Linearity of Expectation (LoE)

Apples to Apples: Conducting a Cost Analysis of mHealth Interventions

jamesbontempo@gmail.com (James BonTempo) — Sun, 08 Nov 2009 18:26:00 +0000

Note: I am not a clinician, a health systems expert or an economist! What follows is my naive attempt at beginning to understand what sort of cost-analysis is needed for mHealth. I make a number of assumptions along the way but try to be very transparent about them. As a good example of my ignorance, I refer to community health workers (CHWs) and show a breakdown for Preventing Mother-to-Child Transmission of HIV (PMTCT) - I don't even know if CHWs are providing PMTCT services or if it's reasonable to think that they would. Regardless, I think the basic principles of my approach and argument are relatively sound if not well implemented. Of course, you can help me work through this by leaving a comment below. And perhaps most importantly, I really like Neal Lesh & think that tools like CommCare are pretty cool :) I've only used it as an example.

Lately, I've been thinking a lot about methods for evaluating mHealth (and more broadly, eHealth) projects. And I was excited to learn about the upcoming Education Technology Debate on assessing ICT4E initiatives. As I wrote recently, I think the simple framework of "More, Better, Faster, Cheaper" provides a promising foundation for developing and conducting these sorts of evaluations. Within that framework, though, some elements are easier to tease out than others. In particular, I've spent a significant amount of time wondering how one might effectively assess if an mHealth approach is less expensive than one that is not technology supported.

I've been inspired to think more about this lately as it seems every week I learn about another mHealth project that involves putting high-end devices (e.g, Android phones) in the hands of CHWs, requires data network access, uses "the cloud" as a key element of its foundation, or depends on other advanced - and more importantly for this discussion, expensive - technologies. My knee-jerk reaction to these sorts of applications is to wonder: Is this appropriate? Do these solutions, which are available but not necessarily accessible, provide benefits commensurate with their cost?

At the recent FNIH mHealth Summit I had a conversation with Neal Lesh (I always enjoy our talks) and was giving him a hard time about the financial feasibility of rolling out something like CommCare to the 30,000 CHWs that the Ethiopian government is planning to deploy to address challenges in providing maternal and child (MCH) services. If I understand correctly, the phones (which have to be Java-enabled) that are being used in the CommCare pilot project in Tanzania cost around $100. So just providing the hardware to implement CommCare in Ethiopia would cost $3,000,000. We all know that there are plenty of other costs associated with an mHealth initiative - training, support, maintenance, replacement, etc. - but let's just work with that figure.

Neal's counter to my point was to look at that cost on a per capita basis. I think that's a great idea because it will allow us to form a picture that can then be compared to widely available data on per capita healthcare costs. According to Community Health Workers, The Ethiopian Experience there are 77.4 million people in Ethiopia (BTW, we know the calculation of that figure is fraught with issues) and women and children make up 72% of the population. So we get:

$3,000,000 / (77,400,000 * 0.72) = $0.06/person

That looks pretty good, right? 6¢ per capita? And when compared to the $13/person that was spent in 2006 (see the UN's Human Development Report for Ethiopia - 2009) that's downright cheap!

But as the title of this post implies, we need to "compare apples to apples." We need to keep in mind that CommCare most likely will not be involved in the delivery of the entire suite of MCH services, probably only a subset of them. And remember, the application does not actually deliver services directly but rather is used to support services being delivered by a CHW. So we cannot logically compare the 6¢ to the $13. We need to break that $13 down into the individual services that are being delivered and then pull out the costs for the specific ones that are being supported through the use of CommCare. And further, we need to pull out the cost of those components of the individual services that are effectively being replaced by the application. Only then will we have a more accurate picture of the relative costs.

Hierarchy of health services, their constituent components and where mHealth is being applied [click on the image to see a larger version]

In the diagram above I have attempted to give an example of how we need to break down the components of the healthcare delivery system in order to arrive at a state where accurate one-to-one cost comparisons can be made between current methods of delivery and those that are technology-supported. As you can see, that original $13 gets spread over a number of elements that span multiple levels in the hierarchy. And it's not until we get a significant number of levels deep that we begin to see where the mHealth intervention is being applied.

Hierarchy of health services and the cost per element at each level [click on the image to see a larger version]

If we make some rather sweeping assumptions (as we did above with the $3,000,000 cost for implementing CommCare) we can get a sense for how much each individual element of the healthcare service delivery system costs. The main assumptions that I've made (that are most likely rather spurious) are:

Costs are spread equally across elements at the same level
Where "..." denotes other elements at that level, only one additional element has been considered in calculating costs

Working with these assumptions, the $13 for all health services gets reduced rather quickly and is almost immeasurable at the level where the technology is being introduced. Once we traverse the hierarchy to the level where performance support and data collection are introduced the per capita cost per element is significantly less than 1¢. Given that there are two elements the total per capita cost of these components where mHealth is being introduced is just over 1¢. And that is 1/5th the cost of implementing CommCare (which you'll remember is 6¢ per capita).

So from a cost perspective it seems it might be difficult to make the case that this sort of mHealth intervention is warranted: total expenditures for these elements of healthcare service delivery would be about 5 times higher than they currently are without the technology. But remember that cost is only one component of the "More, Better, Faster, Cheaper" framework and it could very easily be the case that impact in the others - More, Better & Faster - would outweigh the negatives in the Cheaper component.

I think a similar analysis conducted by someone who actually knows what they're doing would be really helpful! Any takers? Or can anyone point me to existing work in this area?

More, Better, Faster, Cheaper: An Evaluation Framework for ICT4D, eHealth, mHealth, etc.

jamesbontempo@gmail.com (James BonTempo) — Mon, 02 Nov 2009 00:56:00 +0000

Earlier this year I participated as a technical expert in a consultative meeting at USAID to discuss eHealth & mHealth viz-a-viz the Agency's Global Health initiatives. Those in attendance came from many of the "usual suspects" of large, international NGOs, a few technology firms and also other departments at AID. The conversation was really no different than the many others that have focused on the same topic and that have included similar types of participants, but there was one element that was particularly unique: the proposal of a potential evaluation framework - "More, Better, Faster, Cheaper." And this same framework was the basis, a few months later, of the session, "Bigger, Better, Faster, Cheaper: How Mobile Technology is Transforming Health Programs," at the MAQ Mini-University.

