Internet Protocol Messaging for Global Health The IP4GH Case Study Series
Photo credit: Praekelt.org
The Internet Protocol (IP) Messaging for This series of case studies is the product of Health case study series is a compilation of a workshop “Leveraging Smartphone- case studies by IP4GH showcasing the Enabled Group messaging for Global innovative work of IP implementers Health” held on the 23rd of May 2019 at globally. Columbia University School of Social Work in New York City, USA. IP messaging refers to real time messaging using mobile phone applications via the Suggested Citation internet. Common IP applications include Batista, T., Ronen, K., Copley, C., Guthrie, WhatsApp, Telegram, Snapchat, Facebook B., Grant, E. (2019). Internet Protocol Messenger, Signal, & WeChat. Messaging for Global Health: The IP4GH Case Study Series. P4GH is a community of individuals and organizations using IP messaging to Corresponding author: support global health. Dr. Eli Grant [email protected]
1 CASE STUDIES
Case Study 1: Médecins Sans Frontières (Doctors Without Borders)...... 3 Group and peer-to-peer interventions for youth living with HIV
Case Study 2: Médecins Sans Frontières (Doctors Without Borders)...... 5 Building a new approach to health promotion using Facebook
Case Study 3: University of Washington………………………………………………….. 8 Projects use WhatsApp to provide social support for youth living with HIV in Kenya
Case Study 4: University of Washington………………………………………………….. 11 Using two-way SMS and WhatsApp to help young women in South Africa to prevent HIV
Case Study 5: VillageReach………………………………………………………………... 14 Using WhatsApp to Understand Adolescents’ Contraception Preferences in Malawi
Case Study 6: Ariel Superstars ……………………………………………………………. 17 Using WhatsApp to Offer Peer and Psychosocial Support for Youth Living with HIV
Case Study 7: Planned Parenthood ……………………………………………………... 20 Republic partners with Planned Parenthood to create a WhatsApp support network for adolescent mothers
Case Study 8: Patient Engagement Lab…………………………………. 23 Application and Testing of Rapid Pro Sidekick WhatsApp Anonymized Group (WAG) Tool
Case Study 9: Empilo Salud……………………………………………………………….. 25 Peer-to peer mHealth support via WhatsApp for Venezuelan refugees
Case Study 10: Jacaranda Health and Jacaranda Maternity…………………………… 28 Moving from IP Messaging to SMS to reach low- income mothers in Kenya
Case Study 11: Dimagi…………………………………………………………………….. 31 A semi-automated conversational agent built by Dimagi and the Department of Women and Child Development of Madhya Pradesh
2 CASE STUDY 1: MÉDECINS SANS FRONTIERÈS Group and peer-to-peer interventions for youth living with HIV
BACKGROUND
Youth in South Africa are poor utilizers of HIV health services (Murray, 2017). From March 2015 to May 2018, Médecins Sans Frontières (MSF) in collaboration with the Cape Town City Health Department, established a youth-only clinic in Khayelitsha, an informal peri-urban settlement in Cape Town. The clinic has piloted a variety of youth-adapted services, including youth-friendly counselors, point of care CD4 testing, and mentorship services. The youth clinic is largely funded by City Health and additional services are provided by MSF, who receives funding through individual public donations only and accepts no institutional funding. PROJECT DESCRIPTION
“When I was in the group, IP messaging is used by the youth-only clinic for peer-led I felt like we were are all virtual mentorship (Hacking et al., 2019) and counselor-led the same. I don’t have peer group support (Hacking, 2019). The project aims to that thing of measuring increase peer support to improve linkage to care, ART myself because of my initiation, and adherence amongst youth, aged 13-25, living condition and we are able with HIV in Khayelitsha. The mentorship program links to advice each other HIV-stable youths with newly diagnosed youths. Dyads can about right things- you communicate over any platform of their choosing, although would say do this now, it usually WhatsApp is selected. Additional support is offered is all right. Do not do this, through counselor-led HIV youth clubs, which have ongoing do the right thing” WhatsApp group chats and meet monthly in-person at the clinic. The project: -HIV Club Participant ● Has bidirectional, rich media, and facilitated group based components ● Offers psycho-social support and information for patients ● Aims to change health related behavior 3 WhatsApp for HIV-positive Youth: Group and peer-to-peer support interventions and MSF
EVALUATION
Two studies by MSF examined feasibility, acceptability, and potential outcomes. One quasi-experimental evaluation found that mentees had higher ART initiation rates (80%) and completed viral loads (80%) than matched controls (42%, 36%). However, no differences were found in viral load suppression or retention in care. In-depth interviews found mentees valued the program and preferred phone calls to messaging or in-person conversations (Hacking et al., 2019). In an earlier mixed methods study, self-reported use of the MXit chat-room was low, but participants expressed interest in interacting with their peers more through social media (Henwood et al., 2016).
HIGHLIGHTS
Software. The same model was piloted over a variety of platforms. MSF initially customized MXit, an open-access software but is now using WhatsApp.
Integration. IP messaging was combined with in-person meetings, SMS, and phone calls and links data to national digital clinical administrative data systems, primary research study data, and clinic or service data.
Inclusion. Expert-led design was combined with beneficiary involvement, with many aspects youth-led. Both MXit and WhatsApp were chosen because they were popular platforms. Youth mentors provided self-directed one-on-one peer support over digital platforms. 4 CASE STUDY 2: MÉDECINS SANS FRONTIÈRES Building a new approach to health promotion using Facebook
BACKGROUND PROJECT DESCRIPTION
South Africans with Tuberculosis, HIV, This first IP messaging project aims to and those who experience gender reconnect persons living with HIV, in based violence are not uptaking and Khayelitsha, to care via Facebook using health services enough. Médecins conversations. To qualify, this population Sans Frontières (MSF) is developing must have been disengaged from HIV care social media and digital communication for more than 3 months. The pilot used health promotion strategies for enabling messages workshopped with Patient hard-to-reach populations in South Ambassadors to create engaging content for Africa to increase uptake and utilisation social media that will drive patient interest to of health services relating to these send messages to a counsellor through chronic diseases and sexual and gender Facebook Messenger. Patients eligible for based violence. The projects are funded extended support were then offered an by MSF, which receives funding through option to physically meet with a counsellor, individual public donations and accepts who would help facilitate reconnection to only minimal institutional funding. This HIV care. The project: case study will focus on one of these projects, a program targeting HIV+ ● Has bidirectional and rich media persons in Khayelitsha. components ● Offers psycho-social support and information for patients ● Aims to change health related behavior
5 Facebook for HIV-positive Youth: Social media counseling advertisements and MSF
EVALUATION
Although MSF does not have any published studies on the Khayelitsha project, the organization is evaluating the health impact, implementation fidelity, and user content internally to make improvements. MSF is assembling a protocol to continue the Welcome Service Digital Ad Campaign, Version 2, and is awaiting ethics approval. Indicators and metrics will be collected along the way to help MSF determine the effectiveness of the ad campaigns. So far, MSF has learned that they are able to reach new populations via advertisement campaigns and the digital advertisements are complementing existing services well.
