D’Arcy Williams, a Peace Corps volunteer in Cameroon, helped build and implement a CommCare-based mobile data collection app to aid in patient data collection for an HTC campaign around World AIDS Day 2017. He outlined the challenges they had with their old data collection process and successes his team experienced when they switched to a new mobile data collection tool, as well as his hopes for the program’s future and evolution.
Consent. Confidentiality. Counseling. Correct test results. Connection to prevention, care, and treatment. These “Five C’s,” as laid out by the World Health Organization (WHO), are the basic requirements for HIV Testing & Counseling (HTC). Each of the five elements, difficult to guarantee even within the walls of a health center, becomes increasingly challenging to maintain when bringing HTC services to the community level. The collection and secure storage of sensitive data is one of the biggest challenges of maintaining these elements.
Across many majority world countries, including Cameroon, HTC campaigns rely on antiquated paper-based data collection methods, where patient information is written by hand. Imagine a community-level HTC campaign. Hundreds of people in a crowded public space, waiting in a slow-moving line, as an overworked HTC team anxiously writes down information as fast as they can. Handwriting gets messy. Mistakes are frequent. And, after a long day of work, someone will spend 10+ hours manually entering thousands of data points into an Excel sheet.
This chaotic image was precisely what my Cameroonian counterpart Dr. Cavin Epie Bekolo and I wanted to avoid as we planned a free HTC campaign in our small town in the Littoral Region of Cameroon.
HIV Testing and Counseling in Cameroon
Free community-level HTC campaigns have long been successful at reducing barriers to accessing critical HIV services in Cameroon. Campaigns bring these services directly to the community, meeting the most vulnerable populations where they are. These community-level testing strategies also play a vital role in reaching Cameroon’s objective of 90% of all people living with HIV knowing their HIV status by 2020. This ambitious goal, set by UNAIDS with support from a number of partners including Peace Corps Cameroon, has promoted a surge of HTC campaigns across the country, encouraging every Cameroonian to know their HIV status.
World AIDS Day 2017
The free HTC campaign would be the first held in four years as part of a comprehensive HIV prevention project in celebration of World AIDS Day 2017. Dr. Bekolo and I designed the project based on clear priorities presented through health statistics and community surveys. Health center records suggested an HIV prevalence rate of 8.3%, but over 75% of the town’s secondary school students had never been tested. Due to the lack of youth-friendly health services, many young people had never been presented with the opportunity to be tested for HIV. The project also aligned with the opening of a new HIV Treatment Center at the sub-divisional hospital, so Dr. Bekolo decided to jump-start the new treatment program with a community wide testing event.
I worked with Peace Corps Cameroon staff to secure a PEPFAR grant and established partnerships with local schools, youth leaders, and government authorities. As the center of the project, the free HTC campaign would last five days, accompanied by a variety of engaging activities such as talent shows, football matches, HIV/AIDS murals, “10K Race Against HIV/AIDS Stigma”, and Gender & HIV/AIDS workshops. Our team hoped the collaborative nature of the project would bring free HTC services to all local secondary school students (about 1,300 young people).
Based on the project’s desired scope, it was clear that the traditional paper-based data collection method wouldn’t work. How would the HTC team hand-write people’s information quickly enough to reach thousands of people, while also maintaining data quality? Would they be able to keep the information private as people constantly crowded the tables? Who would be tasked with the tedious deed of manually entering the data into Excel?
These concerns led to an innovative yet simple response. I suggested turning the original paper HTC data collection sheet into an digital survey with the help of CommCare.
CommCare served as an easy-to-use platform, whose improved data collection and case management features would be exactly what we needed. Early in my service, I had used CommCare to conduct a community priorities assessment – interviewing over 300 community members on an Android tablet. It was obvious that the same technology could be beneficial to the HTC campaign through a simple data collection application. Peace Corps Volunteers across West Africa have had great success with CommCare, specifically with effective malaria focused projects in both Senegal and Benin.
With technical guidance from Dimagi Academy and Dimagi Senior Field Manager Siobhan “Chevy” Lazenby, I was able to replicate the Ministry of Health’s HTC survey onto a CommCare application. Same questions. Same sequence.
Questions that once took 8-10 seconds to write on a sheet of paper became 4-5 seconds to tap on a screen. Instead of having a physical sheet of paper with patients’ names, personal information, and HIV statuses – all of this information would be safely stored in CommCare. Whether testing 10 or 10,000 people, there would be no sensitive pieces of paper to keep track of. At the end of the day, data would automatically upload to the server via mobile data. Then it could be downloaded as a clear and simple Excel document, ready to analyze instantaneously.
In some cases, CommCare’s functionality in the survey helped avoid data entry mistakes. Telephone numbers – the most important method of contacting an HIV+ patient – are easily miswritten when recorded by hand. Using more advanced logic, the application validated telephone numbers that began with a “6” and were nine digits long – otherwise an error message would appear. The CommCare application provided a safety net when collecting this crucial information.
The HTC team was made up of 13 local medical professionals – one supervisor, one pre-counselor, three recorders, three lab technicians, and five post-counselors. Dr. Bekolo designed the logistical flow to prevent bottlenecks and cut individual wait times. The Cameroon Baptist Convention (CBC), a well-known actor in the area of HTC in Cameroon, graciously agreed to train the team on proper HTC protocol. While CBC trained counselors and technicians, I worked with the recorders on the operation of CommCare on Android tablets. They were instantly enthralled by how easy, clean, and quick the application made their job. It was clear that none of them missed the responsibility of writing thousands of data points by hand. To quote Lisette, one of the recorders, “It is truly doing the work for us!”
Most importantly – no one would have to spend weeks manually entering data into Excel.
The speed and efficiency of the HTC team improved each day. They were able to process hundreds of people in a matter of hours. CommCare changed the face of the project and allowed patients to advance through the HTC process quickly, while maintaining their confidentiality and dignity. All of their information was stored safely and securely thanks to CommCare.
In the end, the results of the dedicated HTC team’s efforts exceeded our expectations. Over the span of five days in schools, churches, and markets, the team provided 2,024 community members with free HTC services. Over 50% of those tested were young people (15-25 years old) and 77% were first timers.
Upon the project’s completion, all data was directly uploaded to the CommCare server and downloaded in an Excel document. Dr. Bekolo was immediately able to analyze the results and plan next steps. Positive cases were contacted to begin treatment, care groups discussed, and target populations formed for future work.
As a prominent actor in the fight against HIV/AIDS in Cameroon, CBC is recognized for testing thousands of people for free each year. Upon witnessing CommCare during the training, CBC was interested in learning more about the technology. Lauretta Kometta, CBC’s Program Manager for the South-West Region, discussed with me the potential for piloting their own CommCare application. CBC realized the software’s potential to revolutionize their data collection methods. Since the HTC campaign, CBC has purchased three Android tablets to begin piloting CommCare applications that I have helped build. If successful – Lauretta hopes to leverage CommCare across all their national programs.
Given the success of the World AIDS Day 2017 project, CommCare’s simple data collection platform might earn its place as the sixth “C” of HTC. It made the project quicker, more confidential, and more accurate. Such technology has the potential to revamp the entire HTC strategy in Cameroon. Other Peace Corps Volunteers have begun to collect their HTC data via CommCare and CBC is about to pilot the strategy for their own work. In addition, through a publication with the Pan-African Medical Journal, Dr. Bekolo and I hope to share our HTC best practices with Cameroon’s Ministry of Health.
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