Better, Faster, Cheaper: A traditional system of constraints in software development

This framework is particularly interesting to me given my background in application systems development. By removing the "More" component one is left with a constraint system that typically gets mentioned during the initial stages of an application development effort: "Better, Faster, Cheaper." The general idea is that one can achieve only two out of the three options simultaneously. So for example, if one wants to develop something good in a short period of time (Better and Faster) it will require significant investment (not Cheaper). Or if one develops something fast and without spending much money (Faster and Cheaper) the quality will suffer (not Better).

But the deceptively simple "More, Better, Faster, Cheaper" framework transforms constraints into opportunities. The idea is that through the application of ICT one can potentially:

Replicate and scale initiatives more easily;
Improve the quality of interventions;
Expedite processes and procedures; and
Save money over existing approaches.

And the framework readily lends itself to the development of indicators to test each potential outcome. One only needs to monitor if after the ICT intervention they're doing more, doing it better, doing it more quickly than before, or doing it for less money. (The last element - Cheaper - is arguably the most tricky to measure and will be the topic of a future post.)

As the eHealth, mHealth and other ICT4D communities grapple with the need to demonstrate the outcomes and impact of their technology-supported initiatives - a need reiterated at last week's FNIH mHealth Summit - I think the "More, Better, Faster, Cheaper" evaluation framework provides a simple yet powerful and effective means for doing so. Do you agree?

Who needs a listserv when there's Twitter?

jamesbontempo@gmail.com (James BonTempo) — Sun, 04 Oct 2009 15:12:00 +0000

My colleagues over at NPOKI recently sent out an email to crowdsource information about "the best listserve ever." What follows is the short back-and-forth of messages where the question is posed and I, half-jokingly at first but then completely seriously, explain how I use Twitter (and other tools) to learn and seek answers to questions.

NPOKI: When you have pressing question about your work, where do you turn for answers? While NPOKI is your trusted resource for technology solutions for results and performance management questions, we know that we don’t answer all of your critical questions. We want to know which listservs or forums you use frequently and provide useful replies to your business questions.

Me: Forget listservs. Who needs them when there's Twitter? :)

NPOKI: Thanks - Im taking you seriously... Any specific practice you use? hash tags? Do you get quality replies?

ME: It's not so much about hastags but rather about following the right people. Tools like WeFollow & other lists (e.g. the ICTWorks ICT4D Twitter list) make finding these people easier. Couple that with a tool like TweetDeck that allows you to group those people into separate feeds & you've got an amazingly effective learning tool.

As for replies, I've worked on cultivating relationships w/in the groups of people I follow (& who follow me) & so have had good response rates when looking for input. See my blog post enquiring about the meaning of mHealth for an example of how I was able to crowdsource data from Twitter. And that led to an in-person engagement @ a Technology Salon conversation [about mHealth] in DC :)

Twitter has rapidly become one of my top learning tools. It takes some work - you get out what you put in - and some getting used to, but once you get comfortable & settled it's really quite useful.

So what about you? Do you agree? Has Twitter become more useful than listservs?

uHealth, Ubiquitous Health, You Health!

jamesbontempo@gmail.com (James BonTempo) — Wed, 16 Sep 2009 23:06:00 +0000

In a recent series of posts on mHealth - What is mHealth all about? and What is mHealth all about? Part 2 - I grappled a bit with what the term itself actually means. Is mHealth about mobile phones and other mobile devices: the technology? Or, is it somehow more about mobility? While we may not all be in agreement as to what is actually moving - people, services, data, etc - I think most agree that the latter, mobility, gets more at the core concept of mHealth.

But, inspired by David Isaak's comment to the post, I found myself thinking that mHealth is really just one element of a larger picture. That mHealth is one "tool in the toolbox" that can be used to ensure that health services - broadly defined to include service delivery, behavior change & communication, learning, monitoring & evaluation, etc - are available whenever & wherever they're needed. That mHealth along with all the other traditional approaches, and the ones not yet even known, should be combined - or to borrow a term from the learning technology world, "blended" - to ensure ubiquitous health. uHealth. And in the end, this really is (or at least should be) the goal of any health systems strengthening initiative.

Now, I want to be clear. As with mHealth, uHealth is not about technology. I understand that the term "uHealth" has been used by the IEEE in Asia to describe the use of ubiquitous computing technology in the delivery of healthcare. But I want to advocate for a more broad usage of the term. uHealth should be about developing the right combination - engineering (& re-engineering when necessary) the right ecosystem - of tools, technologies & approaches to meet the goal of providing quality health services to all. uHealth is about you!

What is mHealth all about? Part 2

jamesbontempo@gmail.com (James BonTempo) — Wed, 02 Sep 2009 23:24:00 +0000

Like most, I don't think the "m" in mHealth refers to specific device types (mobile phones, PDAs, netbooks, etc). I think the "m" is more tied to the concept of mobility, but I'm not sure to whom or what that mobility refers. I may actually have more questions at this point than answers!

Photo credit: Joel Selanikio, DataDyne.org
The most obvious "who" to me is the service provider: doctor, nurse, midwife, lab technician, community health worker, etc. mHealth is then an approach that empowers these health workers to provide services wherever and whenever they're needed. And I think it's important that the concept of mHealth be inclusive of the broad array of inputs & outputs that make quality service provision possible. That means that mHealth must include education & training, monitoring & evaluation, and other components in addition to the actual point-of-care activities.

Another potential "who" is the client or beneficiary: the member of the public, the health care seeker. In this context, mHealth allows individuals to seek out, find and receive health care services wherever and whenever they're needed. But as with service providers, I feel definitions of mHealth need to cover not only direct provision of services but also public education & behavior change communication, participatory monitoring & evaluation, and other activities that factor into improving public health.

