2012 Triangle Global Health Case Competition

1. 2012 Triangle Global Health Case Competition Prevention of Cardiovascular Disease (CVD) Risk Factors in Kenya ENGAGE. EDUCATE. EMPOWER. UNC Team 4 Adam Jutha Gladys Manzur Joel Lugones Leena Patel Hans Peng

2. Executive Summary • Objective: Prevent and manage cardiovascular disease (CVD) risk factors in Kenya Recommendation: Develop public health prevention programs and strategies to target Kenyans under age 45 in urban areas OPPORTUNITY ENGAGE SMS MED EDUCATE HEALTH AMBASSADORS EMPOWER HEARTY GARDENS • Under 45 years • Urban Areas • Risk factor: obesity • Widespread mobile use • Effective health education channel • Personal community approach to care • Culturally sensitive • Low-cost training • Sustainable, fresh and healthy alternatives • Local job creation Impact: $12.3MM grant from Gates Foundation will initiate sustainable programs for the prevention of CVD risk factors in Kenya

3. Agenda

4. As Kenya’s population grows, CVDs are expected to increase unless public health programs are expanded • Kenya’s population has steadily increased • The growth rate will likely slow down in the coming years 3.5% Kenya’s population growth rate, average

5. Annual deaths from CVD are projected to increase 86%, reaching 80,000 deaths by 2030 Projected deaths from cardiovascular disease in Kenya (’000s) 79.9 • Forecasts suggest significant increases in CVDs 58.7 • Ischemic heart disease • 84% 42.9 Other Hypertensive heart disease Ischemic heart disease • Cerebrovascular disease • 88% Cerebrovascular disease

6. Obesity is one of the leading factors for CVD and affects a large portion of Kenya’s growing urban population Correlation between obesity and CVD Overweight/obese populations Increasing urbanization 7.5M people (21%) 11.1M people (24%)

7. Effective public health and CVD programs should target Kenya’s largest demographics Population by age 3% 9% 53% 35%

8. Successful CVD prevention programs should target three key demographics

9. Agenda

10. Widespread use of texting presents an opportunity to communicate with majority (75%) of Kenyans Cell phone penetration Cell phone usage Efficient Communication Year (2012) Text message costs in Kenya (USD) Sending: $0.06/TXT Cost-Effective Receiving: FREE

11. Texting has been proven to be an effective channel of health education Read TXTs: 100% Found it educational: 95% Complied with msg: 66%

12. SMS Med engages Kenyans to learn more about CVD prevention through texting • Author • Subscribers • Ambassadors for their respective community • Community members • Features • Frequency • Weekly educational email • Event info • Find ambassador • 78 texts per year • Average 1.5 texts per week

13. SMS Med can expect to reach over 200,000 people in its first 4 years of programming Community reach forecasts for SMS Med

14. Agenda

15. Despite rising obesity and CVD, Kenya lacks a cohesive prevention plan and personnel resources Lack of prevention programs Significant lack of trained personnel Rise of early indicators of obesity and CVD

16. Lay Health Advisors (LHA) model shows proven results in curbing health issues factors in culture driven communities Initiate primary care: 98% Mortality: -23% Decreased average systolic BP from 140 - 108mm Hg Diagnosed: 85% Treated: 91% Mortality: -49% Reduction in hospitalization for stroke, heart attack: 9%

17. Training represents the highest cost in this relatively inexpensive program

18. Agenda

19. Accessibility to healthy alternatives should complement educational programs to allow for lifestyle modifications Educational programs through SMS Med and Health Ambassadors provide awareness for people to try new alternatives Accessibility to healthy food alternatives enable people to practice new habits Healthy Alternatives Education

20. Urban food gardens (including “Hearty Gardens”) provide access to fresh and affordable produce Improved access to food alternatives Targets at risk urban population MicroGardens use Woolly Pocket system Fresh, organic produce Decreased risk of CVD Community Empowerment

21. “Hearty Gardens” can use Woolly Pockets, innovative and cost-effective technology, to enhance urban gardening • The Woolly Pocket System • A Modular Gardening System • Space efficiency ideal for urban areas • 33% less space required to grow crops • Requires 50% less water. • Made from 100% recycled plastic bottles • Easy set-up and user-friendly

22. Woolly Pocket Gardens can be established in Nairobi as a self-sustaining business to target at-risk populations Actions Details and Justifications Implement in capital city (Nairobi) • Largest urban center in Kenya • Targets population of 40% overweight, 15% obese 640 Woolly Pocket Gardens • Potatoes, soy beans, tomatoes, salad greens, beats, onions, cabbage, beans, etc. Supplement produce needs for up to 30,000 people in Nairobi Offer cheaper produce while maintaining profitability • Self-sustaining after initial capital investment Source: WHO, Woolly Pockets Website, Horticulture Development Centre

