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Scientific Research on Mental Health by the Kintampo Human Research Center has revealed depression as one of the leading mental health problems in Ghana. The study proves that in Ghana, about 80 percent of the population is suffering from different forms of depression and that mental illness contributes to a loss of seven percent of the country’s Gross Domestic Product (GDP).

MindIT Mental Health Service is an initiative which uses innovative IT tools to screen Ghana’s population for mental illness and helps them access affordable care that’s close to them. The neologism, “MindIT” comprises the words “Mind” and “IT.” The “Mind” in the neologism connotes mental health and the “IT” stands for Information Technology. Also, the word “Mind,” when used as verb in a sentence means “to pay attention to.” Thus, “MindIT” essentially connotes to having to pay attention to one’s mental health, mainly through the use of IT interventions.

Following the spate of suicides in Ghana in the year 2017, the founder of MindIT, who is also the erstwhile president of the debate team of the University of Ghana School of Medicine and Dentistry initiated a project to help reduce the incidence of suicides in the Ghanaian population. This was their flagship project, which facilitated their winning the 2017 Psychiatry Intermedical School Public Speaking Competition. Coupled with the barriers to mental healthcare which include the presence of only 18 psychiatrists and three psychiatric hospitals to serve the entire population, and the heavy stigma associated with mental illness, the founder was inspired to begin this service to improve access to mental healthcare in Ghana. The first tool which is used to screen the population is a USSD, colloquially known as a short code. It is free on all networks in Ghana and has a screening tool incorporated within it. It is * 7 1 1 * 8 8#. The screening tool was developed by the management team and focuses on the common symptoms of Depressive Disorder, Generalized Anxiety Disorder, and psychotic disorders. When users dial the USSD, they follow the text prompt and answer the four questions of the questionnaire. Their telephone numbers and responses are automatically forwarded to our call center via an instant text message and an email after the call which users are then connected to the community psychiatric unit, which is closest to them for management. The community psychiatry units are health centers found in every district in Ghana, and they are manned by Community Psychiatry Nurses and Community Mental Health Officers.

The code to call is absolutely free and the service directing users to their local community psychiatry unit is also free. There’s no fee for consultation and although there are costs for those individuals who aren’t registered with the country’s National Health Insurance Scheme in the amount of 15 Ghana cedis ($3 USD) to create a file for the individual, while those who are registered with the National Health Insurance Scheme have files created free of charge. The service has a nominal cost compared to what is charged in the mainstream health centers for similar services.

Poster for USSD Screening Tool

Descriptive Posters Method:

Another strategy is the use of descriptive posters to help screen people for mental illness. These posters have symptoms of Depressive Disorder, Obsessive Compulsive Disorder, Generalized Anxiety Disorder, and psychotic disorders. They ask people who identify themselves as suffering from any such symptoms to text our call center using a letter to represent their symptoms, after which our call center will follow up with them by phone call.

153 people used the service during its pilot phase. Out of this, a preponderance of them were casual users who were only trying the code, although 10 people who genuinely needed help were also identified. One caller was contacted and received a free Cognitive Behavioral Therapy Session (CBT) session at the Department of Psychiatry in Korle-Bu Teaching Hospital. Four contacts were known or diagnosed cases of Depressive Disorder who were already receiving care at other mental health facilities and opted to continue seeing their mental health professionals. One of the users used the code as a means to reach us in a bid to solicit support for her mental health project and another used the code in order to ascertain the authenticity of the service so that she could confidently refer anyone with psychological distress to use the service. The service is currently only in its second week of operation during its second phase.

Our target group is people who are living with undiagnosed mental illness, particularly Depressive Disorder and Anxiety Disorders. This is because these mental disorders don’t present classically like other mental disorders which are apparent to the untrained eye. The aforementioned illnesses are also highly prevalent in this country.

MindIT Mental Health Service Posters

MindME App

The team has also begun work on a mobile app which would provide immediate help for users during episodes of psychologically distress. The app has Google Maps incorporated into it and at the push of a call button locates a community mental health nurse closest to the user and automatically places a distress call to him/her for attention. The community psychiatry nurses would also have the app installed on their phones so that they can use the google map to locate the user. This initiative is geared towards drastically reducing the prevalence of suicides in the country.

“Bare”-In-Mind Animation Series

This animation series seeks to create awareness of mental illnesses and how they present. It features clinical vignettes on some mental health conditions using animated characters. The caption, “Bare”-In-Mind connotes the importance of the series which is to lay bare the mental distress that many people experience and also emphasize the fact that mental illness is usually not depicted on people’s faces. 

To view animated videos from the “Bare-In-mind” Series visit:
https://drive.google.com/open?id=1uh72nrFR5VJVMh0xWdJK2tFY7kOgU-8p

Presently, the management team of MindIT Mental Health Service is comprised of eight people. The founder, Atsu Latey, as well as two other members, Irene Appiah and Maame Werekoa Nimo Baffuor, are final year medical students of the University of Ghana School of Medicine and Dentistry, and they manage the offices of Research and Innovation and Monitoring and Evaluation of the Service respectively. The team also has a computer engineer, Edem Segbedzi, who is a 2017 graduate from the University of Ghana School of Engineering. The co-founder and head of ad content and publicity, Edem Latey majored in Radio and Television production at University of Ghana. Robert Ketor, is a Clinical Psychology Intern at the UGSMD Department of Psychiatry, Maame Esi Coleman is a graduate student in counseling psychology from Southern Illinois University Carbondale, as well as Rejoice Homeku, who majored in Management Information Studies at Ashesi University. The team also has psych corps members who play a valuable role in managing the call center. Essentially, the team is comprised of a group of youth who are passionate about mental health and use innovative IT interventions to provide care for people who are suffering from mental illness/psychological distress.

The service is principally funded through contributions from the members of the management team, associates to the service, as well as benevolent friends and family.

You can follow MindIT Mental Health Service on social media by following us Twitter & Instagram @minditgh and liking us on Facebook at Minditgh

 

The babies of the Aakanksha, Shishu Kalyan Kendra Women and Children Centre (Babies’ Home), Mahatma Gandhi Institute of Medical Sciences, India. The Center’s name translates to Baby Ambition Welfare Center, reflecting that dreams for the infants’ safety, wellbeing, and future can all be accomplished.

Summary

Adolescents with unwanted, advanced pregnancy who seek abortion late are in danger of getting killed, their babies are in danger of dying in utero, immediately after birth, or during infancy. Complications of unsafe interventions remain a major public health issue globally.

Social responsiveness can help mothers with unwanted advanced pregnancy.

Girls who reported for abortion with pregnancy beyond 20 weeks (under India’s abortion law) knew about pregnancy, were counselled and offered medical, social, and financial help to safely deliver and legally surrender their baby to the Aakanksha, Shishu Kalyan Kendra Women and Children Centre (Babies’ Home) under India’s legal system. Most girls were admitted, some were not, but those who came back, had a safe birth and babies were legally adopted. It was long journey filled with obstacles before a system of local, legal adoption was established.

Over three decades 547 girls were helped, with the youngest 12 years of age. 147 girls were victims of rape under Indian law because they were in relationships and under the age of 18 and therefore unable to consent, while 26 girls were victims of sexual assault. In addition, abandoned babies were brought in by police from temples, railways, hospitals, and farms. Some babies brought in had defects but were helped and under the local system there were 203 direct adoptions during the last decade. 

The mission of preventing deaths, disabilities with long term health impacts, honor killings, dangerous interventions for termination, and enabling girls to lead normal lives was achieved with the safe survival and adoption of unwanted babies who brought joy to infertile couples wishing to become parents. 

Background

Unwed mothers many times do not seek abortion in time, and report unwanted, advanced pregnancy when abortion is no longer an option under Indian Abortion Law. They are then in danger of getting killed, (an honor killing), committing suicide, or suffering health complications due to unsafe interventions. Their babies are in danger of dying in utero, immediately after birth, or during infancy due to complications. Unsafe interventions to terminate an unwanted pregnancy remain a major public health issue around the world (Neutiyal et al 2012, Stubblefield et al 2012). Preventive strategies to reduce the problems that arise due to unsafe termination interventions are essential. Unfortunately, prevention of death from abortion remains more of a political issue than a medical one. Laws are made to clarify what is legal and what is illegal. However, a law’s first purpose is to prevent unjust action, yet the question of unjust to whom and by whom are big questions which need deliberation. There is a need for society to take action now.