HIGHLIGHTS
Integration. The initial pilot focused on conversations happening inside Facebook Messenger. Currently, MSF is exploring ways of enrolling patients from Facebook into WhatsApp messaging.
Inclusion. The project uses human-centered design and participatory approaches. The content of the campaign was created based on focus groups with former patients, probing into barriers that prevented them from re-accessing the care.
Scale. The volume of messages received proved to be challenging. Even though reaching people is automated and easy, intense manual labor and clinical skills are needed to address the very serious problems of those who respond to the ads. Yet, MSF is looking into opportunities to replicate the pilot in other places, possibility accessing even larger populations. 6 Facebook for HIV-positive Youth: Social media counseling advertisements and MSF
FUTURE DIRECTIONS
MSF is based on the principle of proximity to the patient. Services offered are provided as close to the patient as possible and tailored to their needs and community practices. Digital communication in today’s connected world is another way of achieving proximity to the patient. Therefore, MSF is moving to implement similar IP messaging projects in other parts of the Southern Africa region. MSF has currently launched very successful IP messaging campaign around family planning in Zimbabwe, and, later in 2020, is considering launching additional campaigns in Swaziland or India (Jakub Hein, personal communication, September 18, 2019).
7 CASE STUDY 3: VIJANA-SMART & MPACT Projects use WhatsApp to provide social support for youth living with HIV in Kenya
BACKGROUND PROJECT DESCRIPTION
Investigators at the University of Vijana-SMART and mPACT are two Washington (UW) and Kenyatta National adaptations of an intervention designed to Hospital (KNH) partnered to conduct improve mental health, engagement in HIV research on the use of WhatsApp groups care, and transition to independence in to connect youth living with HIV (YLWH) to YLWH, ages 14-24, in Kenya. The each other and to healthcare workers, to interventions provide multidimensional provide peer support and improve mental support from peers and healthcare workers health and engagement in HIV care. through asynchronous interactive group WhatsApp messaging with a healthcare Youth age 10-24 in sub-Saharan Africa are worker facilitator sending weekly disproportionately affected by HIV and pre-developed messages. The intervention experience poor treatment outcomes. Lack is opt-in and not anonymous as users can of social support and access to reliable see other members’ phone numbers. information from healthcare workers are significant challenges for YLWH. Mobile The intervention: health strategies show promise in ● Has manual bidirectional and improving HIV treatment adherence, but facilitated group components studies in youth are limited. Inspired by ● Allows sending of rich media such as organic youth-initiated WhatsApp groups videos, images, and voice notes and using a user-centered design ● Offers psycho-social support and approach, the UW/KNH team conducted information for patients, including two related studies funded by the US referrals for services National Institutes of Health to develop ● Aims to change health-related facilitated WhatsApp support groups for behavior youth living with HIV (YLWH) in Kenya.
8 WhatsApp for HIV-positive Youth: Social support and the University of Washington
EVALUATION
Vijana-SMART is a non-randomized pilot study and mPACT is a pilot cluster-randomized trial (cRCT).
The goals of the first study, Vijana-SMART, were to conduct formative work to develop a WhatsApp group intervention for YLWH in Nairobi, and to evaluate its feasibility, acceptability, and preliminary impact on youth mental health, along with measuring the group facilitator time spent. Activities include: 1. Analyzing chat content of two organic, youth-initiated WhatsApp groups over six weeks. 2. Conducting in-depth interviews and focus groups with YLWH age 14-24 to explore experiences and limitations of existing WhatsApp groups and design structured groups. 3. Administering a technology access questionnaire to 300 YLWH to determine the most feasible IP messaging platform. 4. Piloting structured, facilitated, WhatsApp groups with 55 YLWH for six months.
The second study, mPACT, builds on Vijana-SMART and adapts the intervention to support YLWH during the time of transition from pediatric to adult care. This study involves: 1. In-depth interviews and focus groups with YLWH, ages 16-24, in Nairobi and Western Kenya to define adaptation of the Vijana-SMART intervention for the transition period. 2. A pilot cluster-randomized trial of a 1-year intervention with 100 YLWH at 8 clinics in Nairobi and Western Kenya to evaluate preliminary impact on HIV care outcomes. Outcomes evaluated include depression, social support, stigma, engagement in HIV care and antiretroviral therapy adherence.
9 WhatsApp for HIV-positive Youth: Social support and the University of Washington
HIGHLIGHTS
Inclusion. The Vijana-SMART and mPACT interventions use User Centered Design. The studies began with the observation that since 2014, YLWH have run informal WhatsApp peer support groups at HIV clinics in Nairobi. The content and health impacts of these groups were not documented. Vijana-SMART attempts to learn from what YLWH are already doing by analyzing the content of their unstructured group conversations. With permission from the group administrators and notification of all group members, the Vijana-SMART study joined existing youth-initiated WhatsApp groups. Additionally, both studies conducted user-centered focus groups. The Vijana-SMART study used them to define the design of structured study groups and the mPACT study used them to define adaptation of the Vijana-SMART intervention for the transition YLWH will have to make to adult care. User preferences identified in these focus groups were combined with social support theory to develop responsive, theoretically grounded interventions.
FUTURE DIRECTIONS
Completion of these studies will provide insights about how social media can support YLWH. Beyond this goal, priorities for the Vijana-SMART and mPACT teams include defining best practices for ethical use of IP messaging with vulnerable populations, and working with technology companies and other practitioners to develop accessible, secure, interoperable software.
10 CASE STUDY 4: PrEP SMART Using two-way SMS and WhatsApp to help young women in South Africa to prevent HIV
BACKGROUND PROJECT DESCRIPTION
HIV pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention approach when taken daily during periods of HIV risk.