23. Four-year plan of 640 “Hearty Gardens” would require $9.1MM investment (result in $3.3MM net cost after revenues) Year 150 Gardens Year 2120 Gardens Year 3360 Gardens Year 4640 Gardens Cost-Revenue Structure for 4-year Implementation Plan Capital Costs Variable Costs Net Cost After 4 years, “Hearty Gardens” projected to turn $0.40MM annual profit Source: Team Analysis

24. As revenues grow, investments totaling $6.5 MM are required to offset capital investments Projected Revenue Growth (’000s) Total Investment Required: ($534K + $714K + $2486K + $2728 K+$0) = $6.5MM Source: Team analysis

25. Agenda

26. Recommendations will provide education, outreach and opportunities for reduction of CVD risk factors in Kenya’s urban population Costs Impact SMS Med $4.5MM Cost-effective widespread outreach Health Ambassadors $1.3MM Culture-sensitive community engagement Hearty Gardens $6.5MM Empowering with healthy and sustainable nutrition alternatives Total: $12.3MM Sustainable programs for the prevention of CVD risk factors

27. Executive Summary • Objective: Prevent and manage cardiovascular disease (CVD) risk factors in Kenya Recommendation: Develop public health prevention programs and strategies to target Kenyans under age 45 in urban areas OPPORTUNITY ENGAGE SMS MED EDUCATE HEALTH AMBASSADORS EMPOWER HEARTY GARDENS • Under 45 years • Urban Areas • Risk factor: obesity • Widespread mobile use • Effective health education channel • Personal community approach to care • Culturally sensitive • Low-cost training • Sustainable, fresh and healthy alternatives • Local job creation Impact: $12.3MM grant from Gates Foundation will initiate sustainable programs for the prevention of CVD risk factors in Kenya

28. Appendix Index

29. Three-quarters of Kenya’s population is literate and nearly half of the population is enrolled in secondary school education Literacy rate, as per 2005 Secondary school enrollment Literacy rates and school enrollment will increase due to introduction of free primary and secondary schooling in last 6 years

30. Financial and Impact Calculations for SMS Med

31. Texting programs for Sex Education

32. Where else is texting being used? • A pilot study at Nationwide Children's Hospital in Columbus, OH, found that adolescent patients with diabetes who received text messages related to their medication plan were more likely to comply with it than those who didn't. • http://www.healthy-txt.com/#info • The Pediatric Heart Transplant Program at NewYork-Presbyterian / Morgan Stanley Children's Hospital is launching a one-year program that will use a text messaging platform to increase medication adherence in its teenage heart transplant patients. • According to BabyCenter, a social networking site for over 10 million Moms, the mobile phone is a Mom's companion that makes juggling easier. It is also changing behavior as seen in several pilot studies from Harvard and Johns Hopkins Children's Center. Healthy behaviors can be inspired and sustained by using mobile platforms where people live, work, and play.

33. Texting Case Studies “For better or worse, this technology is here, and sending a text to a patient’s cell phone about an upcoming appointment or a test or simply to remind them to take their meds is a great example of how we can harness new communication technology for a greater good.” Research has shown that up to half of patients may fail to take their daily medication properly, with forgetting being a top reason for non-adherence, so at least in some cases, a text reminder may be all that a patient needs, adds Robotham, who has encouraged the use of appropriate texting among pediatricians at Hopkins Children’s. one study involving children with diabetes showed improved blood glucose testing rates. These children were also more likely to share their blood glucose test readings with their doctor’s office. patients on immunosuppressive drugs after a liver transplant had improved medication adherence. The liver study detected measurable clinical benefits from text-messaging: Acute liver rejection episodes dropped dramatically as a result of better medication adherence. Chronic conditions that require daily medication, like HIV, asthma and TB, or daily testing, like diabetes, are great candidates for “SMS therapy,” Robotham says. “Texting is an even more popular mode of communication outside the United States, and especially so in developing countries, where most of the TB cases are, so I could see this being a great new way to reach those hard-to-reach patients,” Jain says. “Why wouldn’t it?” she says. “A patient can read a text instantly and respond unobtrusively, it doesn’t require Internet access or picking up the phone in the middle of class or an important meeting. Sometimes, I call patients and I get no response, but when I text, I get a response immediately.”  “It won’t be a silver bullet but it could certainly be a nice little tool in an arsenal of many other tools,” Robotham says. By asking questions about glucose testing, meal boluses and frequency of high and low glucoses, Dyer said she saw an increase in teens taking their medications. After three months of sending text reminders she reported that they were three times less likely to miss a dose. "This form of communication allows for real-time health management which is extremely valuable for patients that suffer from a chronic illness like diabetes," said Dyer. The study, which was conducted by Mt. Sinai Medical Center's Pediatric Gastroenterology Department in 2008, found that as a result of receiving regular text alerts liver transplant patients were more likely to have higher adherence rates. The number of rejections dramatically decreased from 12 episodes the previous year to only two during the study

34. Football Injury Prevention Texting Program “Texting is an effective way to reach teens and adults where they are today, on their mobile phones,” says Dr. Vishal Mehta, a Chicago area sports medicine orthopedic surgeon, as well as the medical advisor and co-founder of Healthy TXT, the organization behind the public service venture. “Harvard University and John Hopkins Children's Center studies show that healthy behaviors can be inspired and sustained using cell phone technology.”