In Indian sociocultural milieu, an unwed pregnancy is a social stigma. It not only ruins the girl’s life, but her family’s too. While advocacy of “do and don’ts” for young girls continues in families and society, girls do indulge in sex either because of their own desire or because of exploitation by relatives or friends and rape by acquaintances and strangers alike is not rare. Resulting pregnancies are responsible for suicides, honor killings, sufferings of the mother, and even the loss of babies. India has a liberal abortion law under which pregnancy can be terminated up to 20 weeks for various reasons. However, there are problems with many girls seeking an abortion because of the lack of awareness, availability of services, and resources among other reasons. Oftentimes, unwed mothers with advanced unwanted pregnancy are reported or brought in by mothers, relatives, and neighbors due to the distension of an abdomen that is thought to be a tumor and the diagnosis of pregnancy is a shock for their family. When abortion is refused, termination of pregnancy is somehow attempted at home or in unsafe places by untrained health providers which can lead to death, permanent problems, and the loss of the baby. Tracking girls in this situation is impossible because usually false addresses are given. 

Objectives 

The objective of this work is to share information about social responsiveness to help unwed adolescents and widowed mothers with unwanted advanced pregnancies.

Material Methods

In response to all of the problems girls with unwanted advanced pregnancies face, socially responsible treating clinicians created a system under which the hospitalization of girls with unwanted advanced pregnancy were helped. This was in response to the girls’ feelings of insecurity with staying at home due to the social stigma attached to their circumstances. In the hospital they were provided safety, meals, medication, and a safe delivery. Safe abortion services were always available for those reporting pregnancies under 20 weeks of gestation. In the beginning the babies delivered were sent with their mothers to nearby babies’ homes. It was difficult to reach the homes and track the mothers and babies. Oftentimes when social workers checked in to ensure that they reached the place for legal surrender, the deaths of the babies and other problems with the babies were revealed. So, another system was created under which social workers from better run babies’ homes came to the place of birth. Mothers could surrender babies, but the legal system did not permit surrender to distant babies’ homes. Eventually, one of the babies’ homes opened a branch nearby the hospital but the branch was required to have a license which they were unable to attain. A licensed home for babies, The Aakanksha, Shishu Kalyan Kendra Women and Children Center (Babies’ Home). was then started at the same location where the system for safe births was created. Abandoned babies, be it at temples, farms, roads, railway stations, or hospital gates, were also admitted to the home through the legal system. It has been followed by a licensing for national adoption which has become an international license under current adoption laws. 

Results

Over the years, 547 girls, nearly all of whom were unwed although a few were widowed, with advanced unwanted pregnancy reported that they were helped, with the youngest, a 12-year-old girl. Abandoned babies were brought by the Woman and Child Department of Government police and those who had defects were helped through surgery. There have been 203 direct adoptions under this system during the last decade.  

Discussion

In the beginning, civil society management had apprehensions about helping adolescent girls with advanced unwanted pregnancies, later of keeping such babies and their eventual adoptions, especially overseas. However, results demonstrated, two lives were saved, two families were given an opportunity to be happy, and so the system was embraced. Human rights issues came about with cases where the baby’s life was lost, with babies who had low birth weights, or anomalous babies. However, most babies are happily living with families or in the Babies’ Home. Along the path it was realized that there was a lack of awareness, availability, and/or use of contraceptives. Many times girls had no knowledge about how conception occurred. In view of the information gathered from these unwed girls about the lack of knowledge of conception, beginning in the year 2000 Family Life Education (FLE) has been imparted in schools in the district which have a population of around 1.5 million. The stakeholders (education and administrative departments of state government and civil society) have been involved. Adolescent school girls are provided information with visual aids in local languages about their growth and development, menstruation, conception, contraception, prevention of sexually transmitted diseases including HIV/AIDS, safe abortion, safe birth, and breastfeeding. Adolescents are also helped in finding answers to their doubts and dilemmas about reproductive health to ensure that there is a promotion of overall health of adolescents’ preventive, curative, rehabilitative, and promotive health (Chhabra 2016). The mission is the prevention of deaths and disabilities with long-term health benefits to adolescent girls who should be able to lead normal lives. They become better prepared for their role as mothers, knowledgeable about the prevention of sexually transmitted diseases, and learn the essentials of safe birth and care of a baby. Many infertile couples go from pillar to post seeking pregnancy and oftentimes fail to get pregnant even after assisted reproduction. Under this project the unwanted babies of unwed mothers are surrendered under the legal system to adoptive parents who desperately want a baby thereby creating a new joyful family. 

If mothers need further help in rehabilitation they are also provided support. However, utility of this remained limited because the attempt to help them become self-sufficient was not well received because of social issues. The girls do not wish to stay in the same area or be around people they are recognized by. However, some girls have been rehabilitated by taking positions in households, or even as nurse assistants or seamstresses. Over time their confidence is rebuilt as they earn money and settle down and have the possibility of a bright future ahead of them. 

Sensitization of health professionals, medical students, and nurses towards the needs of society requires action and sustainability is essential. In the beginning, Children Protection Fund, Aarhus, Denmark, a nongovernmental organization, helped in running the project for unwed girls with advanced unwanted pregnancy and running the Babies’ Home for some years. Now the system is almost self-sufficient with some support from the Medical institute, Kasturba Health Society, Sewagram, and philanthropists.  

This project demonstrates the effectiveness of comprehensive care of adolescent girls in a cost effective and sustainable way from a clinical department of a medical educational health care institute. It involved midwifes, social workers, postgraduate students, in addition to stakeholders, a health care medical education institution, communities, and government. The startup phase of this project was made possible with the support of an international nongovernmental organization focused on saving adolescents’ lives, promoting their health, and couples who wanted to become parents being paired with as a one-of-its-kind program in this country. At this institute there are medical and nursing students from all over the country and neighboring countries so this project is sure to have a ripple effect.

Conclusion

A simple step can help by providing social justice to many unwed girls and women with unwanted advanced pregnancy, enabling the safe survival of unwanted babies, and help to parents and babies in becoming families. Unwanted babies of unwed mothers now are longed for and bring joy to infertile couples who want to be parents from around the globe – there were a lot of obstacles on the journey of this program but it we have reached our destination – a successful program protecting the lives and health of unwed mothers, ensuring safe delivery and surrender of their babies, and creating new families across the globe. 

Works Cited

Chhabra S, Pohane D, Jadhav N, Mishra S Adolescents Reproductive Health Dilemmas and Doubts. The Indian Practitioner. 69,6,41-44,2016

Title of Project

Health promotion and the Combat of Endemic Diseases in Wadabooshar Village: A Real Model of Community Empowerment.

Project Start Date

November 25, 2016

How Long Have I been Involved with this Project

Two years 

Project Context and Goals: Problem, Issue or Opportunity Addressed 

Why is this significant?

This project was conducted at Wad-Abuoshar Village, located 113 Kilometers east of Wad Medani (Capital of Gezira State), with a population of 4,000.

The problems of the village can be classified into:

  1. Health problems: In a period of two weeks prior to our study; the incidence of Malaria was 58 percent, Typhoid Fever was 21 percent, Urinary Tract Infection was 33 percent, gastrointestinal problems were 42 percent and 20 percent were diarrheal disease in children under 5 years old. There was only one midwife in the village, who provided that the prevalence of alcohol consumption increased significantly. Also, they reported high prevalence of hypertension at 38 percent and frequent use of fattening pills and skin whitening creams among the girls in the village.
  2. Services problems: There is no health center in the village, the only medical assistant provides the medical care and there was difficulty with transportation. In addition, there were a lack of a healthy market. No high school. The dental unit was not functioning nor the cleaning vehicle and or garbage collection.
  3. Environmental and community problems: The village residents are not interested in cleanliness, there was a presence of animals inside the house, lack of shady and fruitful trees in the village, absence of healthy place to slaughter and sell meat, vegetables and fruits are exposed in the ground surrounded by dirt, animal waste, and stagnant water. Teen marriage and relative marriage are common. There were problems, disagreements, and disputes with the residents of neighboring village, which prevents them from getting the benefit of available various health and social services.

