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Postcard #9 - Week 10

We just wrapped up week 10 of this phase of work. This week marked the second round of our field work in Kenya, this time in Nairobi. We came back to spend time with health care providers to discuss antibiotics, AMR, and healthcare in Kenya, as well as to test our ideas with them and get their feedback. Over the week we met one patient who has been taking a lot of antibiotics, two doctors, two pharmacies, a community health worker and a clinician.

Here are some highlights from this week.

What happened this week...

User testing Interviews and observations with healthcare providers

People we spoke to.

Here's a summary of the best interviews and observations, with links to the short blogposts for each.

Dr Susan - an ENT surgeon, working in various private clinics. See more here

Harriet - 29 years old, is a clinician who prescribes in a small private clinic in Nairobi. See more here

Erick - a Community Health Volunteer with 15 years of experience in Kibera, slums in Nairobi. See more here

Peter - pharmacist who works in a pharmacy attached to a small community wellness clinic in Nairobi which is privately owned by a GP. See more here

Mufid - 31 year old architect, who has has been suffering from recurring stomach infection over the past two years. See more here

Dr Jabilio - works in a Community Wellness private clinic that he owns for 3 years. He has been a GP for 26 years. See more here

Top General Quotes

“Antibiotics should not be sold without a prescription, but they do at the moment.”

On self medication

"The Kenyan culture of self medication is horrible. Patients will go to pharmacies and get OTC medication save a coin or two, instead of going to the doctors (who cost money). People will literally try a medication to rule out illnesses." - Dr Susan, ENT surgeon
“Patients will say: I took anti malarial, and i didn’t change, so I don’t have malaria.” - Dr Susan

Time pressure

"In busy clinics, GPs have to clear the queue in a certain time. This leads to a lot of misdiagnosis and mis-prescription" - Dr Susan

The guessing game:

“Without too much clinical evidence, doctors will prescribe antibiotics just in case they can clear the infection." - Dr Susan
“In the case of my patient Joyce, I gave both, anti allergens and antibiotics, because it could be both. I wanted to make sure she would be okay. Sometimes people only have 500 shillings, I have to assist the client - sometimes you’re pressed into the wall." - Dr Jabilio, GP

Campaigning with simple health messages works

"I will go around the area with a megaphone and spread messages such as 'My health, My responsibility". We're trying to get people to take care of themselves while they are still young. We also use ghetto radio." - Erick, CHW

It is up to the pharmacist's judgement when to consult and when to refer patients:

“I can do some diagnosis on a certain level for things like coughs, sneezes, wounds. I know whether a cough needs an antibiotic or if it's just due to a weather change. If it's something I don't know I’ll refer to a doctor." - Peter, pharmacist

Mistakes are common when doctors prescribe on paper

"It's my job to review the prescription and notice any mistakes in dosage. The doctor may see 45 patients a day and be very tired. I will correct it. We work together, it's a synergy"

Feedback on prototypes

1. Smart Prescription

On the system giving recommendations and warnings if she is not sticking to protocol (when prescribing).

"Seeing the guidelines would help, It’s OK to be reminded. This would make think twice, about what I am prescribing." - Harriet, clinician
"Sometimes you need to not follow the guidelines. For example they might say you need to do tests before prescribing antibiotics, but some patients don't have money for tests." - Harriet, clinician

On the system giving (automated) clear instructions and educating the patient:

"Thats a great idea, it involves the patient in the process and gives them responsibility for their health" - Dr Susan

“No two patients are the same, you would need to give some different advice for each patient" (eg: if this is a recurring condition or not). - Harriet
“Yes, I never read the packaging. It would be good to have it in layman's terms” - Mufid, patient

On compliance and reminders:

“Reminders are great, would make sure people are compliant which is important. Sometimes you can take the donkey to the river but you can’t force it to drink water.” - Dr Susan

"Those reminders are great because most people take their medication for the first day and then they forget. It means you’re serious about patient management." - Harriet

On the potential impact of the service:

“Patients would be really happy someone is following through, it would be really beneficial for them and would lead to less AMR and more compliance.” - Dr Susan

“This service would make patients come back to the clinic, because they would think you’re taking care of them. We'd get more business, more patients. Nothing like that exists.” - Harriet

“It will make the client feel more high profile.” - Peter, Pharmacist
“If I use this service, patients would prefer it, they would think I am with them all the time and that I am taking care of them even when they’re sleeping. This tool, it will bring me more clients” - Dr Jabilo, GP

2. Visual Aids

“Oh that means overkill. I would use it to show there are more appropriate antibiotics to use in this case, don’t start with the more powerful ones" - Dr Susan

3. Serious Stories

"Making patients understand the dangers of antibiotics is important. But you have to make it relevant to them.Most people don't know what a superbug is." - Harriet
“This would help people to go to the proper doctor for a prescription more often” - Mufid, patient

On what kind of stories will resonate

"If you talk about death, people will listen." - Harriet
"I tell people a story about a man who got 'Steve Johnson' syndrome because went to a quack and was given medication without them knowing he was on HIV medication. He had a terrible skin reaction, he was in hospital for 3 months and lost half his tongue. That story made a lot of people careful about where they buy their medication" - Erick, CHW

4. Top Doc

“Antibiotics is a very wide topic and you forget what we learned in college, it would be helpful to have an app like this for to remind myself.” - Harriet
"I would like this to be from a reputable organisation and would like a certificate that I could use while applying for a job to show I understand antibiotics." - Harriet
"I would want to use this, it's very good. It's clearer than the M-Learning and you can see the different modules you've learned" - Erick, CHW
"One thing I learned about was how to help people Disclose to their loved ones that they have HIV. I now run 3 support groups in the area to share this knowledge. It's 3 simple things - choosing 'Who', knowing 'When' and 'Why' you're telling them." - Erick, CHW
"I think would be better for people who are less educated - the nurses, or paramedics of the community health workers." - Dr Jabilo, GP

5. Doc in booth

"This would be really good for when the doctors have gone home. Then i can still be dispensing prescriptions." - Peter, pharmacist
"It would not work at the counter because of privacy issues. It would need to be in the back. It would be great to have as an extra service" - Peter, Pharmacist

6. First Opinion

"Sometimes I don’t have the time to go in person so this would be great. Otherwise face to face is still better."  - Mufid, patient
“How can you be sure enough to prescribe on the phone without tests?” - Mufid, patient

Coming up on week 11

Next week, we are traveling to Bangalore, to test our concepts there too. Keep an eye for the blog posts.

--- Did you miss our previous postcards? Have a look:

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