins Children's Center studies show that healthy behaviors can be inspired and sustained using cell phone technology.”
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Does texting work?
• Quantifying services is difficult. But Ms. Levine, who hosts Sex::Tech, a conference about sexual health programs for youth, said that requests to make presentations about online or mobile services had soared. Typically, she receives between 40 and 50 applications. This year, she received about 120.
• Most online services receive grants from philanthropies, like the Ford Foundation, and health and education agencies on the state and federal level.
• Real Talk held a classroom contest to see which student could send the most texts containing this prevention message: “ROFL!!!” (Translation: rolling on the floor laughing). “STDs and HIV can spread as fast as this message. Still laughing? Pass on the message not HIV/STDs. 518-HIV-TEST.” Within an hour, the message had been sent to nearly 450 phones.
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Technology to make this work exists
Supporting Education through SMS in Kyrgyzstan• The teachers and students we’re working with are attached to their cell phones, and therefore our team
decided to experiment with text messaging as a method of communication. FrontlineSMS software enabled us to use mass text messaging, which streamlined our communication and allowed us to use time more efficiently. It only takes about a minute to send out text messages to all of our teachers through FrontlineSMS, whereas in the past staff were making individual calls which took a lot longer.
• Few people have internet in their homes, yet everyone has mobile phones and so using SMS makes regular communication accessible to more of those we work with. When we ask teachers how they like working with SMS, they say that they find it very convenient, useful and flexible.
• We plan to collect SMS feedback reports from our program participants on how often they attend IREX trainings and where trainings are being held. We will then map these reports using online mapping tool Ushahidi, and this will allow us to visualize our impact. addition, the GCE program is also planning to use FrontlineSMS to conduct polling and short surveys among students and teachers, which will help us to further understand the value of our program and the needs that program participants have.
CareSpeak Communications Inc., a privately held mobile health company in New Jersey • The study was so successful that half of the patients that participated in the study in 2008 are still in the
program today, says Miloh. • “Before this program, we had only the power of people trying to educate the children and their families
about the deadly nature of noncompliance,” adds Addonizio. “Now we have the ability to give these adolescents a safety net to help them become responsible.
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
What is the purpose of answer, sex ed ?
• They are only focusing on the risk-reduction model - Valerie Huber, executive director of the National Abstinence Education Association
• Those who run digital programs say they simply want teens to have accurate information, to help them make good decisions. Even though popular culture is saturated with sex, facts and advice can be hard to find.
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Sensitivity Analysis for LHA Costs
Conservative Estimated LiberalEvents per Year 4 4 4Locations 10 10 10Total Events per Year 40 40 40
Attendees per Event 400 400 400Tables Needed per Event 20 20 20
Per Tables + 6 Chairs Rental Cost $ 20.00
$ 13.50
$ 10.00
Source: www.costhelper.com
Table+Chair Cost per Event $ 400.00
$ 270.00
$ 200.00
Highschool Gym Rental $5,000 $2,000 $1,200
Total Cost per Event $5,400.00 $2,270.00 $1,400.00 Total Cost of Events per year $216,000.00 $90,800.00 $56,000.00
Total Number of Health Ambassadors 200 200 200Training Cost per Ambassador $8,000 $4,500 $2,000
Medical Supplies $450 $150 $30
Source: http://www.mystethoscope.com/
Total Training Costs $1,690,000 $930,000 $406,000
4-year Total Cost$2,554,000.0
0 $1,293,200.00 $630,000.00
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med39
Education via lay health advisers (LHA)-led workshops will surmount to sustainable and long-term benefits
Similar programs have a track record of success
Improves access, the role of the health worker, and outcomes among at-risk population
Addresses a more effective and
communal approach that educates
preventable care
Program will train health workers in
educating the at-risk populace adopt
preventive care and adherence to
suggested treatment=
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
CVD risk factors are increasing
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A partnership with the Canadian Public Health Association (CPHA) can aid the success of preventative education for at-risk populations
• Prevention• Promotion• Protection• Policy
Shared Principles
• Previously helped fund $110,000 to 100 LHAs throughout Kenya
• Extensive Training; Low Drop-out Rate
Precedent• Use budget to organize
health workshops in the community; visit households.