Before the intervention: The market shows vegetables exposed dirt from the ground and surrounding environment.

 

After the intervention, an active simple waste disposal system consisting of a donkey cart and a vehicle in use. 

 

Massive health education program.

 

The newly established health center during the project intervention. 

 

The newly established healthy market during project intervention.

Credit: All images courtesy of Yussein Elhussein

The general gall of the project is health promotion and the combat of endemic diseases, reduction of morbidity and mortality rates, and to provide primary health care services.

My Role in this Project

How Much Time and Effort Have I Contributed to the Design,

Implementation, or Continuation of the Project?

This project was developed throughout three phases during academic courses within the curriculum of the University of Gezira, Faculty of Medicine in “The Interdisciplinary Field Training, Research, and Rural Development Program (IDFTRRDP).”

I was a leader of a group of 22 medical students. Each phase was four weeks in length and we stayed in the village for a week during each phase except for the second phase. In the first phase (November 2016) all time and effort have been put together to study the village and discover its problems. We observed the village and studied the community, health system, and health status by conducting home surveys, analyzing the data, detecting the problems, and classifying them. In this phase, I helped by filling out the questionnaire forum by "SPSS – v20" to analyze the questionnaires and chart the results, project, and discuss them. Also, as a group leader I prepared a seminar presenting the work for colleagues, I wrote a report for the course coordinator. I helped in designing the criteria for priority problem selection and designing the intended interventions and projects.

During the second phase (December 2016 - November 2017) we designed the intervention after creating a priority listing of the problems and I wrote a proposal of the project with a rational budget. Then we went to the village and applied planned intervention. I contributed in designing a "criteria of prioritization (Scoring System)" for the problems to guide the project for the most serious problems, and so the application of the intervention could achieve its objectives. I headed a meeting with the local committee of citizens and community leaders in which we discussed the project, its components, justifications, objectives, strategies, plan of working, and the expected results and outcomes. I coordinated the implementation with the related authorities, including: visits, meetings, writing proposals, and fundraising. The authorities included: University of Gezira, Faculty of Medicine, the "ministry of health" in Gezira state, "health services administration" in the locality, the local committee of citizens, "youth union and women union in Wad-Abuoshar Village," administrators of schools, and "Sudanese Red Crescent Society" and other charitable associations.

In the third phase (December 2017), we assessed the effects of the interventions by running the same sample survey and comparing the results. We measured the incomes, processes, outcomes, and impact indicators to assess the successful projects. I designed a questionnaire aimed to directly assess the project, it was completed by the community leaders and the residents, I also analyzed the survey questionnaires, comparing the results to phase 1. Also, as a leader of the group, I prepared a seminar showing the work to colleagues, and I prepared a draft report for the course coordinators.

In between the period of phases I helped with fundraising from charitable associations and other donors, with the rest of the budget from the students and the village’s committee.

Later after the end of this course, I continued to visit the village to ensure that the project was doing well.

Project Innovation and Creativity 

This project represents a model of community empowerment as we led the community initiatives through their full participation in all stages of thinking, planning, implementation, management, and evaluation of the project and encouraged them to develop their health system on their own. At a cost that they can afford to maintain the development at every stage, and in the spirit of self-reliance and self-determination. It is characterized by multi sectors and authorities. So, we helped in strengthening the cooperation between various authorities, building active partnerships and relationships for development. The implementation was based on prioritizing the problems through a scoring system which includes importance, danger, urgency, the community concern, solvability, sustainability, and cost. The project was designed in an integrated approach. The main integrated components were: establishment of a health center, establishment of a healthy market, massive health education program (about the infectious, endemic, and chronic diseases, bad habits, beliefs, and behaviors), foundation of a simple, active, and permanent waste disposal system, planting 400 fruitful and 20 shady trees, training volunteers from the village on first aid, nursing skills regarding emergency situations, providing two electronic devices to facilitate the periodic follow-up of hypertensive patients in the village, and fighting malaria through periodic spraying with pesticides and using other means of control.

Our interventions

These interventions aim to support health through diagnostic and therapeutic aspects for the village in a permanent manner, reduce of travel related to seeking medical care, increase the level of health awareness (about infectious, endemic, and chronic diseases, and eradication of bad traditional habits), train volunteers to become midwifes, provide plantings for the village, provide a stable source of income to support the needs of the village, and especially support the health needs of patients with disabilities and patients with chronic diseases. Also, to improve the standard of living of village residents, especially the sellers, by supporting the commercial movement inside and outside the village, maintain a healthy environment, minimize the incidence of infectious diseases (malaria, typhoid fever, urinary tract infection, gastrointestinal diseases and diarrhea, reduce malaria complications especially for pregnant women and children under five, enable training for village volunteers in first aid, nursing skills and how to deal with emergency situations. Empowering the community by encouraging and generalizing the idea of a pilot project, which aims to establish projects that enable the village to provide a steady income to help solve its health and social problems.

Measurement of Project Impact on Community Health

Regarding project evaluation, we compared between the data that we collected in phase one before the interventions with the third phase. We assessed the effects by running the same sample of survey and comparing the results. The outcome was measured. The impact indicators to assess the successful projects was settled. I designed a questionnaire aimed to directly assess the project, it was completed by community leaders and the residents. I also analyzed the survey questionnaires, comparing the final results to phase 1 results. Also, we organized a charity health day with participation by practitioners of internal medicine, pediatrics, obstetrics and gynecology, dental clinics, and included a comprehensive lab for testing and drugs supply. We used the results of these tests and diagnoses to measure the change in the diseases distribution and behaviors of the patients. We also made observational checklists to evaluate the project.

The following figures reflect the impact of the project, compared before and after the interventions. Percentage of families who get rid of waste by burning or placing it randomly in the village decreased from 78 to 21 percent, while families that got rid of the waste by placing it to be picked up by the transport vehicle raised from five to 54 percent. The presence of water pools around the house decreased from 33 to 14 percent. The concept of mothers with children under the age of five has improved on absolute breastfeeding and the percentage of those who have not heard about it has dropped from 40 to 13 percent. Women vaccinated against tetanus during their last pregnancy increased from 65 to 87 percent, and women who take folic acid during pregnancy increased from 73 to 94 percent. Diabetics who follow a periodic follow-up once a month increased from 22 to 59 percent, incidence of malaria, diarrhea, pneumonia during the two weeks before the visit decreased from 58 to 16 percent, 42 to 21 percent, and 40 to 11 percent respectively. The use of insecticide-impregnated mosquito nets for pregnant and children under five years of age increased from 51 to 78 percent, while only three percent did not use nets, and the rest used other means of control such as spraying with pesticides. There were no maternal deaths during birth and the incidence of complications decreased from four to one percent. The attitude of the hypertensive patients to control their illness (practice physical activities and exercise) rose from 51.55 to 87 percent. Individuals following a special hypertensive diet increased from 71 to 90 percent. Avoidance of smoking, coffee/tea, and obesity changed from 74.3 to 86 percent, 49.2 to 73 percent, 37.2 to 79 percent respectively. 28 percent were used to going for follow up every month and used to recording the results to measure blood pressure. The percentage of hypertensive patients on regular treatment increased from 68 to 91 percent, and the rate of periodic monitoring of blood pressure increased from 28 to 72 percent by using electronic pressure devices according to the project.