However, prior studies have found that adolescent girls and young women (AGYW) have difficulty adhering to daily PrEP, All participants will receive either 1) limiting the effectiveness of this HIV two-way SMS messages from study staff prevention option. South Africa has the to triage concerns around PrEP pill-taking highest incidence of HIV among young or 2) WhatsApp group messaging with women worldwide and the South African other participants and a counselor to Department of Health (SA DoH) recently provide social support around PrEP use. began a national campaign to scale-up PrEP These are meant to serve as low cost, delivery for priority populations including “light touch” interventions that could AGYW. Investigators at the University of potentially be delivered to a large Washington’s Department of Global Health population of AGYW on PrEP to support (UW DGH) and the University of PrEP adherence. Participants will be Witwatersrand in Johannesburg, South followed for two months and those who Africa are seeking to inform SA DoH efforts are having difficulty adhering to PrEP by by exploring ways to sustainably integrate that time will then be re-randomized to PrEP adherence support approaches for receive either monthly counseling visits or AGYW in South Africa that are both scalable quarterly visits with feedback based on and tailored to individual women’s needs. PrEP drug levels. These are more intensive They are testing the effect of two-way SMS intervention approaches reserved for only messages or WhatsApp peer support a subset of young women who may groups, either alone or in combination with benefit most from such tailored support. either intensive monthly counseling or and All participants will also receive one-way feedback based on PrEP drug levels on SMS messages throughout follow-up to PrEP adherence in a cohort of 500 at-risk remind them of clinic appointments. To AGYW. The project was launched in May “[The SMS and WhatsApp messages] make summarize, PrEP SMART: 2019 and follow-up is anticipated to me feel that they care about us...we can ask conclude by early 2021. questions and get responses immediately.” ● Has one-directional, bidirectional, and
group-based components -PrEP SMART participant ● Offers psychosocial support and
information for patients
11 WhatsApp for HIV prevention: Social support and the University of Washington
EVALUATION
The PrEP SMART study aims to test the effectiveness, acceptability, and usage of four adaptive intervention approaches on daily PrEP adherence among AGYW in Johannesburg, South Africa. It was funded by a United States National Institute of Mental Health grant (R01 MH114544; Investigators: Dr. Connie Celum at the University of Washington, Dr. Sinead Delany-Moretlwe at the University of Witwatersrand; Project Director: Dr. Jennifer Velloza).
The study is named PrEP SMART because it uses a Sequential, Multiple Assignment, Randomized, Trial (SMART) design, whereby participants are initially randomized to either two-way SMS or WhatsApp groups and then those who need more intensive PrEP adherence support are re-randomized to monthly counseling or feedback based on PrEP drug levels. Approximately 500 young women between the ages of 18-25 were recruited in Johannesburg to participate in the experiment. The primary outcome is to determine the proportion of participants who adhere well to PrEP with minimal support defined as two-way SMS messages, WhatsApp digital support groups, and South Africa’s standard of care and counseling, by nine months post-randomization. The study will also determine the proportion of participants who need more intensive interventions and the optimal sequence of intensifying adherence support intervention approaches for young women in this setting. As secondary analysis aims, the study will assess the level of engagement in mHealth interventions, qualitatively examine SMS and WhatsApp message content, and explore staff perspectives of the interventions, to inform future SA DoH and regional policy on PrEP delivery in this population. As the study is still in progress, results cannot be reported yet. . 12 WhatsApp for HIV prevention: Social support and the University of Washington
HIGHLIGHTS
Integration. SMS and WhatsApp messages are integrated with other modalities such as in-person meetings and phone calls with intervention staff.
Inclusion. The PrEP SMART study engaged beneficiaries in the design and planning of the interventions. A community youth advisory board (YCAB) reviewed the one-way and two-way SMS messages, provided feedback on the structure of the WhatsApp groups, and ensured that the interventions were appropriate for the setting. The YCAB includes youth ages 16-26 years from the surrounding community and includes youth living with HIV as well as youth using PrEP. The YCAB meets monthly. Board members also helped determine recruitment procedures and appropriate participant incentives.
FUTURE PROMISING PRACTICE?
Early qualitative results point to the importance of regular WhatsApp and SMS messaging for HIV prevention and expanding the reach of these platforms in the future. For example, one participant said:
“In the WhatsApp group, those guys get to chat every day, they talk about stuff that is happening and they remind you to take the pill, so eventually it’s something that is basically in your life like it’s your everyday thing. Because if as a person you have a smartphone, you are always on WhatsApp. So you are going to be reminded no matter what.”
13 CASE STUDY 5: IZIZI Using WhatsApp to Understand Adolescents’ Contraception Preferences in Malawi
BACKGROUND PROJECT DESCRIPTION
In the field of adolescent sexual and The aim of project Izizi was to better reproductive health (ASRH), candid youth understand the needs, preferences, and perspectives are important to use of contraceptives amongst adolescents understanding the nuances of in Malawi. To meet this aim, fifteen contraceptive access and use. In Malawi, WhatsApp Focus Group Discussions were 22% of married and 52% of unmarried conducted, in which youths freely sexually active women between the ages discussed with one another answers to 8 of 15-19 report an unmet need for family scenario-based questions. Moderators planning (National Statistical Office, 2017). posed follow-up questions to facilitate the More precise data on the contraceptive conversation and/or obtain more detail barriers, needs, and preferences of about participants' statements and Malawian adolescents are needed. The Bill answers to the questions. and Melinda Gates Foundation awarded VillageReach a Grand Challenges The project: Exploration Grant to gather these ● had bi-directional and facilitated context-specific data. The ultimate goal group based components was to inform the development of future ● provided data for research and contraceptive methods and products to government better meet this population's needs.
14 WhatsApp for Adolescents’ Contraception Use: Understanding preferences through digital participatory research
EVALUATION
VillageReach employed innovative participatory research methods to understand contraceptive use among Malawian adolescents. Their mixed-methods study recruited more than 500 adolescent (age 15-19) participants, both male and female, married and unmarried, in rural and urban areas in the Nkhatabay, Lilongwe, and Machinga districts. To collect data, the study administered a phone survey via a national nurse hotline, in-person theater-based focus group discussions (FGDs), remote and in-person digital FGDs and human centered design (HCD) workshops to understand barriers to contraceptive use and develop new contraceptive designs. For both the in-person and remote digital FDGs, participants were asked to respond to scenario-based questions about contraceptive use. Participants participated in the conversation by posting voice memos and texts in WhatsApp. The participatory aspects of this study design are featured in the Special Spotlight box on the next page.
