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Cycle 9 (2020 Deadline)

Community and hospital-based obstetrics WhatsApp triage, referral, and transfer (WAT-RT) system

PI: Veronica Millicent Dzomeku (, Kwame Nkrumah University of Science and Technology
U.S. Partner: Jody Lori, University of Michigan
Project Dates: May 2021 - April 2023

Project Overview: 
The overarching project goal is to increase continuity and access to quality maternal care, reducing preventable obstetric-related deaths through (1) a WhatsApp Triage, Referral and Transfer (WAT-RT) System connecting community health workers (CHWs), midwives at rural health facilities, and healthcare personnel at referral hospitals; and (2) an obstetric (OB) triage system implemented at referral hospitals to decrease facility delays. The WAT-RT system will allow two-way communication to assist in early problem identification and prompt referral to the next level of care. It will allow the facility to prepare for incoming increased workload, thus preventing delays upon arrival. Phase I will employ a participatory action research design to identify health system challenges from the perspective of patients, providers, community leaders, and government. The team will conduct a learning needs assessment of the familiarity of CHWs and healthcare providers with the WhatsApp platform and a review of the risk factors for OB emergencies warranting referral from the community to the facility. Next, with stakeholders, the team will design the protocol for the WAT-RT system. Using a train-the-trainer model to implement the system at 40 rural clinics and two referral hospitals, the team will train clinic staff who will then become facilitators, training CHWs from their respective catchment communities. Phase II training will take place at the referral hospitals. Following an assessment of current OB triage protocols, including observations of admission and labor ward activities, structured intake assessments, waiting times, and focus group discussions, the project team will use an iterative approach to design and deliver an interactive triage training course for all emergency department and labor and delivery hospital personnel.

The project will have a population-level effect by engaging multiple partners, working in collaboration, to achieve a significant impact on maternal health in Ghana and Liberia. Using robust data, the team will design and measure improvement in anticipated outcomes. In both countries, a fundamental gap exists with preventable deaths disproportionately affecting poor women living far from healthcare centers. Involving government and USAID Missions in the program design will contribute to the development of a sustainable and scalable intervention. Evidence generated from this research will be presented to the ministries of health in both countries, as well as stakeholders from other sub-Saharan African countries, with the ability to replicate and scale up the WAT-RT system in their settings. The anticipated outcomes of the project include (1) timely care-seeking along the referral pathway for pregnant women between first-line CHWs, rural health facility nurses/midwives, and district hospital staff; (2) optimization of patient care through a triage protocol for high-risk OB patients; (3) reduced wait time and delay upon arrival at the health facility; and (4) improvement of the quality and experience of care.

Summary of Recent Events

In this reporting period, baseline Data Collection was done in Ghana. Baseline data collection started in July. This activity was carried out by five RAs (3 females and 2 males). The data collected include:
1. Focus group discussion
2. In-depth interviews
3. Data extraction (A retrospective review of referral logbooks from November 2020 to date in all health facilities)
4. Need assessment
5. Focus group discussion was organized in health facilities where there were five or more health workers while in-depth interviews were conducted in facilities with less than five health workers.

The project team from both countries (Ghana and Liberia) together with the United State partners held bi-weekly meetings to discuss and strategize project activities.

The University of Liberia also conducted weekly project coordination meetings with the multi-site teams with the US Partners to keep track of planned project activities and plan for next series of events.
Retroactive Baseline Data collection was also conducted using chart and record reviews from 20 rural health facilities and 2 referral hospitals. This activity was undertaken by two Bong County local Staff (2 males) Qualitative Data Collection was also conducted at 20 Rural Health Facilities and two Referral Hospital .
Data Collected Methods include:
• 24- Focus groups discussion held with community health assistants
• 20- in-depth interviews held with midwives and nurses at 20 RHF

In the next 3-6 months, the PI and her team in Ghana will work on :

• Identifying risk factors for OB emergencies warranting referral from the community to the rural clinic.
• Utilizing WhatsApp OBs Emergency Network to communicate from rural clinics to hospital staff.
• Prompt closed-loop communication from hospital staff with rural healthcare workers.
• Pre-intervention assessment of OB triage protocols at Kwame Danso Hospital
• A second training of Nurses and Midwives on WAT-RT

In Liberia:
Two trainings are planned. A train the trainers (TOT) will be led by the in-country research team for the nurses/midwives at the RHFs and consists of:
• Identifying risk factors (community-based triage) for OB emergencies warranting referral from the community to the rural clinic,
• Utilizing WhatsApp Obstetric Emergency Network groups to communicate from community to rural clinic to hospital, and
• Prompt closed-loop communication feedback. The nurses/midwives will then each train 10 CHAs from their catchment area under the supervision of the research team

A Second training of Hospital and Rural Health Facility staff in the following:
• Identifying OB emergencies warranting referral from the RHF to the hospital,
• Utilizing WhatsApp Obstetric Emergency Network to communicate from the RHF to the hospital, and
• Prompt closed-loop communication feedback.
• Use of labor and triage form previously developed for use in Ghana

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