Regarding the results of the two therapeutic days, the presence of UTI, Pneumonia, Malaria, Gastroenteritis, and Giardiasis decreased from 27 to 13 percent, 34 to six percent, 11 to four percent, 14 to zero percent, six to zero percent respectively. Regarding the healthy market, we found that the vegetables and fruits and presence of a suitable place for selling increased from 13 to 100 percent. Exposure to the ground decreased from 96 to zero percent. Waste in the surrounding environment decreased from 78 to six percent. Contamination decreased from 57 to 11 percent. Regarding project evaluation from the perspective of the community leaders 45 copies of the questionnaire were completed by part of the local committee of citizens and youth and women unions with 100 percent very satisfied, 96 percent said it was very useful project, 98 percent said it was appropriate, necessary, and fulfilled the community’s needs and maintained the healthy environment, 100 percent said it was empowering the community to seek solving its own problems and maintaining the sustainability of the project development. This project contributes to solving health problems, it also meets the community needs, and enhances the health culture.

Sustainability of Project 

Sustainability is a major indicator for project success, so as we designed our project we also were concerned about the sustainability and continuation of project components. The first component of our intervention established a health center: sustainability was assured by registration of the health center in the ministry of health, a committee was formed composed of the community leaders including the local committee of citizens and youth and women unions who were responsible for follow up progress in the building of the center and regular assessment, follow up appointments of the health staff, and providing them with housing in the community to contribute to their stability.

Regarding the market; the land has been authenticated and registered with the local citizens committee, as well as the formation of a committee of community leaders responsible for supervising the market, collecting the monthly subscription from the sellers, which represents a source of fixed income that contributes to the development of the market, increasing the sales places, and supplying the people with special needs and patients with chronic diseases. To address controlling blood pressure a committee of community leaders was formed and trained on the use of electronic blood pressure meters. We also provided information about hypertension signs, complications/natural levels, etc. This committee is responsible for listing the contact information of hypertensive patients in the village, allocating one day of the week to contact all patients for periodic monitoring of blood pressure, allocation of a booklet for each patient to record their  measurement, giving advice and transferring patients to the doctor in the case of high or very low blood pressure readings, collection of contributions and purchases of new equipment, all of which ensure continuity of the project.

To minimize the incidence of malaria a committee of community leaders and village health officers has been established. A malaria technician is responsible for health education. It has been agreed with the local health department and the Ministry of Health in the state to provide materials and spray pumps to spray the village with pesticides in each period to prevent reproduction of mosquitoes. The plantings in the village will be supported by a  responsible committee to follow up the growth of trees and watering, as was agreed with an agricultural expert from the Department of Agriculture and Horticulture in the locality in addition to providing them with instructions and guidance on trees, and in the future will be allocated agricultural land to plant fruitful trees and return to support development projects in the village and the health center and needy patients.

To support first aid 20 people were trained including school teachers and youth at the sports club. Some of them were from the general population of the village. The school students and football players in the stadium were the most vulnerable groups and it was agreed that they would teach others from time to time to maintain the sustainability. The massive health education program is sustainable, as the health center works, the medical staff gives health education as a part of their job description and we also encouraged active community leaders to continue health education programs and campaigns. The foundation of a simple, active, and permanent waste disposal system’s sustainability was made possible by providing a donkey cart, and employment of a worker from the village to take care of the donkey, collecting the waste two times per week, and burning it outside of the village. The worker has been authorized to use the donkey cart for his own benefit the rest of the week, also he collects weekly taxes from every house as a salary, and a committee of community leaders was formed to follow up and maintain the sustainability.

Diffusion and Extension of the Project

I helped in communicating and extending the project by presenting seminar sessions to our colleagues in the faculty, I also conducted a lecture about project management using this as an example of a successful project for the 2nd-year batch medical students that was supervised by the head of family and community medicine department in the faculty. This project was also presented as an exhibition to all medical students, staff members, the dean of the faculty, the university manager, and other stakeholders. I also wrote a report about the project and it was given to the community medicine department. I am now applying to this (the 2018 TUFH Competition) competition and exited to extend this experiment and model project worldwide.

Why Does this Project Work? What Can Others Learn from This Experience?

The project works because it was achieved through applying the primary health care concepts in community leading initiatives and community empowerment, it also enhanced the role of multi sectorial approach in project success. The project was implemented in a clear methodology and strategic plans, the community was involved in all stages of the project: selection, planning, implementation, supervision, monitoring, and evaluation. The society has been mobilized and empowered by strengthening and encouraging it to solve its various problems, it also enhanced the role of sector integration in the success of the project and creation of relationships between different institutions and society. It demonstrated that health promotion and disease prevention have a role on socioeconomic development, so it solves the village’s basic problems. One of the main reason is raising awareness of the villagers as they showed great interest in developing themselves in various fields.

What Was the Most Important Element of the Project that Led to the Huge Improvement of the Community Health?

This project was designed in an integrated approach, which helps a lot in project success and the huge improvement of the community’s health. The project works because it was achieved through applying the primary health care concepts in community leading initiatives and community empowerment, it also enhanced the role of the multi sectorial approach in project success. The project was implemented in a clear methodology and used strategic plans, the community was involved in all stages of the project: selection, planning, implementation, supervision, monitoring, and evaluation. The society has been mobilized and empowered by strengthening and encouraging it to solve its various problems, it also enhanced the role of sector integration in the success of the project and creation of relationships between different institutions and society. It demonstrated that health promotion and disease prevention have a role on socioeconomic development, so it solved the village’s basic problems. One of the main reason it was successful was that it raised awareness of the villagers as they showed great interest in in developing themselves in various fields.

Anything Additional You Would Like to Share with Readers

This abstract reflects great efforts done by medical students, it is also a great model of community empowerment for health promotion. I have to mention that students have an important role and impact on community health as they helped a lot by leading the community initiatives towards health promotion throughout different programs, projects, and opportunities. In general, not only medical students can do this but it is the responsibility of all youth to serve our communities with all kinds of help that we can contribute. We have to be socially accountable and responsible towards the community and this cannot be achieved unless all the sectors, authorities, and community leaders cooperate and build extended partnerships together to reach to the dream -- health for all and all for health!

Author bio

Photo Credit: Monzir Abdelmonim Osman‎‏, Kapoor Photography

Yassein Elhussein is a 20-year-old, fourth-year medical student at the University of Gezira, Faculty of Medicine, Sudan. 

Yassein’s posts and leadership experiences include:

  • Acting president for Gezira Medical Students Association (GMSA): 2016-2017.
  • Scientific secretary of Gezira Medical Students Association (GMSA): 2017-2018;
  • Deputy Secretary General of Gezira Students network organization – G.SNO: 2017-2018;
  • Financial Secretary at Safety Motherhood and childhood friendship Association: 2017-2018;
  • Training division Director at Sudanese Medical Innovation community SMIC: 2017-2018;
  • Local Member organization (LMO) MedSIN-GMSA president at MedSIN Sudan at IFMSA – 2017-2018;
  • Human rights trainer at International Federation of Medical Students’ Association IFMSA – 2017;
  • President of Hayat Charitable Association 2017-2018; 
  • Member of Accreditation committee, university of Gezira, faculty of medicine 2017;
  • Vice head of Media at Hayat Charitable Association 2016-2017;
  • Trainee at Khartoum International Summer School KISS: 2017;
  • Events “symposium” organizer at Royal College of Physicians of Edinburgh RCPE: 2015-2017;
  • Head of Media at Sudanese Medical Innovation Community SMIC: 2016;
  • Member of Student Assessment committee at Education and researches development center (EDC), University of Gezira, Faculty of Medicine;
  • Volunteer at TEDx Wadmedani;
  • Member of The Network: TUFH 40th Anniversary programming committee (TUFH Australia Conference 2019);
  • Member of The Network: TUFH 40th Membership committee (TUFH Australia Conference 2019);
  • Presenter in World Summit on Social Accountability, The Network towards Unity for Health (TUFH) conference in Tunisia April 2017; and  
  • Winner for SNO-GEMx international exchange program 2018, in UHL.