• Act as health facilitators and advocates
Partnership
CPHA will fund the training of LHAs while also providing them a budget for health promotion events (i.e. workshops)
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med42
Focus should be on recruiting community leaders in Kenya’s urban areas
Note: Education level of LHAs does not matter: study shows it makes no significant impact
WHERE WHO
Recruit local
community leaders
Has more knowledge of
their community health status &
needs
More respect and resources
Able to develop better
relationships
Hypertension and obesity is more prevalent in urban areas
LHA model is more needed in urban areas
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med43
Health Ambassador Program will train LHAs to budget and program health workshops
Provides and teaches basic health
services
Introduce innovate
technologies
Encourage healthy
action plans
Organize health
workshops
Acts as a facilitators
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Health Ambassador Survey – Metrics
Measure awareness, comparing pre and post-event awareness from likert scale
Measure effectiveness of event and how likely you’re going to incorporate newly learned info into their daily regimen
Measure attendance of events, from those that were marketed (at-risk population). This measures response rate
Assessment of health ambassador and their confidence and respect for them. Perceived effectiveness?
How entertaining was the event; receptiveness
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Information on Training and Recruiting
The CHWs in the Krieger et al., Jafar et al. and Gary et al. interventions were trained to counsel patients to adopt preventive care and adhere to the treatment of hypertension
They were taught the risk factors for cardiovascular diseases and trained to conduct blood pressure measurement
The CHWs recruited in these interventions were mostly locals from the community
Having a personal experience of managing own illness or someone else in the family resulted in producing highly significant results
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Information on Canadian Public Health Association and Testimonial/Quotes
Community Health Workers in Kenya Stir Broad ChangesThis article appeared in the January-March 1996 issue of One Country.Active in more than 200 communities, a project to promote vaccinations has also helped to build a new level of intersectoral and interfaith collaboration - collaboration that has paid off by stimulating the construction of latrines and helping create better access to clean water
“The project is funded in part by the Canadian Public Health Association, which has provided about $110,000 to the project over the last three years.”
Testimonial: "When I attended the first community health worker training, I did not know that I would find my answer there," she said. "But since the training program, I've been able to help my family, my neighbors, all the village and the surrounding villages to understand what is primary health care and how easy they can improve their health. And I feel there is an answer to my question, that we all can do something to improve our health.Dr Santau Migiro, Division of Child Health, Ministry of Public Health and Sanitation, disclosed that currently, the doctor to patient ration is 1: 10,000. The WHO recommends 1:1000.46
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Health Ambassador Program is not expensive
Adviser incentives were reported to be more on knowledge, empowerment, and public recognition
Proven that when communities take a grassroots effort---public health campaigns are more effective
Focuses on how the info diffuses and who the sender is
Not expensive
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More support on Health Ambassador Program
CVDs impose severe costs on the health-care system but there is not enough present
emphasis to combat this
Essential to move to programs in that focus on risk factor prevention and initiatives for health promotion at every level (individual, family, community and national).
A Health Ambassador Program does this:Primary control and prevention of CVD risk factors helps strengthen, rather than compete, with health-care interventions for other diseases
Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Capital costs (land, site development, Woolly Pockets) total $4.0MM to build 640 “Hearty Gardens” over 4 years
Cost per Woolly Pocket Unit (USD) $ 30.00 Source: woollypocket.com
Cost per Acre (USD) $ 300,000.00 Source: http://grahamgjfencing.co.uk/GJFENCINGServices.aspx
Fencing Cost per Meter (labor included) 67.18
Perimeter per Garden (m) 22
Total Fencing Cost (USD) $ 941,460.52
Total Land Cost (USD) $ 1,337,700.00
Total Woolly Pocket Purchase Cost (USD) $ 1,718,220.00
Total Capital Cost (USD) $3,997,380.52
Capital Cost Analysis for the 4-year “Hearty Garden” Construction Plan
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Total Produce Servings demanded 5727388Annual Produce Servings per Woolly unit 100Units Required (demand/servings per unit) 57274
Units per Hearty Garden 90Total # of Hearty Garden Required 637
Kenya Minimum Wage per month (USD) $100.89 Source: BloombergAverage Workers per garden 2Labor Cost per Month (USD) $128,533.86 Labor Cost per Year (USD) $1,542,406.32
Soil+Water Annual Cost per unit (USD) $ 15.00 Seed Annual Cost per unit (USD) $ 7.00 Material Cost per Year $ 1,260,028.00 Total Annual Variable Cost $ 2,802,434.32
Labor and material costs to build 640 “Hearty Gardens” total $2.8MM over 4 years
Variable Cost Analysis for the 4-year “Hearty Garden” Construction Plan
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Opportunity Health Ambassadors Hearty Gardens ImpactSMS Med
Capturing just 1% of Nairobi’s produce market at a reduced price would yield an annual revenue of $3.2MM
Market Demand Analysis for “Hearty Gardens”
Nairobi population 3,138,295 Source: World Bank
Average Servings per person per day 0.5Days per year 365
Price per serving (USD) $ 0.56 Source: http://www.numbeo.com/cost-of-living/city_result.jsp?country=Kenya&city=Nairobi