But I can't help but feel that this concept of mobility is too closely linked with individuals and their movement: the community health worker going from home to home, the mobile service unit, the member of the public getting counseling while walking to work. In the end, I think it's the services themselves -- not the individual providing them & not the beneficiary receiving them -- that is the real focus of mHealth. The "m" describes the ability of these services to move; to be delivered in real-time or to be packaged up, transferred & replicated wherever they may be needed. In this sense, mHealth is as much about the roving health worker or the traveling public as it is the immobile brick-and-mortar health facility.

But that's just what I think :) And chances are I'll think something else tomorrow!

Previous post in the series → What is mHealth all about?

What is mHealth all about?

jamesbontempo@gmail.com (James BonTempo) — Wed, 02 Sep 2009 23:00:00 +0000

I was trying to get a better handle on what folks thought about mHealth & so did a quick twtpoll on the focus of mHealth. Here are the current results on the statement "Definitions of mHealth should"...

It seems pretty clear that folks think the focus of mHealth is really mobility more so than specific device types. But what I find particularly curious is that mHealth continues to focus on the mobile phone & the PDA but not the netbook (or even laptop). And the Wikipedia defintion of mHealth is very device-focused. Why is that?

And on further reflection, I realize that my curiosity about the dearth of netbooks & laptops in mHealth projects just falls into the device-type trap. What will it take to escape the gravitational pull of the device & think "outside of the mHealth box" in which we currently find ourselves?

Next post in the series → What is mHealth all about? Part 2

20 Things We've Learned About Learning Technology: Debriefing Riddhish & Trudy

jamesbontempo@gmail.com (James BonTempo) — Tue, 01 Sep 2009 21:48:00 +0000

Before he left, I made sure to sit down with our intern, Riddhish Ruparelia, who has been clutch in helping us develop Jhpiego's updated ModCAL Clinical Training Skills materials, to find out what he learned in the process. We were also joined by Trudy Conley, Jhpiego's Desktop Publishing Specialist, who led the graphics, animation and PowerPoint development.

Direct link to MP3

Here are 20 key points that came out of our conversation. But we covered quite a bit, so you'll most likely learn even more by listening. Anyway, on to the list...

Processes, &tc

Organize all your files in a standardized folder structure before you start working. It's helpful when developing content and also when retrieving & editing it later.
Do your best @ the beginning to capture multimedia at a high & consistent level, it's hard to improve or undo later.
Have a standardized & consistent naming structure for all files so that linking is easy -- #_SlideName.mp3, Tab#_TabName.(mp3|flv), #_SlideName.intr -- and use these in the script.
We need to ask ourselves, how much is appropriate to put on a single slide? The more content (e.g. long animations) the harder it is to manage edits in Articulate Presenter.
We're actually in some kind of middle ground between bullet points & movies. When designing our content, do we need to be thinking about scenes instead of slides? And about creating a "performance"?
It's actually worth upgrading to PowerPoint 2007 for the new features & tools.
We could really use a toolkit that would include guidance that folks could use for developing multimedia electronic learning materials.
SourceForge & Wikipedia are great resources for finding free & open source multimedia tools.
We need to have another conversation just about copyright & licensing.

Video

Have video source in MPEG-2 format & at the highest quality possible.
Do not use the Articulate Video Encoder or Adobe Media Encoder for files larger than 50MB, try Xilisoft Video Encoder ($25).
Make sure you use the Fill Left/Right effect in Adobe Premiere if audio is recorded in Mono.
Maximize audio in Premiere using the Gain effects.

Audio

Use WAV as your standard audio format.
Use Audacity's Amplify effect to maximize audio.
Use the Normalize effect in Audacity, not an external program (e.g. Levelator or Sound Normalizer), to normalize audio files in batches.
What might also help? A better microphone, separate recording space & better guidelines for narration (to help make them more engaging).

Graphics & Animation

Have as much script guidance for animation & graphics possible from the beginning - sometimes things just don't work once you build them!
We need more & better photos in all subject areas! It's particularly hard to find clinical photos. Is this because one has to get consent for them?
Check online sources for graphics: Google Image Search, Wikipedia/Wikimedia Commons, Flickr, iStockPhoto, Getty Images. A lot of them are free and licensed for reuse.

SALT Conference e-Learning for the Hands-on Workforce Notes

jamesbontempo@gmail.com (James BonTempo) — Wed, 19 Aug 2009 15:15:00 +0000

Some of the typical training challenges: time, availability, convenience, cost (monetary as well as time away from job). We've all seen these @ some point.

Creating good e-Learning from existing written material is like translating a novel into a screenplay. It's a different (multi) medium and there are some things that just won't work.

I need to seek out this reference when I have time: Khan, Budral Huda (1997) Web-based Instruction. It apparently has recall data based on different acquisition methods. You remember 10% of what you read, 20% of what you hear ... 70% of what you say & 90% of what you do.

Create & use case studies, this will help bring things to life. These case studies will be even more engaging & effective when delivered using multimedia (think virtual patients & clinical sumulations).

All the scenarios that were shared in the presentation are available online @ http://www.propanesafety.com.

High quality (but remember quality doesn't necessarily mean effective) e-Learning isn't cheap. Spend your time & money on the important stuff. Of course, that would be a natural outcome if you just limited content to what is most important :)

BTW, their 3 courses + the STARS customization & tracking application cost $5M!

While converting materials into electronic format, you should be looking for opportunities to update & improve content along the way. After all, who knows if you'll have the time or money to do it later.

SALT Conference Creating Irresistible e-Learning Notes

jamesbontempo@gmail.com (James BonTempo) — Wed, 19 Aug 2009 14:30:00 +0000

Email is irresistible. So is Google, Facebook, Wikipedia, online banking, etc. How do we make e-Learning the same?

We need to focus on the learner. And a significant part of that is not simply recreating the elements of traditional learning that they're already resistant to. And if you think about it, most e-Learning is actually
developed & implemented in a way that satisfies instructors & administrators, so we focus on controlling, monitoring, assessing, management, etc.

Irresistible e-Learning is not about content, a specific development tool, media (people see all kinds of media all the time) or delivery platform (e.g. Web).