Summary

Community-based participatory research approaches can be useful for stimulating social innovation. Such approaches involve community members at various phases of the research process and have several positive outcomes for the research and communities. This paper discusses the community mobilization approaches that are at the heart of research on HIV and related issues conducted in a rural community in KwaZulu-Natal, South Africa. We present affirmation and acknowledgement as an innovative and empowering strategy in community mobilization, as it affirms community members’ voices, dignity, and agency concerning issues that affect their lives.

Introduction

Community-based participatory research (CBPR) approaches can be useful for stimulating social innovation. Such an approach involves community members at various phases of the research process and has several positive outcomes.1 Acknowledging community members’ views on issues that concern them counters the distrust and unintended harm caused by traditional “helicopter” research where there is little consultation, data is extracted, and feedback is often not given. Community involvement in research also assists with transfer of research knowledge and findings into actions that could lead to greater uptake of these ideas.2 Such an approach is especially important when working with communities who have been marginalized or stigmatized, so as not to reinforce the stigma or inflict further harm to people. In South Africa, considering the racialized history and persistent socioeconomic inequalities, community participation and engagement in research can help to manage the power dynamics between researchers and community as these interactions may amplify historical or current differences. 

Aim and Outline

We have used CBPR approaches to inform our work in a rural community in KwaZulu-Natal, South Africa for the past 15 years. This community acts as laboratory for understanding social and health issues affecting communities such as these, as well as innovative ways of engaging with and addressing these problems. All studies conducted here rely heavily on formative work to shape and frame the interventions and studies conducted here. The aim of this paper is to discuss the community mobilization (CM) approaches that are at the heart of this work. We provide a brief overview of the model and discuss affirmation and acknowledgement as an innovative and empowering strategy in CM. 

Community Mobilization 

We developed a CM model to guide our community engagement efforts towards enhancing greater participation and uptake of research.3 Community mobilization involves the systematic inclusion of the maximum number of community members, including commercial and other institutions and organizations, to take action towards a common goal.4 These mobilization strategies, irrespective of the type of study, are culturally appropriate and respectful. Our model, based on current CM5 and engagement models,6 consists of four interconnected phases, namely range, recognize, recruit, retain, and sustain. Firstly, the range phase concerns determining the physical boundaries of the communities where a study will be located. Secondly, recognize involves identifying the community leaders, networks, decision-makers, and any other role players within communities. The third phase, recruit, concerns all the specific efforts to spread the mobilization messages throughout the community by the local community members. Lastly, retain and sustain involves the efforts to retain participants through the duration of the research and to nurture the collaborative relationship with the different community stakeholders. 

Affirm and Acknowledge as Social Innovation

Social innovation is not always something brand new, but it can include ways of doing something differently in order to achieve different outcomes. In our work, we prioritize community involvement in making decisions about culturally appropriate ways of going about the research. This kind of community involvement goes beyond just acknowledging the community members’ input on issues of concern, but also acknowledges their ways and beliefs. It affirms their voice, dignity, and agency concerning issues that affect their lives. Through affirming and acknowledging, researchers can gain more insight as to why people would participate in research or interventions and understand why not. Moreover, researchers can gain insight into the dynamics that influence the daily lives of people -- the very aspects which the research and social innovations intend to address, change, or enhance.

Affirmation and acknowledgement is important from the outset and throughout the research process. We recognize the lived experiences of the particular community members where studies are located. We do this throughout the engagement efforts as we practice awareness of how various social, economic, cultural, and psychological or experiential factors may intersect and directly or indirectly affect participation in research. 

We affirm community members’ views on issues that concern them. To this end, we have put various structures in place. Firstly, a community advisory board (CAB), consisting of voluntary representatives of various organizations and institutions in the target communities. Members on this structure acts as consistent sources of knowledge regarding the appropriateness of potential research, identifying potential barriers to participation, signalling appropriate ways to go about recruiting participants, and framing messages and findings. The approach to the work is participatory as we engage with, and recruit community members and key stakeholders into the research process to ensure that research questions develop out of the convergence of both science and practice. Research results both come from and return directly back to the people who need them most and can make the best use of them.

Even though CABs are common practice in community interventions, engagements need to be consistently facilitated with affirmation of local knowledge in mind and recognizing the strengths and influence of the community representatives on the board. We also construct a community working group that assists with identifying community-based organizations and social networks in the community; assist with mobilization efforts; and help to retain participants in studies. In this way, community members gain experience, which empowers them, and the study benefits as participants are reached in appropriate and accessible ways -- through their own networks within communities. 

Conclusion

The genuine involvement and participation of community members in all facets of the research process can stimulate greater uptake and use of research. Communicating research findings in ways that speak to people can be transformative. This paper highlights that the ways of interacting with community members need to be affirming and acknowledging of their knowledge, dignity, and agency about issues that concern them. Structures like the CABs and community working groups enable us to reach people respectfully. By foregrounding community mobilization and participation in all our studies, we are able to address a large number of health and social problems encountered in the day-to-day lives of ordinary South Africans. 

Works Cited

1 Wallerstein, Nina B., and Bonnie Duran. "Using community-based participatory research to address health disparities." Health promotion practice 7.3 (2006): 312-323.

2 Lazarus, Sandy, et al. "Lessons learnt from a community-based participatory research project in a South African rural context." South African Journal of Psychology 44.2 (2014): 149-161.

3 Fluks, Lorenza L., Ngubani, T., and Van Rooyen, Heidi E. “Community mobilization for HIV research and prevention: Process, strategies and researchers’ reflections.” Forthcoming.

4 Lippman, Sheri A., et al. "Conceptualizing community mobilization for HIV prevention: implications for HIV prevention programming in the African context." PLoS One 8.10 (2013): e78208.

5 Person, Bobbie, and David Cotton. "A model of community mobilization for the prevention of HIV in women and infants. Prevention of HIV in Women and Infants Demonstration Projects." Public Health Reports 111.Suppl 1 (1996): 89.

 

6 Suarez-Balcazar, Yolanda, Gary W. Harper, and Rhonda Lewis. "An interactive and contextual model of community-university collaborations for research and action." Health Education & Behavior 32.1 (2005): 84-101.

The authors state that there is no conflict of interest in this article.

This article is supported by the China Medical Board (CMB). Title of the project: “5+2+1 Joint Medical Education Model for General Practitioner. No.11-076.”

Abstract

Establishing a general practitioners’ system is a significant and difficult point of medical reform in China. The key problem of establishing a general practitioners’ system is that qualified general practitioners who have undergone the standardized training will be the gatekeepers of health. Presently, the general practitioners in China are short-handed and the training and employment of general practitioners is not keeping pace with need. This will cause an impasse in the establishment of a general practitioner system. There are many reasons for the impasse, but this paper argues that the core reason is the traditional pattern of interests is solidified and the new pattern of interests has not been established. The authors suggest that the government in the process of pushing grading diagnosis and treatment, could be refactoring the pattern of interests via fusion between Internet and medicine based on “Internet +” to reach a win-win situation in order to push the establishment of a general practitioner system. 

Introduction 

Primary healthcare systems mainly rely on general practitioners, health insurance, and health investment from government [1]. In order to improve China's primary health care system, in addition to reforming the government's health investment and medical insurance financing and paying mechanism, China has also continuously strengthened general medicine education and promoted the establishment of the general practitioner system, which has become one of the key issues of China's education and medical reform. The authors of this article attempt to analyze the predicament of the establishment of the general practitioner system in China and the practice of the Internet in the medical industry, combined with the characteristics of primary health care and "Internet +", to put forward the idea of promoting the establishment of a general practitioner system in China based on Internet technology.

Comparison of the General Practitioners in China and Beyond

The data from the website of Organization for Economic Co-operation and Development (OECD) and China Health and Family Planning Statistical Yearbook (2015) indicates the number of general practitioners per 1,000 in China is 0.14 which is lower than the United States (0.31), the United Kingdom (0.79), Israel (0.27), Turkey (0.57), and other countries. The proportion of general practitioners in China is 7.52 percent, which is also lower than the United States (11.89 percent), Canada (47.22 percent), Israel (8.67 percent), and other countries (Table 1) [2-3]. China still has a large gap in the number of general practitioners compared with other countries.

