Over the past week, a team staffed by volunteers recruited by Medic Mobile has been working on 2 SMS messaging flows to help support CHW physical and mental health. We are posting these two flows and the specific messages so we can get feedback and improve them.
We want to support CHWs, their health worker colleagues, and their patients by helping them to be physically safe and mentally well.
Please review our draft Reference App documentation that now includes links to our 2 demo videos. The documentation is meant to give you more information about how the reference apps work technically, the insights used to create them, and what additional options may be possible.
We just added another Option we have been working on. It’s Option 3 ( slide 4) and it’s a stand-alone regular Mental Health check. We only recommend that a health system adopt this if they have appropriate resources such as a Mental Health professional that can get back to the CHWs who need support. In our research, we have found examples such as:
Kenya Red Cross is running toll-free mental health and psychosocial support service.
Nairobi County runs a help line at 0207903939
Moi Teaching and Referral Hospital in Eldoret and Mathari Hospital in Nairobi should still be operational.
Please note that the above examples are not vetted nor recommended, but are examples of the types of services that we strongly recommend are available, operational, and have capacity before deploying the Mental Health check to CHWs.
Our overall objective is that a tool like this could:
Help health workers stay safe
Be reused and adapted as needed, integrated into existing apps and platforms
We’d appreciate input from you all. Do you have feedback on the messaging flows or any other part of this idea? Thank you!
This is great work, Rupesh and team! I hope this type of proactive check-in makes CHWs feel cared for. Some feedback on the very helpful diagrams:
Does Covid-19 literature or survey best practice recommend check-ins in the morning or evening?
Consider asking just one question at a time, e.g. Have you experienced [symptoms list] since our last check-in? Y or N
For the integrated flow, as a CHW I’d expect to get the worry check right after the symptom check. I’d put the “thanks for checking in” message after the worry check.
For many health workers, I guess they’d answer “yes” to the worry check on many days. I imagine we’d reply with strategies to address anxiety, improve sleep, etc. while escalating to the supervisor / flagging in the CHT… but would we want to do the same every time they reply “yes”? Flagging that we may want to build out this workflow a bit more.
If they reply “no” to the worry check, we might provide a helpful practical mental health tip or motivational message.
If they have symptoms that warrant follow-up, I think we’d encourage CHWs to call the health facility/nurse (rather than the CHW waiting for a call). We can still let the CHW know that we’ve alerted their supervisor and the nurse.
I like that we’re doing risk screening. I’d gather than info in the first onboarding session, perhaps use it to determine check-in frequency, and ask them to confirm it’s accurate (summary text) rather than asking for their input at the time of reporting symptoms.
If a CHW reports a relevant symptom and difficulty breathing, I wouldn’t ask about anxiety right after… perhaps in the follow-ups after the nurse has consulted.
Also, a few ideas…
When CHWs reply “no” to the symptom check and worry check, should we deliver other timely information? Is this a good opportunity for a daily or weekly “briefing by SMS” from the Ministry of Health? (One thought was that the MOH twitter feeds could provide daily content…)
Many but not all CHWs will have thermometers. Is it clinically helpful to have temperature taken and reported?
Who should these message be from? The Ministry of Health checking in is probably different than their supervisor (with some help from automation) or a bot that has a name.
In addition to asking about mental health, are there any promising resilience/recovery interventions that could be delivered via SMS?
Really excited to see this evolve and get into the world soon…
This looks great, Rupesh and team! I echo Josh’s comments. I think that incorporating his feedback will further strengthen the app and CHW supports.
I am still a little concerned that asking about anxiety without being able to address it may do more harm than good. Also, I am unsure who is /not/ having symptoms of anxiety these days, and I wonder what we would do with that information? What happens if they report having those symptoms? It says report back to CHT or even the nurse. But, then what? Will it simply be registered in the system and noted in the CHW chart? Would someone interact with them by text as follow-up or would they receive a call from a nurse to check-in? Would that nurse be trained in how to help the CHW?