Make sure not to have the learner spend more time trying to get the tool to work (e.g. trying to get matching elements on an assessment to line up just right) than focusing on the learning. How many times have you gotten caught up in the mechanics of something and completely forgotten why you're doing it in the first place?

Learners will skip ahead (blah, blah, blah) - so, focus on the critical content so they don't miss it. I don't think I'm doing that here :P

Don't just make learners answer questions, make them justify their answers (e.g. in a banking simulation, make them identify specifically why a check is not negotiable). Make the learner think & exercise critical analysis skills. And make it interactive!

BTW, you can use the same content in the classroom, too. We had a whole room full of conference attendees going through some banking content & questions. And enjoying it! There are group dynamics that can be tapped into when you're all together in a room.

What to do:
- Create interactivity that truly engages the learner.
- Create meaningful challenges (i.e. ones that are relevant).
- Allow risk.
- Build suspense by withholding information (don't give the learner all the answers ahead of time).
- Address a concrete need.
- Creat memorable & customized content (i.e. situate the learning in a relevant context).
- Adapt to learner preferences.

All the demos (and some of them are excellent!) shared in today's session are available on the website http://www.alleninteractions.com.

At the end, what did you do right & what do you need to work on? You have to continuously monitor, evaluate & improve.

And don't forget, even seemingly dry content (e.g. HIPAA regulations) has a basis in reality, so tap into that to create engaging learning content. Put learners in a situation that is directly related to the development of the content. Give them the opportunity to share sensitive personal data & show them the consequences. That'll be much more powerful than simply stating the regulation & will lead to improved retention.

There are four elements to irresistible e-Learning: context (how things work in reality), challenges (along with resources to overcome them), activity & feedback (not judging but rather filling in holes).

BTW, the navigation menu has little to do with learning - so don't focus on it so much!

An idea: Partner w/a local art school & create an internship because good graphics are key to irresistible e-Learning.

Not surprisingly, a tool like Articulate makes it difficult to break out of the PPT model of e-Learning. But more on that later in the "Death by PowerPoint 2.0" notes...

SALT Conference Keynote Notes

jamesbontempo@gmail.com (James BonTempo) — Wed, 19 Aug 2009 13:00:00 +0000

I got a kick out of the General's use of the term "chart" in stead of "slide." I wonder where that terminology comes from? He kept barking "next chart!" to his assistant :)

Teams have to go through simulations before deployment. This is analogous to Jhpiego's focus on the use of skills labs to develop the necessary skills before working with live patients (one component of a humanistic approach).

The US Army is only the 6th largest army in the world but arguably the best. How is this possible? Great training & training systems are major parts of the equation.

You hear it all the time. The General said it today. "The perfect is the enemy of good enough." Voltaire is everywhere.

The Army training division has two main goals: to train leaders & troops and to ensure they're ready to be deployed anywhere @ any time. They have an interestig approach they call "Up or out." It basically boils down to this: either you're progressing through a (clearly defined) career path or you're out of the Army. No loitering in a single, comfortable, cushy position for years. Change & growth are fundamental elements of the process.

Given limited resources, you should train to standard on a limited set of the most important & critical tasks rather than below on many of them.

It's necessary to teach team fundamentals & mechanics. People will need to be able to coordinate & collaborate to be effective & successful.

It seems we find ourselves having moved from needing quiet to study & learn to needing constant stimulation. The trick is to avoid overload & distraction.

An interesting thought: Minimal detail in simulation allows more opportunity for the participants to bring their personal experiences to bear. The fewer specific stimuli you provide the more the player will fill in with personal details. This seems like it might be a method for targeting the learning experience to the learner. But it seems strangely counterintuitive that you might provide better focus through reduction.

A lack of cultural competence can lead to significant problems (e.g. inciting a riot in rural Afghanistan by having a male clinician assess a female patient, even in an emergency situation).

Don't tell your learners the answers ahead of time, use simulation to allow them to learn from decisions & (most importantly) mistakes. Put them in the situation mentally before they're in it physically.

The Army has to be ready to do anything from hand out band-aids to roll tanks, but some enemies only have to do one thing & can change course as necessary (asymmetric warfare). How do you prepare 100s of thousands of people to be able to do everything? And also prepare them to adapt to changes in tactics?

It's important to develop a "mission-essential task list." Just the facts, ma'am.

Belief in what your doing along with training allows you to move into the action not run away from it. If you're going to do your job well you have to have the right attitude toward it. You have to love what you do or feel that it's an important factor in attaining a goal in which you believe.

Notes from the SALT 2009 Interactive Technologies Conference

jamesbontempo@gmail.com (James BonTempo) — Wed, 19 Aug 2009 12:30:00 +0000

I'll be spending the next three days in Crystal City, VA @ the summer session of the SALT (http://www.salt.org) conference. I won't have my laptop in tow, but the iPhone will be getting a serious workout taking notes. And I just bought BlogPress from the App Store. So why not combine the two & (not quite live) blog the event?

I'm going to do my best over the next few days to capture & share my take-aways from each session. In true blog fashion, this will be a relatively informal affair, but it will be a good experiment for me. And who knows, some might even find my rambling posts useful!

So with this introductory post out of the way, let's get to it...

A new kind of Interactive Radio Instruction (IRI)

jamesbontempo@gmail.com (James BonTempo) — Wed, 01 Jul 2009 22:05:00 +0000

The typical Interactive Radio Instruction (IRI) model (e.g., see Improving Educational Quality through Interactive Radio Instruction) is used most often in primary education and couples face-to-face group-based activities, facilitated by a tutor, with a radio broadcast. But this approach cannot effectively reach a highly distributed (or overly busy & overburdened) population that would have difficulty gathering in a single place.

Well, what about this?

Now that mobile phones are nearly ubiquitous (at least within our target population of degree-level healthcare providers), why can't we use them to "close the loop" back to the instructor? Instead of a local facilitator, why not use ICT - mobile voice &/or sms - to connect the learners directly back to the point of instruction?