Table 1: Comparison on the General Practitioners between China and Others in 2015

Note: Data from website of organization for Economic Co-operation and Development (OECD) and China Health and Family Planning Statistical Yearbook (2015)

*The data for The United States is for 2014

Comparison of Domestic General Practitioners 

Comparing the number of general practitioners per 1,000 population in various provinces/municipalities/autonomous regions in China, the number of general practitioners per 1,000 in Beijing, Zhejiang, Shanghai, and Jiangsu was 0.38, 0.39, 0.30, and 0.26, respectively, which was significantly higher than the national average level (0.14). Guangdong Province, as a major economic province in China, has a total number of doctors per 1,000 population of only 0.14, which is equal to the national average level (Figure 1). Comparing the proportion of general practitioners who are qualified doctors, it is found that only Zhejiang, Jiangsu, Beijing, Guangdong, et al. are areas that have levels higher than the national average level (7.52 percent) (Figure2). Among the 31 provinces/municipalities/autonomous regions in China, only six provinces/municipalities/municipalities have a higher ratio of general practitioners per 1,000 population and 10 provinces/municipalities/practitioners higher than the national average level, which indicates that there are serious regional and structural imbalances in the distribution of GPs in China.

Figure 1: The number of general practitioners per 1,000 population in China, 2015

Note: Data from China Health and Family Planning Statistical Yearbook (2015)

 

Figure 2: The ratio between general practitioners and practicing physicians in China, 2013

Note: Data from China Health and Family Planning Statistical Yearbook (2015)

In general, the number of general practitioners per 1,000 population and the proportion of general practitioners of qualified doctors in China are still far behind other countries. There is a serious shortage of general practitioner resources, imbalance in geographical distribution, and irrational proportion, which shows that the basic conditions for establishing a general practitioner system in China are poor.

Disconnect Between Training and Employment of General Practitioners

In recent years, in order to establish the general practitioner system, China has continuously improved the training system for general practitioners. In 2011, the “Guiding Opinions of the State Council on Establishing a General Practitioner System” pointed out that during the transitional period, the training mode of general practioners (GPs) in China is mainly the “3+2” training mode (i.e., after completing three years of medical education, continuing to participate in two years as an assistant general practitioner) and transfer training, and actively explore the standardized "5 + 3" training mode (i.e., after graduating from five years of medicine, participate in three years of standardized training for resident or postgraduate education for medicine).

According to statistics from the Guangdong General Hospital Education and Training Center, on January 11, 2016, the total number of postgraduates for general medicine in Guangdong Province was 22,766 of which 18,274 were certified, the number of transfer training for general practitioners was 2,783 of which 2,765 were certified, with 265 participating in standardized training for general practitioners in this center and 124 who actually obtained certificates, and the remaining 141 people who have not yet completed their studies. Currently the training model of general practitioners is mainly in-position and transfer training and the proportion of standardized training general practitioners is extremely low.

Guangzhou Medical University explores the “5+2+1” Master of Medicine joint training model under the state-designated “5+3” clinical medical personnel training model. The characteristics of this training model are as follows.

  1. Multinational: Teachers from home and abroad;
  2. Trans-sectoral: Cooperation between medical universities and Health and Family Planning Commission; 
  3. Inter-disciplinary: Clinical medicine, preventive medicine, rehabilitation medicine, and other disciplines; and
  4. Emphasis on primary health center: focus on primary practice.

The first class enrolled in 2012 to the master’s in general medicine program and graduated successfully in June 2015 with only one student who chose to go to the primary healthcare institution for employment. Obviously, there is a serious disconnect between the training and employment of general practitioners.

Analysis 

At present, China's general clinical medicine education has qualified training based on teachers’ resources. However, the greater challenge is that the training and employment of general practitioners continues to be out of line. General practitioners who undergo standardized training are reluctant to go into service for primary medical care, which also in turn hinders the development of general medical education, and eventually puts the establishment of the general practitioner system into a deadlock.

Reasons that result in training and employment of general practitioners are out of line including lack of professional honor, for example lower salary, poorer professional development prospects, and poor conditions in primary health service institutions. The main reason is the traditional pattern of interests that hinders the establishment of the general practitioner system.

Under the traditional pattern of medical interests, there are cross-cutting business relationships between different levels of health institutions. Hospitals and primary health care institutions have failed to form a collaboration relationship. With brand advantages, hospitals lack internal motivation to refer patients downwards; conversely, primary health care service providers are more willing to refer patients upwards due to insufficient service capacity and inadequate incentive mechanisms [4-5]. Moreover, design of the medical insurance system in China makes the difference in the cost of selecting service from hospitals and primary health care institutions not obvious and fails to exert effective and positive economic leverage in the establishment of a tiered health care delivery system [6-7]. At present, general practitioners have lower job satisfaction, weak will to service in primary health care institutions, and imperfections within their pension system, which results in a lack of enthusiasm for participating in establishment of the general practitioner system [8]. The establishment of the general practitioner system requires cooperation between hospitals and primary medical and health service institutions. Forming cooperating relationships needs government support, on the other hand, it requires hospitals and primary medical and health service institutions to actively participate [9]. Although the establishment of the general practitioner system was actively promoted, because of the uncoordinated interest mechanism under the traditional interest pattern, the hospital was in a position of interest monopoly, and the benefits of grassroots medical and health service institutions could not be guaranteed reasonably, resulting in hospitals and primary health care service institutions unwilling to establish the general practitioner system. General practitioners are reluctant to serve in the grassroots efforts, leading to the disconnect between training and employment of general practitioners, and hinderance of the establishment of the general practitioner system in China.

Establishment of General Practitioners’ System via Refactory of Interest Pattern Based on “Internet+”

On March 5, 2015, Li Keqiang, the prime minister of China proposed an "Internet Plus" action plan in the government work report in the third session of the Twelfth National People's Congress and raised it to the national strategic level. "Internet +" can break through the traditionally solidified interest pattern, refactor a new pattern of interests, achieve value-added benefits, and maintain multi-interest benefits, such as "Internet + traditional bazaar" derived Alibaba; "Internet + payment" derived Alipay; " and "Internet + private car" derived Uber.

The Internet has gradually been valued in the field of medical and health services

On March 30, 2015, the State Council issued the “Outline of the National Health Care Service System (2015-2020).” The document states that the healthy Chinese cloud service plan will be implemented and gradually change the mode of health services through the share of health information between all levels of health institutions. In the meantime, it makes full use of information communication technology to promote the vertical flow of medical resources and further promote the establishment and improvement of hierarchical medical treatment models. On July 1, 2015, the State Council "Guiding Opinions on Actively Promoting "Internet +" Action" put forward 11 action plans, of which the "Internet + Livelihood Service" action plan involves the health field and encourages the promotion of new online medical and health services through the development of Internet-based healthcare services. At present, the use of the Internet in the health field is gradually being considered, as most hospitals build the “WeChat” public platform to carry out information and expand function [10]. The hospital improved the patient consultation process through Internet technology, achieved zero queues for registered visits, improved patient experience, and improved hospital operating efficiency. The characteristics of “Internet+Health” can be summarized as follows: cross-border integration, interoperability, open-sharing, process transformation, and accuracy, all of which helps to break through the traditional pattern of interest by improving accessibility and fairness of medical services [11].

“Internet+ Health” Breaks Through the Traditional Pattern of Interest

Under the traditional pattern of medical interests (Figure 3), government subsidies to hospitals are inadequate, and the hospital tends to be more profitable [12]. Hospitals and primary health care institutions form a competitive pattern. Hospitals collect health and high-quality hardware and software resources. That has prompted hospitals to be placed in interest monopolies under profit motives, which has ultimately led to the erosion of the interests of primary health care institutions so that general practitioners who have undergone standardized training have opted for employment in hospitals. However, further analysis found that the interests of hospitals, patients, and primary health care institutions under the traditional interest pattern were all damaged. First, hospital resources are too concentrated, which can easily lead to lower efficiency. Second, if all kinds of patients visit the hospital it would make the hospital overcrowded and increase operating costs. Third, patients have increased wait times for a visit and this would increase their time-cost. Fourth, the utilization rate of health resources in primary health care institutions is low, and it is difficult to exert its "six in one" function.