Results identified individual and interpersonal, socio-economic, cultural, and systemic barriers to contraception access and use. Examples of barriers identified included: perceptions that accessing and using contraceptives encourage promiscuity and were only for married people, a desire to have many children, cost of transport to access contraceptives, limited contraceptive options (particularly for men), limited access due to stockouts and distance, restrictive service provision policies, lack of trained health care professionals and lack of privacy and confidentiality at health centers. The main undesirable attributes identified were that contraceptives produce negative side effects, cannot be trusted, advertise one’s sexual status, are difficult to use, reduce the pleasure and passion of sex, and don’t protect against STIs. 15 WhatsApp for Adolescents’ Contraception Use: Understanding preferences through digital participatory research
HIGHLIGHTS
Inclusion. VillageReach used a youth-friendly approach by recruiting adolescent researchers (ARs) to lead data collection. At least one male and one female AR was hired per district. ARs moderated FGDs posing initial and follow-up questions to participants. For the theater-based FGDs, ARs led the group debrief, transcribed the recordings, and translated the transcripts.
HCD workshops were also held to design new forms of contraception. Adolescents were engaged as creators and innovators of contraceptive designs that would better meet their needs. In these workshops, adolescents explored common barriers to contraceptive access and use, organized into teams, ideated, and produced contraception prototypes.
FUTURE DIRECTIONS
Christine Lenihan, head of VillageReach’s Supply Chain Technology Services is excited to announce that VillageReach is pursuing opportunities to incorporate WhatsApp, Machine Learning, and Artificial Intelligence into the national health hotline in Malawi and other countries. Knowledge of adolescents’ needs, preferences, and behaviors can now inform VillageReach’s approach to adolescent sexual and reproductive health. Carla Blauvelt, Director, Programs for VillageReach thinks that one of the most important issues that need to be addressed in the future regarding IP Messaging is:
"Figuring out how to ensure important data on the needs of target populations can be incorporated into national information systems in a cost-effective manner that both maintains the confidentiality of the individual and is technologically sound. It is critical for governments to adequately receive, analyze and act upon the data to provide enhanced services that is tailored to the specific needs of the population."
16 CASE STUDY 6: ARIEL SUPERSTARS GROUP Using WhatsApp to Offer Peer and Psychosocial Support for Youth Living with HIV
BACKGROUND
Native Ugandan Brian Ahimbisibwe is concerned about youth living with HIV (YLWH). Approximately 6.5% of youths ages 0-15 have HIV, but only about one third of children living with HIV are on treatment (Avert, 2019). Brian was one of these youths in Uganda living with HIV, taking treatment, but unaware of his status or why he was taking medication. After he suspected he might be HIV positive, sometimes, he would stop taking medication or visiting the clinic and his health deteriorated. In 2007, Brian was PROJECT DESCRIPTION among the first members of an Ariel Club, This IP Messaging project delivers a peer-led psychosocial in-person support peer-to-peer group support and accurate group for YLWH, that took place at Kabale health related information for YLWH via Regional Referral Hospital and was funded WhatsApp. The program aims to increase by The Elizabeth Glaser Pediatric AIDS peer support of YLWH so that they Foundation (EGPAF). His personal increasingly link to care, initiate ART, and experience and concern led Brian to remain in treatment. The project targets youth, ages 14-27 years, living in rural co-found Ariel Superstars Group, a mobile central and south western Uganda, who are phone based virtual support group that newly diagnosed with HIV and invites them offers treatment adherence and into digital groups with youths who know psychosocial support to adolescents with their status and are on treatment. Virtual unsuppressed viral loads in rural Uganda. meetings are held every quarter and Brian and several other Ariel Club alumni in-person meetings are held annually. The formed this Ariel Group Superstars when project: EGPAF’s programs scaled down in Uganda. ● Has unidirectional, bidirectional, rich The Ariel Superstars Group is now a media, live chat, and facilitated group program under the Miles of Smiles based components Foundation. The co-founders of Ariel ● Offers psycho-social support and Superstars Group created the Miles of information for patients Smiles Foundation through grassroots ● Offers training and professional donations from individuals. support to clinicians ● Aims to change health related 17 behavior WhatsApp for HIV-positive Youth: Peer support and Ariel Superstars Group
EVALUATION
Currently, Ariel Superstars Group uses agile methods to monitor their program internally for feasibility, acceptability, uptake, content, implementation fidelity, and health outcomes to make improvements. They also track if health and stigma information learned in the digital group spills into participant networks in other life domains. Currently, the goal is to empower participants to communicate information they learn without fear of discrimination from members of their communities. When the program learned that participants were communicating information learned in the groups to outside members, Ariel Superstars Group started tracking this social network type data.
Although no evaluation has been conducted yet, a research study is being planned for the future. Ariel Superstars Group plans to implement a baseline survey of youth psycho-social supports pre-intervention and then again once youths have participated in the program. The research aims to identify the number and type of how social supports the youths are receiving before and during the program in an attempt to disentangle if the digital support groups could potentially be associated with any change or impact.
18 WhatsApp for HIV-positive Youth: Peer support and Ariel Superstars Group
HIGHLIGHTS
Integration. The project combines IP messaging with in-person meetings and phone calls, and is planning to integrate SMS. The intervention also delivers mobile messaging via Facebook messenger.
Inclusion. The project uses human-centered design approaches. The program was founded by the current facilitators who participated in an in-person version of the program funded by EGPAF. While EGPAF staff also constitute some of the facilitators of the digital groups as well, the lead facilitator is a YLWH as are many of the other facilitators. The users run the meeting agendas, mobilize themselves, and facilitate the in-person meetings. Users will also help plan the baseline survey.
FUTURE DIRECTIONS
Ariel Superstars Group finds that securing funding is an ongoing challenge. Funding will be required for research studies, future activities, and sustainability. The program would like to build out a standalone web platform to access on the computer as well as the mobile phone. The group would also like to secure ethics approval from an institutional review board before conducting research. Ariel Superstars Group has big plans and does important work therefore, they think research ethics and sustainability are the two most important issues for grassroots programs delivering IP Messaging.
“Ariel Superstars, they are like family to me. We are one happy family. I think I will have a reunion with these people when I am 85 years old on the shores of Lake Victoria.”