One reason you need the local facilitator in the traditional IRI model is that radio is a one-way medium. But why not combine multiple ICTs to make the information and communication flow two-way? Then learners could ask questions, reply to polls, submit answers to scenarios & case studies, etc. to a central location obviating the need for gathering as a group.

Just a thought...

What happens to competency over time?

jamesbontempo@gmail.com (James BonTempo) — Tue, 30 Jun 2009 21:53:00 +0000

At one point during the first day of the stakeholders meeting for our Botswana preservice education project, Peter Johnson (the Director of Global Learning @ Jhpiego & my boss) drew a graph on a flip chart that represented various trajectories for clinical competency over time. Taking what he drew, I expanded & embellished a bit and sketched the graph below.

So what's going on here?

On the y axis is competency level and on the x axis, time. As education proceeds, competency level increases (I've drawn the progression as linear but it most likely proceeds in fits & starts). The most important point in time is graduation, after which a number of trajectories could be followed. For purposes of simplification I've only drawn three:

With no opportunity to practice & put to use the knowledge, skills & attitudes developed in school, competency quickly drops.
With a low level of or irregular exposure to opportunities, competency stays flat.
With continued opportunities to practice, competency increases until the individual becomes proficient.

Obviously option 3, represented as the line that continues to climb, is the most desirable. Unfortunately, what we often find is that, after deployment, newly prepared healthcare providers are not exposed to the number of opportunities required to drive them toward proficiency and they struggle to maintain or eventually even lose their newly acquired competencies.

So what do we do then?

Well, the potential answers are worthy of an entirely different post, but a few quick thoughts:

There may be ways to use technology, e.g. clinical simulations, to increase exposure & at least maintain competency levels.
The reason exposure is limited may be due to the fact that their education is not really preparing providers for the reality of their profession; that what they're learning isn't what they'll be doing upon graduation. A task analysis and changes to curricula may be in order.
Policies may not be in place that allow healthcare workers to fulfill the role for which they've been prepared. For example, nurses may be educated to initiate and manage ART but national policy may only allow doctors to do so.

As per usual, I'm not saying anything new. I just felt compelled to share the graph. And maybe it has inspired you to stop & think for a minute. Are you maintaining competency?

Trip Report 2.0 - Jun 24 2009 (Challenges)

jamesbontempo@gmail.com (James BonTempo) — Thu, 25 Jun 2009 00:13:00 +0000

On the 24th & 25th of June I co-facilitated a meeting/workshop of stakeholders in our preservice education program in Botswana. Members included representatives from the Ministry of Health; the Nursing and Midwifery Council; principals, deputy principals and heads-of-department from all 8 Health Training Institutes; and service providers from the Francistown hospital. The session I led was aimed at eliciting challenges from the participants and relating them to some of the findings and recommendations from the learning technology readiness assessment we conducted in February (See Assessing Learning Technology Readiness: A Pre-Service Case Study from Botswana for details and tools).

So, what are some of the challenges?

Too much to do - But not enough time & resources. Pretty self-explanatory.
Additions to the curriculum - Without removing anything. Bloated curricula.
"Forced" programs (e.g. IMCI) - No input from local folks. Hence, no buy-in. And resistance.
Large number of students - Higher enrollments without consequent increase in faculty/staff.
Lack of human resources - See "Too much to do" above. Again, pretty self-explanatory.
Little support for program implementation - Lots of great ideas but not a lot of help to realize them.
Student attitudes - Kids are enrolling to get jobs, not because they want to be healthcare professionals. Doesn't make for the best learning environment.
Meeting student learning needs - Everyone learns differently. And the kids are tied to their mobile phones & all over Facebook :P
Not enough (time for) clinical exposure for faculty - How do you teach something you can't even do yourself?
Curriculum conflicts - How are you sure that what you're teaching is aligned with all elements across the curriculum?
Not enough simulation - Students don't have enough time to practice before they're required to see & treat live patients.
Effective teaching and assessment skills - Just because you're a teacher doesn't mean you really know how to teach. Same goes for assessment. Doing isn't always doing well.
Faculty attrition - The good ones get promoted.

That is a pretty significant list. But it's pretty consistent with what we see in many other countries. And that's a good thing. Because we have some proven ways to address these sorts of challenges -- using traditional methods as well as technology-supported approaches. Again, see Assessing Learning Technology Readiness: A Pre-Service Case Study from Botswana if you're curious to learn about some of the specific ways in which we plan to apply various learning technologies.

I'm excited to see where this all goes...

Does form really follow function?

jamesbontempo@gmail.com (James BonTempo) — Sun, 14 Jun 2009 18:02:00 +0000

After reading Henry Petroski's article in today's New York Times Magazine, "Bridging the Gap," I found myself getting caught up in one of my favorite lines of thought: the relationship between form and function. One familiar relational construct is "form follows function." And it's a popular one -- a Google search for the phrase "form follows function" retrieves almost one quarter of a million results. But can the converse also be true? Is it possible that function can also follow form?

If you were to ask David Nye, I think his answer would be an emphatic "Yes!" I'm currently reading his "Technology Matters: Questions to Live With", and am reminded about the discussion of Thomas Edison and the phonograph in the chapter, "Is Technology Predictable?" Apparently, Edison and his colleagues came up with the following illustrative potential commercial uses for their new invention: speaking doll & other toys, speaking clock, advertisements, calling out directions, delivering lectures. At the end of a long list, and seemingly almost an afterthought, "a musical instrument." The point? Sometimes it's the last application of a technology you think of, or one you didn't even imagine, that catches on and organically becomes the most successful. And I realize now that I have a decent, very low-tech example of this "function follows form" dynamic.

My wife is growing tomatoes in a pot on our back deck. The plant seems to be growing quite well: it's rather tall and we're already seeing a number of tomatoes. The challenge? How do we stabilize the plant under the weight of its fruit? The solution? A wooden dowel, anchored in the soil, placed along the edge of the pot to bypass roots and get support, and positioned deliberately so as to provide support to the plant without requiring it to be tied down. The plant, pot and dowel are all forms with specific pre-existing functions: to reproduce; to hold soil and grow plants; and (commonly) to be cut into small pins that reinforce joints and support shelves. But given their current forms, the functions became: to grow branches at specific points and angles; to anchor a wooden dowel; and to support a rapidly growing tomato plant. Here's what it looks like...