Figure 3: The traditional pattern of interests

The first Internet hospital in Guangdong Province was officially opened on October 25, 2014. It mainly aims at diagnosis and treatment for common diseases and chronic diseases in remote areas by online health services. This new medical service model broke the old interest pattern and formed a new pattern of interests (Figure 4), achieving a win-win goal [13]. Residents signed contracts with village physicians, the number of people visiting the village clinics increased, additionally, salary, social recognition, and professional honor of the village physician increased. At the same time, medical technology training and guidance from large hospitals helped professional development of village physicians. Large hospitals extended outpatient clinics to the primary health care institution, stabilized patients that required hospitalization, reduced hospital operating costs, and increased hospital bed utilization rates; patients could receive medical services previously provided by large hospital experts in village clinics; pharmacies have a loyal customer base and were able to save in marketing costs.

Figure 4: The pattern of interests of the first internet hospital in Guangdong province

“Internet+ Health” Refactors a New Pattern of Interest

The following explores how to build a new Internet hospital platform based on "Internet +" and form a new interest pattern (see figure 5). First, general practitioners provide services to residents based on their contract. Medical insurance is prepaid according to the age, disease structure, and health status of residents signed with general practitioners. Secondly, the compensation mechanism of traditional medical insurance for hospitals is turned to DRGs. Third, under the promotion of the medical reform policy, the policy that eliminates the physicians profit from drugs will be carried out and the drugstore distribution mode implemented. Fourth, in order to share health information and reduce the operating costs of health institutions, medical imaging and other examinations are entrusted to third-party professional institutions. Under the new pattern of interest, interests for different interest subjects are as follows. 

(1) Hospitals fix patient flow, improve hospital operating efficiency, and extend outpatient clinics to the community, hospitals and community general practitioners are responsible for the basic medical and health services of residents together; 

(2) In the case of expanding outpatient care, the hospital stabilizes outpatient and inpatient flow, and can also conduct continuing education for general practitioners, as well as specialize in medical scientific research;

(3) Contracted pharmacies and third-party agencies have a fixed customer base to reduce the associated marketing costs; 

(4) The service capabilities of primary health care institutions are improved. At the same time, patients can enjoy the medical services provided by experts from large hospitals at the primary health care institutions and reduce the opportunity cost for seeking medical attention.

Under the new medical service model, the function of a general practitioner as a health gatekeeper is reflected. First of all, the consultation is done by a general practitioner, if the disease diagnosis exceeds the competence of the general practitioner, online diagnosis can be conducted by connecting with the hospital through the internet hospital platform. Throughout the entire process of medical services, general practitioners and connecting hospitals receive performance awards based on the volume of contracts and the effectiveness of their services to share responsibility and benefit, thereby attracting general practitioners to take root in the primary health care institutions that will promote the establishment of the general practitioner system in China.

Figure 5: The new pattern of interests baded on "Internet+"

From the above, in the process of implementing a tiered health care delivery system, the government in China can build a new pattern of interests through a combination of the Internet and health care, connect all parties' interests with win-win results, boost the establishment of the general practitioner system, improve implementation of the tiered health care delivery model, and finally perfect the primary health care system.

Works Cited 

[1] Huang MF, Wei DH, Rubino L, et al. " Three Pivots" of primary care system: a comparison between State of California in the United States and Guangdong Province in China [J]. Chinese General Practice, 2015, 18 (10) :1105-1108. (in Chinese)

[2] Organization for Economic Co-operation and Development. Health date [EB/OL]. [2016-1-5]. http://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_WFMI#.

[3] National Health and Family Planning Commission of the PRC. Chinese Health and Family Planning Yearbook [M]. Beijing: Peking Union Medical College Press, 2014. (in Chinese)

[4] Shen SG, Zhang B, Tiered health care delivery system, optional visiting and establishment primary health care institutions [J]. Academia Bimestrie, 2016, (02):48-57. (in Chinese)

[5] Xu D, Wang GB, Zhang M, et al. Present situation and strategies of collaboration-division between public hospitals and basic medical and health institutions [J]. Chinese Hospital Management, 2013,33(04):11-13. (in Chinese)

[6] Ma XJ, Dai T, Yang SX, et al. International experiences and implications of the practice and service mode of general practitioners [J]. Chinese Journal of Health Policy, 2015,8(02):13-18. (in Chinese)

[7] Yang XG, Ma XJ, Dai T. Influencing factors of the division and cooperation mechanism public hospitals and primary healthcare service institutions: A qualitative comparative analysis [J]. Chinese Journal of Health Policy, 2013, 6(08):14-19. (in Chinese)

[8] Chang X. Study on the relationship among job satisfaction, career burnout and intent to stay in general practitioners [D]. Shandong University, 2015. (in Chinese)

[9] Chen H, Wang XF. Conflict-cooperation relationship between hospitals and community health center based on F-H method [J]. System Engineering, 2015, 33(03):154-158. (in Chinese)

[10] Li DZ, Wei DH, Ding BF, et al. The discussion on the construction of hospital WeChat public platform under the Background of “Internet +” [J]. Chinese Hospitals, 2015, 19(8):60-63. (in Chinese)

[11] Li XH, Chen YB, Zhao X, et al. Internet + healthcare [M]. Beijing: People’s Medical Publishing House, 2015. (in Chinese)

[12] Li DZ, Wei DH, Wang LS, et al. Interests–oriented behavior of medical treatment and its restrictive mechanism from the perspective of economic man [J]. Medicine and Philosophy, 2015, 36(2a):68-70. (in Chinese)

[13] Tu J, Wang CX, Wu SL. The internet hospital: an emerging innovation in China [J]. The Lancet Global Health, 2015, 3(8): e445-e446.

Oral health is defined as “the state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) diseases, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chowing, smiling, speaking, and (their) psychological wellbeing.” This article covers a descriptive cross-sectional study, using The WHO Oral health survey guidelines. The study was carried out among 149 pupils attending special needs centers in Wad Madani City, al Gazera State in 2017, of which 95 are males and 54 females.  

Children with special needs have a higher prevalence of dental caries (the mean Decay Missing Filled Teeth (DMFT) 5.19±3.931-) and a high prevalence of periodontal disease with only 22.1 percent with healthy periodontium, and a lack of receiving dental services with one student who had a filled tooth in all of the study population. The mean DMFT increases with age and the prevalence of decayed and missing teeth is higher in males than in females, with the highest mean DMFT found in the Autism group and the lowest mean DMFT found in the hearing and speech disorder group. Only 12 percent were caries free and most of these students were in the group of hearing and speech disorder. The prevalence of periodontal disease using the Community Periodontal Index (CPITN) was 37.6 percent who had bleeding with probing, 24.8 percent have calculus deposits, 22. 1 percent have healthy periodontium, 8.1 percent have pockets of 4-5mm, while 7.4 % have pockets of 6 mm or more. More than one third of the speech disorder and hearing impaired group have healthy gingiva, 35.7 percent from the mental disability group have calculus deposition, and half of the Cerebral Palsy group have calculus deposition, and there was only one tooth filled in the hearing and speech group.

Table 1: The Correlation Between Mean DMFt and Age

 

Figure 1: The Percentage of Caries-free of the Total Population

 

Table 2: Distribution of CPTIN According to Type of Disability

Based on research results the dental health of children with special needs should be improved and they should be provided with dental services including regular checkups. The establishment of a referral system and oral health education could help to motivate children as well as their parents and teachers to maintain improved oral health care for children with special needs.