- Ariel Superstars Facilitator
19 CASE STUDY 7: CLINIC IN THE DOMINICAN Republic partners with Planned Parenthood to create a WhatsApp support network for adolescent mothers
BACKGROUND
The Dominican Republic (DR) experiences the highest adolescent fertility rate in Latin America. One in five adolescents ages 15-19 has had a child or has been pregnant. Adolescent mothers often experience social stigma and isolation, which can affect their perception of support and their ability to care for themselves and their children. The Módulo Anexo Materno Infantil (MAMI) is an PROJECT DESCRIPTION adolescent sexual and reproductive health FAMA is a digital peer support network for clinic located in the peri-urban setting of adolescent mothers in the DR. The project La Romana in the DR and provides a range uses WhatsApp groups facilitated by clinic of services for adolescents up to 19 years staff to deliver educational messages and of age. Planned Parenthood of the Great provide a forum for questions and Northwest and the Hawaiian Islands conversation. FAMA aims to increase the (PPGNHI), headquartered in Seattle use of: postpartum family planning; Washington, has partnered with MAMI in attendance at pediatric consult and their sexuality education work since 2011. vaccination appointments; access to social In 2018, they began a new project to support; autonomous functioning; and support adolescent mothers. health knowledge. Participants include 60 MAMI and PPGNHI, with input from MAMI clients, ages 15-19, who are 6 participants, designed and implemented months or less postpartum. The project an intervention to improve the knowledge, starts with an introductory in-person social support, and self determination of meeting to establish group norms and adolescent mothers so that they can better expectations, distribute phones, and set manage their, and their babies’, health. up WhatsApp groups. The WhatsApp They created a proof of concept project group discussions are moderated by called Fortaleciendo la Autodeterminación MAMI clinic staff. The intervention then de Madres Adolescentes (FAMA - closes with a final in-person meeting to Strengthening the Self-determination of conduct end line data collection, exit Adolescent Mothers), supported by Grand interviews, a reflection activity, WhatsApp Challenges Canada (GCC). group handoff, and a celebration. 20 WhatsApp for Adolescent Mothers: Digital Peer Support and Planned Parenthood
The project: ● Has bidirectional and facilitated group based components ● Offers psycho-social support and information for patients ● Aims to change health related behavior
EVALUATION
Preliminary results from an evaluation of FAMA can be found below.
Quantitative Results: There was significant difference in health knowledge survey scores (p<0.05) and no significant difference in social support or autonomous functioning survey scores. Participants’ modern contraceptive prevalence (71.93%) was statistically significantly higher than that of adolescent nationally (21.4%). A case control analysis found that participants were 6.58 times more likely to likely to attend more than two indicated well-baby visits than controls. A comparison of vaccination coverage could not be determined from the data collected.
Qualitative Results: Qualitative analysis was conducted on post-intervention interviews completed with 27 study participants. The results of this analysis showed that interviewees expressed having received social support, were highly satisfied, and would recommend the support group to others.
Conclusion: Support groups administered through WhatsApp are feasible and acceptable and have a positive impact on adolescent health. 21 WhatsApp for Adolescent Mothers: Digital Peer Support and Planned Parenthood
HIGHLIGHTS
Integration. FAMA integrated digital support groups with in-person meetings. The discussion groups also served as customer service for the MAMI clinic as the participants would often ask the group moderators questions about clinic hours and services.
Inclusion. The FAMA project started with an initial user-centered design process. This consisted of activities to allow participants to share their perspectives and opinions, which informed the design of the intervention. Participants shared their experiences around childbirth and motherhood and the information that they wish they had previously. They also mentioned health topics they were interested in learning more about through the WhatsApp group. WhatsApp educational message content was developed with PPGNHI and MAMI staff based on feedback from this user centered design process.
FUTURE DIRECTIONS
Preliminary results of the evaluation reported on the previous page seem promising. PPGNHI also has plans to conduct analyses of WhatsApp chat transcripts to analyze the chats for key themes and evidence of social support. It is expected that the thematic analysis will substantiate the other types of evidence that FAMA is beneficial. Respondent feedback like the quote from the FAMA participant below also support intervention scale up.
“Well, it is a very excellent group, very excellent, it should be extended more in the country because it provides significant help to first time moms."
Therefore, MAMI and PPGNHI are interested in adapting the FAMA intervention’s methodology for use with other vulnerable populations. MAMI also plans to share the FAMA innovative model with the Ministry of Public Health’s network of youth clinics.
Liz Haight, MPH, Global Programs Manager at Planned Parenthood of the Great Northwest and the Hawaiian Islands believes efforts should be made to reach groups that historically lack access to personal mobile phones and consistent data packages so that, “young people and women can access the information and services that IP messaging interventions can offer.” 22 CASE STUDY 8: PATIENT ENGAGEMENT LAB Application and Testing of Rapid Pro Sidekick WhatsApp Anonymized Group (WAG) Tool
PROJECT DESCRIPTION The WAG tool was developed to enable safely scalable: 1. digital peer groups interventions 2. qualitative data collection 3. participatory guidance BACKGROUND The WAG tool leverages WhatsApp API Praekelt.org’s Patient Engagement Lab (PEL) access to offer a secure way to enable was an initiative funded by the Bill & digital groups to be delivered via Melinda Gates Foundation to develop WhatsApp without participants being able adaptive experimental protocols for to see each other’s telephone numbers. The optimising at-scale mHealth programs. RapidPro Sidekick WGA tool offers
participants private and more secure digital The PEL developed and implemented a conversations. tool called RapidPro Sidekick, which builds a host of features onto existing open-source The PEL WAG project: Rapid Pro software to enable faster ● used the WAG tool to run facilitated implementation of experimental protocols. truly anonymous WhatsApp groups One key feature developed as part of Rapid ● used unidirectional, bidirectional, and Pro Sidekick is a WhatsApp Anonymized chatbot facilitated messaging and Group (WAG) tool. groups 23 Patient Engagement Lab: Anonymous WhatsApp Groups
EVALUATION The PEL conducted a series of pilot studies using the Sidekick WAG tool for peer support, participant advisory, and research groups. The studies aim to assess: 1. the technical viability of the WAG tool in practice 2. clinical requirements for safety scaling anonymized digital group-based programs 3. levels of demand for such groups in nationally representative samples 4. feasibility of using Natural Language Processing (NLP) to classify peer-to-peer interactions and Social Network Analysis (SNA) to monitor safety of group dynamics 5. participant preferences for alternative group delivery features, with a focus on developing user-centered informed consent procedures.