And now, if I think back to my Introduction to Biology course in my Freshman year at Villanova University 18 years ago, this question of the relationship between form and function was raised in the very first few weeks. I have always remembered it this way: in biology, form follows function. Luckily for me, I still have the textbook, Neil Campbell's Biology (2nd Edition). What is actually written? In "The Correlation of Structure and Function" section of the first chapter: "Form fits function." I'd like to think that Campbell, in using the term "fits" rather than "follows," was implying that the relationship was not necessarily unidirectional; that, like pieces of a puzzle, both are required to complete the picture and neither can really be elevated to the point that one is dependent upon the other.

From the Mind of a Coder: Can I be an honorary AfriGadgeteer?

jamesbontempo@gmail.com (James BonTempo) — Mon, 11 May 2009 23:02:00 +0000

This post might be slightly different from the usual "From the Mind of a Coder" entries -- as if there was anything usual about the series! -- but it is indicative of the almost insatiable desire to solve problems.

Erik Hersman, a.k.a. WhiteAfrican, along with a whole cast of characters, maintains AfriGadget, a "website dedicated to showcasing African ingenuity... a testament to Africans bending the little they have to their will, using creativity to overcome life's challenges." I really enjoy the little glimpse it provides into creative problem-solving from the African perspective. But I'm wondering, Erik & club, can I be an honorary AfriGadgeteer? After all, you don't have to be from Africa to make use of existing resources! Exhibit A, my solution for a broken doorknob...

The problem: Turning the doorknob no longer retracts the bolt, but the deadbolt above it still works (and is sufficient for locking the door). How do I keep the bolt out of the catch so I don't have to jam a screwdriver in there to open the door?

The solution: Cut a piece of scrap wood so that it fits through the catch hole & is slightly deeper than the hole in the door frame. Then wrap a rubber band around the wood block so that it won't pop out. Screw the catch back into the door frame, et voila!

Now, the question is, at what point does my wife accuse me of simply being lazy?! After all, I am much luckier than the African problem solvers: I can easily afford to buy a new doorknob or even hire someone to replace it for me. But I can definitely empathize with their drive for coming up with creative solutions to various challenges. Wait. I did spend a good deal of my younger years growing up in New England. Maybe it's that "Yankee ingenuity." :)

Assessing Learning Technology Readiness: A Pre-Service Case Study from Botswana

jamesbontempo@gmail.com (James BonTempo) — Sat, 02 May 2009 18:21:00 +0000

This past Tuesday I led a brown bag lunch (BBL) session @ Jhpiego to share w/folks our Learning Technology Readiness Assessment (LTRA) process. From the invitation that was sent out:

"Please join the Global Learning Office for a discussion about the process of, and tools available for, conducting a Learning Technology Readiness Assessment. Originally developed for use in the Ethiopia e-Learning project, a Learning Technology Readiness Assessment has been conducted at all 8 Health Training Institutes in Botswana. We will be sharing with you our recent experiences there, highlighting both site-specific as well as the more broad challenges and opportunities, and the recommendations that have been made to the Ministry of Health and the local CDC office (BOTUSA)."

The BBL was just under an hour and you can watch an archived version online -- Assessing Learning Technology Readiness: A Pre-Service Case Study from Botswana.

You can also download copies of the Learning Technology Readiness Assessment tools (CC By-NC-SA 3.0).

Looking forward to your comments & questions...

Extending FrontlineSMS

jamesbontempo@gmail.com (James BonTempo) — Tue, 28 Apr 2009 12:33:00 +0000

These are some thoughts I've had about how the External Commands functionality of FrontlineSMS can be used to develop all sorts of cool performance support applications. In addition, I can't help but wonder how the tool might be used also to develop mobile communities of practice. And why think just about a single instance of FrontlineSMS? Why couldn't one develop entire networks of individual nodes, connected to each other, to extend the reach of communication and support?

From the Mind of a Coder: The one-minute countdown

jamesbontempo@gmail.com (James BonTempo) — Wed, 15 Apr 2009 23:19:00 +0000

This is the microwave in the first floor kitchen (actually, you can see that it's on the last second of heating up my food - goodies provided at this morning's staff meeting that I was only getting around to eating close to noon). Pretty unassuming, right? That's what one might think!

I wanted to heat my food for one minute, so I entered it as...

But then I found myself wondering: why didn't I enter it like...

They're the same right? Right?! My first instinct was to enter it as "1.00" but then I realized that it would actually have been more efficient -- requiring one less digit, hence one less button-push -- if I had entered it as ".60" instead. I've never been one for the whole mind/body separation thing but this may be one instance where the two just go their separate ways :P

And that's another quick glimpse into the mind of a coder...

LEssMed (Twitter-based WHO Model List of Essential Medicines Lookup) - A few screenshots

jamesbontempo@gmail.com (James BonTempo) — Wed, 08 Apr 2009 01:47:00 +0000

Now that I've got the LEssMed service up & running, I thought I would share a few screenshots so you could see what it actually looks like in action!

What you see here are three requests -- for praziquantel, isoniazid & aluminium -- and the multiple responses. This is on Twitter (obviously).

And now, just to prove that it works from a mobile phone, here's a screenshot of two SMS requests -- for sodium & calcium -- and the responses. BTW, don't get thrown off by the fancy iPhone, this is just plain ol' SMS and so will work from any phone.

Pretty cool, eh? :) Now, to figure out what my next Twitter lookup tool will be...