Background

The Alex Community Health Centre (CHC) in Calgary, Canada serves a diverse array of community members vulnerable to poor health outcomes. Social innovation in this setting helps the community solve their own complex problems, but in doing so also offers an empowering moment where they can experience the dignity of their own power and resilience. This is predicated on the concept of agency, of having control of one’s life, being an important determinant of health.1,2

The Alex CHC has been an innovative organization from its early days. Established in 1973, in a small basement in a low-income neighborhood, it has grown into a wrap-around complement of services that solve both health and social challenges. In addition to a team of physicians at youth, family, and senior clinics, there are social workers, case managers, nurse practitioners, and housing specialists. Beyond the medical centers, there is a Community Food Centre that focuses not only on healthy eating but also relationships and social justice. There are three housing first programs within the organization that are helping those who are homeless at the intersection of mental health diagnoses. Patients often suffer from multiple chronic diseases in the context of social isolation. Many have experienced addictions, housing and food insecurity, and have a history of adverse childhood events.

The field of social innovation had not been explored through any local CHC, and the intention was to conduct a pilot (prototype) to learn how it might benefit the community. The facilitator (author), space, and materials were provided by The Alex CHC. Further funding is outlined below.

Methods

The Solutions Studio (Studio) was launched in October 2017 with an initial focus on mobility, as this is known to be an area where agency can prove beneficial from a public health perspective.5 Community members who had challenges in this realm, using a walker or wheelchair, were invited to participate, with the intention of hosting between six to ten participants. The meeting was opened to both the Family and Seniors Clinic patients, and nine people joined in the first session. 

Participants were taken through a three-step process, an abbreviated version of traditional social innovation labs.3 In the first step, they used an Empathy Map to establish the lived experience of a hypothetical person who was dealing with mobility issues (see image 1). They discussed feelings, goals, pain points, tasks, and influences of this imaginary person. This step took the pressure off each participant to appear vulnerable about their own story. In this way, they approached the rest of the session from the point of view of an invented scenario that was collectively created. The Solutions Studio Mobility Group described a person who faced many systemic challenges throughout their day, including multiple barriers to adapting to the environment where they live and carry out the activities of daily living, who often was left feeling hopeless and frustrated as a result of their need. The group described the intersectionality of poverty and housing insecurity due to the lack of affordable, accessible options.

The second step in the process was the use of an Iceberg Model of systems leveraging4 (see image 2). This tool enables an emergent deepening of leverage points within systems, starting from the inciting event to the superficial trending patterns, to change within policy or structures, and what would potentially be most sustainable through mental model shifts. They spent some time discussing possible leverage points for this hypothetical person that they had manifested through the Empathy Map exercise. Using the Iceberg Model, our community members brainstormed the third step, where they each came up with solutions and then discussed them as a group. Solutions were ranked from easy to complex and from individual to system-level.

Results

The Solution Studio Mobility Group came up with a myriad of solutions that would be very difficult for those without lived experience to envision. For example, at the level of a solution that was midway between “easy to complex” and between “individual to systemic,” they decided to film and edit a video that would demonstrate to key stakeholders how difficult it is to navigate the city streets in Calgary. Especially in wintertime, inconsistent snow removal and the need for low-income patients to use public transit, can cause people to remain at home due to fear of safety. This leads to enhanced social isolation among a group who often has difficulty making it to appointments for medical or psychosocial reasons. Participants used the Iceberg Model to determine how to leverage opportunities and decided to make the video aimed towards our municipal councillors – to ask for an “accessibility audit” of the buildings and to ask for their participation in a “take a wheelchair to work for a day” event.

Other proposed solutions included calling the city’s non-emergency services line to describe the conditions of their public transit or sidewalks (simple, individual). They recommended organizing co-operative housing units where single mothers, those with various disabilities, and the elderly could cohabitate to solve each other’s problems rather than rely on strangers through paid or public caregiving (complex, systemic).

There has not yet been a formal evaluation of the process yet, as it was deemed that the existing metrics to measure self-empowerment might not be an adequate reflection of any potential benefit,6 and it has been less than a year since we began meeting. The group meets with their facilitator (the author) monthly and has been awarded a $750 CAD ActivateYYC grant through the City of Calgary’s Innovation Fund to make their video that is a work-in-progress.

The second Studio was held in February 2018 and focused on the theme of chronic pain. There were six people who attended and interestingly all participants were male. One of their requests was to form a men’s support group for this condition, as they felt that it is difficult for men (and those who identify as male) to express mental or physical pain in our society. This was done within the week and has been well-attended by both the men from the Studio and others in our community. They asked for many other medical and research interventions, around medical marijuana and more, which are underway or currently being researched for collaborative opportunities.

A third Studio is planned for the fall of 2018, with the topic of Addiction and Recovery. Afterwards, in partnership with our Community Food Centre, we intend to try larger facilitated table-groups to go through the process around Poverty Reduction. 

Discussion

The Solutions Studio experiences at The Alex CHC in Canada demonstrate that through facilitation of a social innovation lab process, community members can generate inventive solutions to their complex challenges. For health care administrators or primary care providers, often these solutions would not come to mind, as we generally lack the lived experience.

Outcomes of the social innovation lab are, by definition, desired by the community being served, and thus more likely to be effective solutions to suit their needs and context. One common complaint of existing health systems is a lack of understanding of the determinants of health that influence illness experiences. Solutions Studio’s focus on the Empathy Map process allows those suffering from these conditions or circumstances with an opportunity to share their experiences thus providing additional knowledge to health care professionals and ultimately a learning opportunity for all. 

Since it was a physician facilitating the Studio, any triggering events due to traumatic topics were handled clinically. The solutions that involved medical interventions could be guided through this lens. Participants were noted to express trust, given a primary care provider was listening and acknowledging their stories. However, there is also the possibility that having a physician lead the process could create friction for those who have not had good experiences within the health care system. There have been many instances of vulnerable community members being treated without respect or made to feel powerless. Thus, the facilitator made many mentions of privilege in the context of her role and their power to make change. It is hoped that once sufficient members of The Alex’s patient-base have gone through the process, confidence in the organization and greater systems might be achieved. Any forthcoming policy changes at the institutional or government level would be further proof of their collective agency.

The model works, as community members, even those who are marginalized or have low literacy, are capable of understanding this simplified process. When their proposed solutions become tangible, it provides a crucial sense of agency that is often lacking in this population. We have been informally collecting narrative experiences of the Studio members, and they have been positive. Our hope is to involve University students to generate a narrative-focused research project to learn more about how the process can be further refined and scaled. A developmental evaluation process using principles-focused evaluation may be best suited for this stage in the innovative process.7,8

Endnotes

1. Abel T and Frohlich K, “Capitals and Capabilities: Linking Structure and Agency to Reduce Inequalities” Soc Sci Med. 74,2 (2016): 236-244

2. Rutten A and Gelius P, “The Interplay of Structure and Agency in Health Promotion: integrating the concept of structural change and the policy dimension into a multi-level model and applying it to health promotion principles and practice” Soc Sci Med. 73, 7 (2011): 953-959

3. Social Innovation Lab guides available for download through http://www.sigeneration.ca/home/labs/ accessed July 26, 2018

4. Image 2 was downloaded from the Academy for Systems Change website from donellameadows.org/systems-thinking-resources/ accessed July 26, 2018

5. Blacksher E and Lovasi G, “Place-focused Physical Activity Research, Human Agency, and Social Justice in Public Health: taking agency seriously in studies of the built environment” Health Place. 18, 2 (2012): 172-179

6. Ibrahim S and Alkire S, “Agency and Empowerment: A Proposal for Internationally Comparable Indicators” Oxford Dev Stud. 35,4 (2007): 379-403.

7. Patton, Michael Quinn. Developmental Evaluation.

8. Patton, Michael Quinn. Principles-Focussed Evaluation.

Author Bio 

Dr. Christine Gibson is a family physician who has a special interest in medical education and in health inequity. As part of a master’s in medical education, she created the Global Health Enhanced Skills training residency in the Department of Family Medicine at the University of Calgary. She is Executive Director and Founder of Global Familymed Foundation, a nonprofit that works with international academic partners to support the training of generalist physicians to practice where they are needed most. As a Social Innovation Wellness Specialist, she looks to create a niche of positive deviance within her work environment at The Alex Community Health Centre. Click here to view her TEDx talk from 2015 after being caught inadvertently in the earthquakes in Nepal.

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