One in-person and six digital focus groups discussions were conducted on the South African National Department of Health’s MomConnect platform, delivered to over 800,000 pregnant women and mothers at any one time. Random samples of women were invited to participate in WhatsApp groups. Topics included: engaging in participatory research for MomConnect; digital informed consent procedures; time preferences and medical adherence; family planning; preferences and concerns with mHealth programing on WhatsApp.
FINDINGS ● The WAG tool was found to be technically robust and is now being deployed in a new project offering fifty anonymized groups to 500 users. However, WhatsApp terms of service prevent use of rich media when the WAG protocol is applied. ● Participant demand for WhatsApp group participation was lower than anticipated, with only 9% of invited MomConnect users responding with interest and even fewer actually taking part. ● The vast majority of comments addressed the facilitator or the entire group, limiting development of an NLP-SNA approach to safety monitoring. This could be due to groups meeting twice at most, with peer-to-peer interactions expected to increase in stable groups. ● Participants valued the anonymity afforded by the WAG tool and reported feeling more free to share honestly; however, comparison between digital and in-person discussions on family planning suggested that participants were willing to share more personal information in-person than in the WhatsApp. ● Written information and consent questions sent via WhatsApp were reported to be sufficient; additional telephone calls to confirm informed consent prior to the group were reported to be unnecessary and potentially intrusive. ● Lack of data was cited as a key concern and reason for non-participation. Data ‘gifts’ sent as reminders just before groups began were effective in increasing participation rates among those who had consented. 24 CASE STUDY 9: EMPILO SALUD - JES Peer-to peer mHealth support via WhatsApp for Venezuelan refugees
BACKGROUND
Venezuela is experiencing the worst refugee crises in Latin American history. Since 2015, over 12% of the national population has fled the country (Arnson, 2019). The UN estimates that by 2020, there will be 8 million Venezuelan refugees, making this the largest refugee crisis in the world.
Conditions in Venezuela are dire. Over 90% of the population now live below the poverty line and more than 50% can not meet basic food needs. There are shortages for 85% of medicines (Prichard, 2019). By 2018 over a fifth of the country’s medical personnel had fled, vaccines were largely unavailable, 2% of infants died within four weeks of birth and cases of SPOTLIGHT diabetes and hypertension had doubled (O’Neil, 2018). Emergency medicine physician Dr. Ilon Rincon is the Managing EMPILO SALUD Director of Empilo Salud, the The Juntas en Salud (JES) program is delivered Venezuelan non-profit behind JES. by Empilo Salud, a Venezuelan and US American Dr. Rincon is herself a Venezuelan non-profit. Empilo Salud supports grassroots refugee and believes that digital health services for displaced and user-centered services require user underserved Latin American populations, particularly Venezuelans. The organisation involvement at every level of provides medical and technical support, sourced design and delivery. As medical from the Venezuelan diaspora, to expedition leader bringing primary community-initiated projects. Such projects care to remote indigenous include, for example, Facebook communities for communities across the diaspora health professionals to support services Venezuelan Amazon region, Dr. for individuals in need of medical advice; digital Rincon is passionate about the peer groups for first-generation trans Latinos in importance of ensuring that health the United States; and health worker facilitation services are offered to even the and information groups via WhatsApp groups hardest to reach populations. and networks (such as JES). 25 Digital support for Venezuelan Refugees: Peer-to peer mHealth and Empilo
EVALUATION
Empilo Salud launched a pilot study to test tools and support strategies that could be shared with other digital groups. JES Mother’s Pilot used snowball recruitment for their sample. Women who participated in the pilot were ages 24-38 with 1-4 children.
Formative work documented a range of concerns amongst refugee populations about the use of WhatsApp in fragile political contexts, as well as the need for accessible non-governmental digital support. The pilot indicated that there is a high level of interest in these kinds of interventions for this population because there is a need for information and connection. The optimal size of groups were reported to be 10-20 people. Group facilitation was proactive at first, then just responsive and safeguarding. Rules and purpose need to be defined and agreed upon clearly at the beginning and policies about power sensitivity were considered essential. Encryption and privacy mattered a lot.
PROJECT DESCRIPTION
JES comprises community- developed WhatsApp groups serving Venezuelan diaspora refugees. Groups connect peers to facilitate access to news, relationship maintenance, and the more efficient delivery of health and legal support via digital moderators and prepared messaging. JES serves women in Venezuela and other parts of South America, Europe, the U.S.
The project:
● Has bidirectional, rich media, and facilitated group based components ● Offers psycho-social support and information for patients ● Aims to change health related behavior
26 Digital support for Venezuelan Refugees: Peer-to peer mHealth and Empilo
HIGHLIGHTS
The project combines evidence-based practice and expert-led design with participatory research approaches and a user-centered perspective. The JES Mother’s Pilot members were already known to one another and recruited other mothers within their networks. Participants were supportive and interested in being part of research, using evidenced-based material and to pro-actively designing the format for a service that would meet their needs.
FUTURE DIRECTIONS
Going forward, the community of practitioners need to know the donor communities interest in funding IP Messaging Projects so the outcomes achieved in the space can become more sustainable. Researchers need to examine if those with the greatest need are being reached. Equally important,
“The Empilo project gives me the information I need when I ask. I have friends I never see but chat with all the time. I can ask things in my group that I can never ask a doctor.”
-JES Participant
27 CASE STUDY 10: SMS INSTEAD Moving from IP Messaging to SMS to reach low- income mothers in Kenya
BACKGROUND
In East Africa, 33% of maternal deaths are caused by delays in seeking care. Approximately 68% of new mothers have an unmet need for postpartum family planning. Jacaranda Maternity and Jacaranda Health aim to ensure women visit health facilities more frequently during and after pregnancy. Jacaranda Maternity is a social enterprise providing high quality maternity hospitals in East Africa. Its replicable low-cost model can return investment capital to investors. Jacaranda Health is an associated non-profit that adapts low-cost and sustainable innovations to improve quality of care in public PROJECT DESCRIPTION hospitals. Jacaranda works with mothers in the Scaling Jacaranda’s programs in Kenya is lowest income quintile in Kenya. partnership intensive due to the decentralized Clients did not have consistent nature of the Kenyan Health care system. access to data plans or Counties have autonomy over the smartphones. Instead, Jacaranda management of their health system, and found that SMS-based Jacaranda currently partners with 5 counties. interventions scaled more Jacaranda Health has also officially partnered successfully and more with over 150 public hospitals and with the cost-effectively with a cost of 71 Kenyan government. Nevertheless, Jacaranda cents per mother. had to use nurse or facility led recruitment drives and posters to recruit mothers and The SMS-based project: painstakingly scale their digital platform. ● Has chatbot facilitated While many organizations are transitioning group-based components from SMS interventions to IP Messaging, ● Offers psycho-social support and Jacaranda has gone in the opposite direction. information for patients Jacaranda started using IP messaging and ● Provides professional support to found the modality to not be feasible, nursing staff cost-effective, scalable, private or accessible ● Aims to change health related enough. behavior 28 From IP Messaging to SMS: Jacaranda helps low income mothers in Kenya
EVALUATION
Jacaranda has conducted a number of innovative research studies on IP Messaging including function and feasibility studies. However, these studies did not find that IP tools changed health behaviors or were sustainable or realistic to implement at scale.