A Twitter-based WHO Model List of Essential Medicines Lookup Tool or How ICT Can Wrangle the "Massive Essential Drugs List" Without Breaking a Sweat

jamesbontempo@gmail.com (James BonTempo) — Mon, 06 Apr 2009 23:02:00 +0000

Inspired by a post on the Urban Health Updates blog, Kenya - 90% of Nairobi's poor get wrong medication, I wrote up a half-baked idea about a way to use SMS and a tool like FrontlineSMS to create a real-time lookup for medication information (indications, dosages, contraindications, etc.) and sent it off to an internal mailing list that is used to discuss Urban Health issues. There was quite a bit of interest & discussion but there was also one response (from a highly-regarded & very senior coworker) that mentioned that the "essential drugs list is massive." My response to that comment was that we could start small, maybe with just HIV/AIDS-related medications, and see how it worked. Well, never having been one to retreat in the face of a challenge -- especially one I think I can handle :P -- I decided to tackle turning the WHO Model List of Essential Medicines into a mobile-accessible database.

First, a few caveats:

I'm a coder, not a clinician (I'm having Star Trek flashbacks :P).
I don't have a test instance of FrontlineSMS running so I chose the next best thing: Twitter (which, as we all know, is accessible via SMS).
The downloadable WHO Model List of Essential Medicines simply lists categorization and formulation information. There is the Essential Medicines Library (EMLib), but it's only available on the web and there doesn't appear to be an easy way to hook into it (e.g. there's no API and no obvious way to generate drug-specific URLs).

As an aside: WHO, if you're listening/reading, I'd be more than happy to work with you to turn EMLib into something much more useful. Just drop me a line. I work @ Jhpiego. I'm sure you can find me without much trouble :)

So, anyway, on to the good stuff -- the steps I took to actually make this work. Before I begin, if any real Perl coders come across this, please forgive my hack job :P

Download a copy of the WHO Model List of Essential Medicines PDF and save it as a text file. I tried XML & HTML, but it turns out it was easier to parse in TXT format. See #3 below.

Create a SQLite database with a single table to hold the medication name, categorization & formulation information. Here's the SQL:

create table medications (id integer primary key autoincrement, name varchar(64) not null, formulation varchar(256) not null, category varhcar(64) not null, subcategory varchar(64) not null)

Write a Perl script to parse the TXT file and insert records into the database. Then run it! Here's the code:

#!/usr/bin/perl use DBI; my $dbargs = {AutoCommit => 1, PrintError=>1}; my $dbh = DBI->connect("dbi:SQLite2:dbname=path_to_sqlite_db","","",$dbargs) || die "$DBI::errstr\n"; my $sql = "insert into medications (name, formulation, category, subcategory) values (?, ?, ?, ?)"; my $meds = 0; my $cat = ""; my $subcat = ""; my $txt = path_to_essential_medicines_txt_file; open (TXT, "<$txt") || die "$!\n"; while (<TXT>) { chomp; s/^(\.\s+|\s+)//; tr/A-Z/a-z/; $cat = $_ if ($_ =~ /^\d+\.\s/); $cat =~ s/(^\d+\.\s|\s+$)//; $subcat = $_ if ($_ =~ /^\d+\.\d+\s/); $subcat =~ s/(^\d+\.\d+\s|\s+$)//; $meds = ($meds == 1 || ($meds == 0 && $_ =~ /^\d\./)) ? 1 : 0; my @med = split(/\s{2}/, $_); if ($meds && $#med == 1 && $_ !~ /^$/) { $sql =~ tr/A-Z/a-z/; $dbh->do($sql, undef, @med[0], @med[1], $cat, $subcat); die "$DBI::errstr\n" if ($dbh->err); print "@med[0]\n"; } } close (TXT) || die "$!\n"; $dbh->disconnect();

Create a Twitter account (I called it @LEssMed - List of Essential Medicines) that will receive queries as direct messages (DM) and respond with another DM containing the requested information.

Using Net::Twitter, write a Perl script that will download the latest DMs, turn them into a query that gets executed against the database, and post a DM (or multiple DMs if there's more than one record returned) back with formated results. Here's the code for this:

#!/usr/bin/perl use DBI; use Net::Twitter; use strict; my $id = "0"; open (ID, "<path_to_pid_type_file_of_last_dm") || die "$!\n"; while (<ID>) { chomp; $id = $_; } close (ID); my $dbargs = {AutoCommit => 1, PrintError=>1}; my $dbh = DBI->connect("dbi:SQLite2:path_to_sqlite_db","","",$dbargs) || die "$DBI::errstr\n"; my $sth = $dbh->prepare("select name, formulation, category, subcategory from medications where name like ?") || die $dbh->errstr; my $twit = Net::Twitter->new(username=>"twitter_username", password=>"twitter_password"); my $dms = $twit->direct_messages({since_id=>$id}); my $i = 0; my $j = 0; for my $dm (@{$dms}) { if ($i == 0) { open (ID, ">path_to_pid_type_file_of_last_dm") || die "$!\n"; print ID $$dm{id}; close (ID); $i++; } $sth->execute($$dm{text} . "%"); while (my @data = $sth->fetchrow_array()) { $twit->new_direct_message({user=>$$dm{sender_screen_name}, text=>"$data[0]: $data[2]. $data[3]. $data[1]"}); $j++; } $twit->new_direct_message({user=>$$dm{sender_screen_name}, text=>"No results for '$$dm{text}'"}) if ($j == 0); } $sth->finish; $dbh->disconnect(); print "Processed $i dm(s)\n";

Write a quick autofollow script (very important!) so that reciprocal following can be set up automagically; otherwise, I'd have to manually monitor for new followers & follow back. And who wants to do that?! :P Here's this all-important Perl code:

#!/usr/bin/perl use Net::Twitter; use strict; my $twit = Net::Twitter->new(username=>"twitter_username", password=>"twitter_password"); my $flws = $twit->followers_ids(); my $i = 0; for my $flw (@{$flws}) { my $name = ${$twit->show_user({id=>$flw})}{screen_name}; print "$name\n"; if (!($twit->relationship_exists("twitter_username", $name))) { $twit->create_friend({id=>$flw}); } $i++; } print "Processed $i follower(s)\n";

Finally, set up two cron jobs so the DM checks & autofollows get triggered on a regular basis. BTW, I had initially set the two scripts to run every minute but quickly ran out of API calls :P I throttled everything back to 2 minutes which seems to work for now. I'd have to tweak this even further if the service got really popular! Just to be consistent & thorough, here are the crontab entries:

*/2 * * * * path_to_DM_and_db_lookup_code */2 * * * * path_to_autofollow_code

So, after a few hours of coding, I had a fully-functional, Twitter-based lookup tool for the WHO Model List of Essential Medicines up & running. As I mentioned already, it's a bit of a hack-job, but it works. Honestly, if you know what you're doing, this isn't really all that impressive: kind of trivial, actually (yes, there's a little bit of horn-tooting there :P).