If you do go the way of offering a refer to services for CHWs who note these mental health concerns, I asked my colleagues who work in mental health in Kenya for referrals. They noted the following options. I do not know how consistently those services are available and how widespread. I would guess that Kenya would be far ahead of other countries in the region for mental health services.
The Kenya Red Cross is running toll-free mental health and psycho-social support service on 1199
Nairobi County runs a help line at 0207903939
Mental 360 has another one 0776543099 (Mental 360)
For clinical services, especially emergencies, Moi Teaching and Referral Hospital in Eldoret and Mathari Hospital in Nairobi should still be operational.
How can we make sure to do not harm in this component of the system checker? Or, if we cannot do anything, I suggest as Josh noted that we respond with the tips you all discussed before: Try to rest, try to get outside, try to call a friend, try to eat healthy foods, etc.
I think this will prove really helpful for CHWs and provide them reassurance that someone is putting them first in terms of the COVID response. There is no effective response without a healthy workforce.
Thanks for this feedback @cfeld! We’ve added more notes in @Rupesh_Shah’s post above about the importance of establishing referral options before implementing a flow that assesses/measures mental health status. One of the challenges here is that we expect those resources to be different in each country where this could be implemented, and for now we’re trying to design a generic reference application. I think this means that the reference app needs to be sparse on details of how to handle that referral pathway, but the docs can make clear how important it is for this to be worked out for each implementation. Make sense?
Yes, that makes perfect sense. I am, of course, in favor of making a mental health assessment available and agree 100% with the need for local adaptation. Maybe we could note in the companion docs that this referral option should be “turned off” in favor of those helpful tips or just suggest that this module only be employed when the local context suggests that a referral linkage would be consistently available?
Hi also to @Rupesh_Shah, @ioflament, @sabinasobhani and team. Thanks for the hard work. These are looking great. I was just reviewing the slides and had a few quick questions:
On slide 2, when it triggers the worry/anxietycheck, could the text have some kindness or on-ramp to the next message? I know characters are tight, but maybe a, “We also want provide support,” or “We know things are challenging now,” or, “Some healthcare workers may be feeling stressed…” The jump right into the “Are you experiencing difficulty…” may seem jarring or odd to some. Is this something that they trigger here or just automated?
On both slides 2 and 3, middle column after they note difficulty breathing, could we state somewhere in source docs that the suggestion would be to immediately include any hotline or national helpline in that automated response? Then, also that a nurse would text/call them back? If this had many HCWs enrolled, the timing on the text/call response could be delayed - something we do not want if the HCW, themselves, could be reminded/informed about existing COVID crisis resources.
On slide 4, option 3, I do not understand how the nurse is supposed to respond to " Over the last week, how often have you felt nervous, anxious, or on edge?. Are they supposed to give a number? A number of days? If we do not ask them to respond specifically, the responses will be all over the map. Do you want to know how many days? How many times per week? Same for all the risk factors if you want a sum. Or, are these supposed to be simple yes/no questions? If that is the case, you would want to rephrase each question with a , " Over the last week, have you felt nervous, anxious, or on edge? 1 for yes and 0 for no, or something like that.
Right now the covid symptom checker and mental health checker are packaged in this repo with two other covid-related workflows, one for testing (demo video here) and one for digital training on covid (demo video here).
CHT-Core has some basic messaging functionality baked in, and it uses RapidPro for the kinds of conversational back-and-forth messaging flows used for the symptom and mental health check. This means you need a RapidPro instance to do your own testing, we used TextIt’s hosted RapidPro service for our testing. The messaging flows also need to be configured in RapidPro to make this work, and I don’t think those flows are in the code repo I linked above, but RapidPro makes it easy to export/import a json file for sharing flows like this. @David is the developer who build most of this workflow–David, would you share the flows in this thread?
@munjoma I realize this documentation is still sparse on technical detail, especially for how the CHT-RapidPro integration works. If you think there’s enough here for you to give it a try, I’d be interested to hear what you think! If there’s not enough detail, let us know because we’ve scheduled two issues for improving documentation on CHT-RapidPro integration. If this is something you want to follow up on I’m sure @Max would be glad to know that for the prioritization process.