Jacaranda conducted a study examining the feasibility of using WhatsApp for pregnancy support. The study held focus group discussions with women who sought care at private and public sector hospitals. Researchers found that it was feasible and satisfactory to use WhatsApp for pregnancy support with a few caveats. The first limitation was that success depends heavily on involvement and moderation by a skilled facilitator so a WhatsApp support group is not easily scalable. Group moderation by a bot is not currently feasible using WhatsApp, given the tool has a closed API. However, the focus groups reported that WhatsApp and telephone were the top preferred modes of communication, followed by SMS and Facebook Messenger.
Jacaranda’s SMS platform provides pregnant women and new mothers in government hospitals with a free service that combines a carefully designed sequence of ‘nudge’ messages with a helpdesk service. Facilities with the service have a 20% increase in mothers completing 4 ANC visits compared to equivalent non-participating facilities. Jacaranda recently completed a randomized controlled trial (RCT) conducted with 900 women seeking care at public hospitals. Preliminary results have demonstrated that platform users were more likely to recognize and seek care for their health symptoms and they are 2.5x more likely to take up postpartum family planning.
29 From IP Messaging to SMS: Jacaranda helps low income mothers in Kenya
HIGHLIGHTS
Software development. Jacaranda is implementing AI triage and prioritize the high volume of questions coming into the helpdesk. This ‘TriageBot’ that leverages Natural Language Processing (NLP) to identify the intents of incoming questions. Integration. Jacaranda communicates with clients according to their preferred channel which is SMS. Women recently indicated that they would like message content regarding breastfeeding, weaning, and early childhood development new content is being developed to incorporate their needs and wants. The RCT framework was designed with users in mind, especially regarding tailoring content to language and cultural preferences. Feedback from FGDs, facilities, and community health feedback are incorporated into re-designs of the service.
Inclusion. The SMS messaging platform is now closing the gap between client and provider. Jacaranda is now able to score a health facilities quality of care based on the feedback client’s provide including customer service and staff or medicine shortages. Facilities are also able to better service their clients because of this feedback. For example, at one facility, an HIV+ client reported via SMS that she was hesitant to ask for additional information about her pregnancy. Routine ‘client experience’ feedback revealed this issue and resulted in the nurse-in-charge tracking down the client and ensuring that she was given the proper guidance.
FUTURE DIRECTIONS
In the future, stakeholders should strike a balance between privacy protection and the need for research to ensure that services are evidence-based, effective, and safe. The balance is not clear right now. Currently, it is challenging to achieve the required levels of privacy when delivering IP health messaging. Sathy Rajasekharan, Chief Innovation Officer at Jacaranda Health, believes that:
“the best way to address challenges of privacy is to work closely with the National eHealth department, to share data with national systems, and align deployment of tools digital health policies. This work is currently underway.”
30 CASE STUDY 11: POSHAN DIDI A semi-automated conversational agent built by Dimagi and the Department of Women and Child Development of Madhya Pradesh
BACKGROUND
Founded in 2002 out of Harvard and MIT, Dimagi is a technology company and recognized Benefit Corporation whose mission is to create digital products that support global development efforts to accelerate the end of extreme poverty. The company’s flagship technology, CommCare, is an open source mobile data collection and service delivery platform designed to improve data collection and the quality of frontline services in delivery and enables effective monitoring, low-resource settings around the world. timely interventions, and enhanced Today, the CommCare platform is used by decision support. over 400,000 frontline workers (FLWs) globally across 80+ countries. More than As part of an effort to further enhance the 60 peer-reviewed publications, including services beneficiaries receive under seven randomized-controlled trials, have POSHAN Abhiyaan and ICDS-CAS, the shown that CommCare improves FLW Department of Women and Child performance and client outcomes. Development of Madhya Pradesh worked with Dimagi to develop and test a new, In 2017, Dimagi began working with the semi-automated conversational agent Government of India to develop the called Poshan Didi--or “Nutrition Sister.” Integrated Child Development The primary goal was to explore a Services-Common Application Software direct-to-beneficiary channel of (ICDS-CAS). The application serves as a communication for new mothers to key pillar of POSHAN Abhiyaan, the Indian receive on-demand nutritional Prime Minister’s Overarching Scheme for information. Poshan Didi was specifically Holistic Nourishment, which was created deployed in Madhya Pradesh to reach to tackle malnutrition rates in India. beneficiaries of AWWs who were already ICDS-CAS is used by healthcare workers actively using the ICDS-CAS platform. called Anganwadi Workers (AWWs) as a Poshan Didi was designed to eventually job aid when they carry out their nutrition support integration between the data and maternal and child health tasks. The collected by the AWWs and the Poshan mobile solution helps AWWs improve Didi conversational agent. service 31 Dimagi and the Department of Women and Child Development of Madhya Pradesh use IP Messaging
PROJECT DESCRIPTION
Poshan Didi is a nutrition-focused conversational agent for new mothers in India. The project uses a semi-autonomous “chatbot”-like persona called Poshan Didi to provide on-demand access to nutrition information to mothers with newborns between 0-12 months who have access to a smartphone and are receiving services from Anganwadi Workers. Queries that are not understood or covered by the automated content are escalated to a live nurse who will respond and engage with the mother directly through the Poshan Didi system. The chatbot uses manual messages, Telegram, and WhatsApp, though is built to be agnostic of the delivery medium and could be extended to support SMS, IVR, Signal, or Facebook with limited work.