The beauty is, the same basic approach can be used to set up any type of automated lookup tool. This just goes to show how truly cross-cutting ICT is. And is but a small window onto the world of opportunities and potential applications for global health & ICT4D.

From the Mind of a Coder: The office bathroom

jamesbontempo@gmail.com (James BonTempo) — Sat, 28 Mar 2009 19:47:00 +0000

Take a look at these photos of the door to the bathroom that is near my office. One fact to keep in mind is that it's located in the back corner of a larger room. This will be important when looking at the last two photos. Anyway...

The sign on the outside of the door indicating the bathroom is not occupied

The sign on the outside of the door indicating the bathroom is being used

A sign on the inside of the door directing folks to leave it open when they're done

What someone approaching the bathroom sees when the door is closed

What someone approaching the bathroom sees when the door is slightly open

Are you thinking what I'm thinking?

Before entering the bathroom, one is supposed to slide the cover on the sign on the outside of the door to change the status from "Vacant" to "In Use." And then slide it back when they're done. They're also supposed to leave the door ajar. But then you can't see the sign indicating the status.

So the most efficient approach would be to always leave the sign in the "In Use" position. When the door is closed (i.e. when someone is using the bathroom) people will know it's occupied. When the bathroom is vacant and the door is open, it doesn't matter if the outside sign indicates "Vacant" or "In Use" because no one will even see it.

Of course, this "solution" would require that people always close the door when they're using the bathroom and then leave it open when they're done. These would be two critical process components. And they're evidence that human behavior needs to be a key consideration in any systems design :)

And that's a glimpse into the mind of a coder...

From the Mind of a Coder: A series

jamesbontempo@gmail.com (James BonTempo) — Thu, 26 Mar 2009 23:16:00 +0000

If you consider web development "coding" (I know there will be some disagreement on that :P), I've been a coder for close to 15 years. If not, it's more like 12. These days, though, I tend to do a lot more high-level design & architecture, and strategery (thanks, W, for that one!), but I can still rock a regular expression, if necessary. Actually, I just did so recently in a Moodle mod that I need to post on the discussion boards. But I digress. Anyway...

I notice that I sometimes have a peculiar way of looking at the world. And I think, in many ways, it's consistent with the approach and thought processes required for being a coder. So, I thought it might be fun to document some of those experiences after which I find myself thinking, "I'm definitely in the right business."

And just to whet the appetite: the first has to do with a bathroom.

Jhpiego's Learning Technology Readiness Assessment Tools

jamesbontempo@gmail.com (James BonTempo) — Thu, 26 Mar 2009 22:57:00 +0000

As part of our learning technology program in Ethiopia, a set of tools (questionnaires, surveys, etc.) were developed to facilitate a learning technology readiness assessment. For our new project in Botswana, we have revised the tools based on our experiences using them. In the interest of openness, transparency & sharing (one of our learning technology strategic principles), we are making the tools available freely, under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License (CC By-NC-SA 3.0).

One thing to keep in mind: because the programs where these tools have been applied focus on pre-service education, they are designed primarily for use in a post-secondary school environment. That being said, they could easily be adapted for an in-service setting, too. Actually, the client, network & server tools would be applicable in any context without modification.

So, without further ado, here are the latest versions of Jhpiego's Learning Technology Readiness Assessment Tools (packaged as a single ZIP file).

Feel to reuse, revise, remix and redistribute as necessary. And if you do, leave a comment here & let us know how you used them, within what context, how they worked out, and what modifications (if any) were made. They can definitely be improved and there's no better way to do that than by putting them out into the community!

Is this appropriate technology?

jamesbontempo@gmail.com (James BonTempo) — Fri, 20 Mar 2009 21:44:00 +0000

At Jhpiego, we are always talking about the appropriate application of technology. In my case, the focus is on using technology to support learning. And for the most part, I more narrowly define this to mean integrating technology into learning activities (formal or informal, self-directed or social) as opposed to using technology for administrative & management purposes (e.g. student information systems). Not that I'm not interested in the latter, but I'm only one person & there's only so much time in the day! Anyway, let's get back to this notion of "appropriate."

Appropedia defines appropriate technology as "technology that is appropriate to the environmental, cultural and economic situation it is intended for." So far, so good. The definition then continues, "It usually describes technologies which are suitable for use in the majority world (or 'developing nations')." [emphasis added] This is where, for me at least, things get difficult. I emphasized the term "usually" in the definition because I think it's very important. Specifically, I want to contrast it with an approach that I often encounter: one that substitutes in the word "always."

Every time I return to the field, I find evidence of explosions in technology availability and access. Below are photos from a recent Learning Technology Readiness Assessment we conducted in Botswana, plus one from Zambia, that provide evidence to that fact. And therein lie my questions:

Given the availability and accessibility of these technologies in Botswana, aren't technology-supported learning interventions based on them "appropriate" there? If computers are available and common, how is computer-assisted learning not appropriate? If WAP-enabled phones and mobile data access are common, how is browser-based mobile learning not appropriate? Shouldn't we be maximally leveraging the opportunities engendered by the environment?

And I guess a natural corollary would be, at what level should we be defining "appropriate" - country, region, global?

An IT staff member at Serowe accessing Facebook on his mobile phone

A personal computer in a (female) student's hostel in Serowe

A USB dongle for Celtel mobile internet access in Zambia

And if we want to be thinking about the (near) future, we should be looking beyond PCs and mid-level phones to smart phones (including iPhones) and high-broadband mobile Internet access. Once again, see proof of the future in the photographs below from Botswana.

An ad for the iPhone at Riverwalk Mall in Gaborone

And ad for mobile video calling at Sir Seretse Khama Airport in Gaborone