An initial 10-person pilot was completed using completely manual messages over WhatsApp. The second pilot expanded to 100 women on Telegram and four women on WhatsApp and introduced a semi-automated chatbot. Push messages are sent twice weekly to the mothers, with content derived from relevant nutrition topics for the age groups and parallel to the AWW’s training material, as well as inputs from the government and the mothers themselves. The project:
● Provides unidirectional, bidirectional, and conversational agent facilitated components ● Offers psycho-social support and information for patients ● Aims to encourage healthy behaviours ● Offers rich media, such as images illustrating correct latching for breastfeeding
32 Dimagi and the Department of Women and Child Development of Madhya Pradesh use IP Messaging
EVALUATION
Baseline and endline interviews have been conducted for all participants in the pilot. The data will be evaluated to assess the change in mobile usage and mother’s knowledge on health behaviours, as well as the usability, likeability, and comprehension of Poshan Didi. Once the pilot has concluded, Dimagi will complete a quantitative analysis of the popularity of modules and nurse-beneficiary interactions. Finally, focus group discussions, which have been conducted with a subset of willing participants, will be analyzed to better understand their experience with the chatbot and how we can improve the user experience and access to information.
HIGHLIGHTS
API Access. In the initial 10-person pilot, Dimagi sent manual messages, but a bot was developed and deployed for the subsequent 100-person pilot, which is delivered over the Telegram and WhatsApp messaging APIs. Software development. Dimagi is committed to open source software and making its work available to the larger community of digital health practitioners to build upon. Diamgi’s page on GitHub hosts well over 200 repositories. Inclusion. Content for Poshan Didi was developed by Dimagi in collaboration with the local government and the beneficiaries. New content was added to include counseling for teething children and low birth weight babies’ mothers. At the request of block-level officials, a new module was created for common childhood diseases. Finally, responding to observations in the field, the nurse developed new content on nutrition for lactating mothers.
FUTURE DIRECTIONS
Mr. Satish Patel - Child Development Project Officer (CDPO) - Bahoriband, Katni, Madhya Pradesh has this to say regarding the future:
“Poshan Didi is an all-new effort to build awareness amongst the public in the field of health and nutrition. It can reach those areas where the ASHA or AWW cannot reach. In the era of the information revolution, Poshan Didi will prove to be very effective in conveying messages and resolving doubts. Thank you .... Poshan Didi” 33 SOURCES AND CONTACTS
Case Study 1: Médecins Sans Frontières (Doctors Without Borders)
Contact: Damian Hacking, [email protected]
Photo credit: MSF Media Database 10/12/2015
Murray, K.R. , Dulli, L.S., Ridgeway, K., Dal Santo, L., de Mora, D.D., Olsen, P., Silverstein, H., and Donna R. McCarraher (2017). Improving retention in HIV care among adolescents and adults in low-and middle-income countries: A systematic review of the literature. Plos One, 12 (9). doi: 10.1371/journal.pone.0184879.
Hacking, D. Mbakaza, Z.E. M., Cassidy, T., Runey, P., Duran, L.T., Matthys, R.H., Boulle, A. (2019) The effect of mobile phone peer-to-peer mentorship program for newly diagnosed HIV positive in Khayelitsha, South Africa: a mixed methods study. Submitted to Journal of Medical Internet Research. doi: 10.2196/14012.
Henwood, R., Patten, G., Barnett, W., Hwang, B., Metcalf, C., Wilkinson, L. (2016). Acceptability and use of a virtual support group for HIV-positive youth in Khayelitsha, Cape Town using the MXit social networking platform. AIDS Care, 28(7): 898-903. doi: 10.1080/09540121.2016.1173638.
Case Study 2: Médecins Sans Frontières (Doctors Without Borders)
Contact: Jakub Hein, [email protected]. Photo credit: MSF Media Database 10/12/2015.
Case Study 3: University of Washington
Contacts: Keshet Ronen, [email protected], Brandon Guthrie [email protected], Irene Inwani [email protected].
Ronen, K., Inwani I, & Guthrie, B. (2019). Vijana-SMART and Mpact projects use WhatsApp to provide social support for youth living with HIV in Kenya.
34 SOURCES AND CONTACTS
Case Study 4: University of Washington Contact: Jennifer Velloza [email protected]
Case Study 5: VillageReach Contact: Christine Lenihan, [email protected] Photo credit: Lucky Gwande, VillageReach.
National Statistical Office/Malawi and ICF. 2017. Malawi Demographic and Health Survey 2015-16. Zomba, Malawi: National Statistical Office and ICF. Available at: http://dhsprogram.com/pubs/pdf/FR319/FR319.pdf.
Case Study 6: Ariel Superstars Contact: Brian Ahimbisibwe, [email protected] Photo credit: Eric Bond.
Avert (2019). HIV and Aids in Uganda. Retrieved on September 17, 2019 from: https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/uganda
Elizabeth Glaser Pediatric AIDS Foundation (2019). Brian Ahimbisibwe. Retrieved on September 17, 2019 from: https://www.pedaids.org/about/egpaf-ambassadors/brian-ahimbisibwe/
PEPFAR (2017). Ugandan population-based HIV impact assessment UPHIA 2016-2017 summary sheet: preliminary findings. Retrieved on September 17 from: https://www.afro.who.int/sites/default/files/2017-08/UPHIA%20Uganda%20factsheet.pdf
Case Study 7: Planned Parenthood Contacts: Mina Halpern, [email protected] Luz Messina, [email protected] Liz Haight, [email protected]
Photo credit: Argenly Emercy Rodriguez Richiez, Clinica de Familia.
ENDESA DHS. (2013). Ministerio de Salud Pública. Centro de Estudios Sociales y Demográficos (CESDEM). 35 SOURCES AND CONTACTS
Case Study 8: Praekelt.Org Patient Engagement Lab
Contacts: Eli Grant, [email protected] Charles Copley, [email protected]
Grant, E. (2018). MomConnect Monitoring and Evaluation Framework (version 7). Cape Town: Praekelt.Org.
Case Study 9: Empilo Salud
Contact: Ilon Rincon, [email protected]
Arnson, C.J. (2019). The Venezuelan refugee crisis is not just a regional problem: Latin American Neighbors are pulling more than their weight. Foreign Affairs.
Prichard, M. (2019). Quick Facts: Venezuela’s humanitarian crisis. Mercy Corps.
O'Neil, S. K. (2018) A Venezuelan Refugee Crisis: Contingency Planning Memorandum No. 33. New York: Council of Foreign Relations Center for Preventive Action.
Case Study 10: Jacaranda Health and Jacaranda Maternity
Contact: Nick Pearson, [email protected] Photo credit: Photo Credit: Roopa Gogineni.
Case Study 11: Dimagi
Contact: Brian DeRenzi, [email protected]
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