35. Does texting work? Quantifying services is difficult. But Ms. Levine, who hosts Sex::Tech, a conference about sexual health programs for youth, said that requests to make presentations about online or mobile services had soared. Typically, she receives between 40 and 50 applications. This year, she received about 120. Most online services receive grants from philanthropies, like the Ford Foundation, and health and education agencies on the state and federal level. Real Talk held a classroom contest to see which student could send the most texts containing this prevention message: “ROFL!!!” (Translation: rolling on the floor laughing). “STDs and HIV can spread as fast as this message. Still laughing? Pass on the message not HIV/STDs. 518-HIV-TEST.” Within an hour, the message had been sent to nearly 450 phones.

36. Technology to make this work exists Supporting Education through SMS in Kyrgyzstan The teachers and students we’re working with are attached to their cell phones, and therefore our team decided to experiment with text messaging as a method of communication. FrontlineSMS software enabled us to use mass text messaging, which streamlined our communication and allowed us to use time more efficiently. It only takes about a minute to send out text messages to all of our teachers through FrontlineSMS, whereas in the past staff were making individual calls which took a lot longer. Few people have internet in their homes, yet everyone has mobile phones and so using SMS makes regular communication accessible to more of those we work with. When we ask teachers how they like working with SMS, they say that they find it very convenient, useful and flexible. We plan to collect SMS feedback reports from our program participants on how often they attend IREX trainings and where trainings are being held. We will then map these reports using online mapping tool Ushahidi, and this will allow us to visualize our impact. addition, the GCE program is also planning to use FrontlineSMS to conduct polling and short surveys among students and teachers, which will help us to further understand the value of our program and the needs that program participants have. CareSpeak Communications Inc., a privately held mobile health company in New Jersey The study was so successful that half of the patients that participated in the study in 2008 are still in the program today, says Miloh. “Before this program, we had only the power of people trying to educate the children and their families about the deadly nature of noncompliance,” adds Addonizio. “Now we have the ability to give these adolescents a safety net to help them become responsible.

37. What is the purpose of answer, sex ed? They are only focusing on the risk-reduction model - Valerie Huber, executive director of the National Abstinence Education Association Those who run digital programs say they simply want teens to have accurate information, to help them make good decisions. Even though popular culture is saturated with sex, facts and advice can be hard to find.

38. Sensitivity Analysis for LHA Costs

39. Education via lay health advisers (LHA)-led workshops will surmount to sustainable and long-term benefits Program will train health workers in educating the at-risk populace adopt preventive care and adherence to suggested treatment=

40. CVD risk factors are increasing

41. A partnership with the Canadian Public Health Association (CPHA) can aid the success of preventative education for at-risk populations CPHA will fund the training of LHAs while also providing them a budget for health promotion events (i.e. workshops)

42. Focus should be on recruiting community leaders in Kenya’s urban areas WHO WHERE Hypertension and obesity is more prevalent in urban areas LHA model is more needed in urban areas Note: Education level of LHAs does not matter: study shows it makes no significant impact

43. Health Ambassador Program will train LHAs to budget and program health workshops

44. Health Ambassador Survey – Metrics Measure awareness, comparing pre and post-event awareness from likert scale Measure effectiveness of event and how likely you’re going to incorporate newly learned info into their daily regimen Measure attendance of events, from those that were marketed (at-risk population). This measures response rate Assessment of health ambassador and their confidence and respect for them. Perceived effectiveness? How entertaining was the event; receptiveness

45. Information on Training and Recruiting The CHWs in the Krieger et al., Jafar et al. and Gary et al. interventions were trained to counsel patients to adopt preventive care and adhere to the treatment of hypertension They were taught the risk factors for cardiovascular diseases and trained to conduct blood pressure measurement The CHWs recruited in these interventions were mostly locals from the community Having a personal experience of managing own illness or someone else in the family resulted in producing highly significant results

46. Information on Canadian Public Health Association and Testimonial/Quotes Community Health Workers in Kenya Stir Broad Changes This article appeared in the January-March 1996 issue of One Country. Active in more than 200 communities, a project to promote vaccinations has also helped to build a new level of intersectoral and interfaith collaboration - collaboration that has paid off by stimulating the construction of latrines and helping create better access to clean water “The project is funded in part by the Canadian Public Health Association, which has provided about $110,000 to the project over the last three years.” Testimonial: "When I attended the first community health worker training, I did not know that I would find my answer there," she said. "But since the training program, I've been able to help my family, my neighbors, all the village and the surrounding villages to understand what is primary health care and how easy they can improve their health. And I feel there is an answer to my question, that we all can do something to improve our health. DrSantauMigiro, Division of Child Health, Ministry of Public Health and Sanitation, disclosed that currently, the doctor to patient ration is 1: 10,000. The WHO recommends 1:1000.

47. Health Ambassador Program is not expensive Not expensive Focuses on how the info diffuses and who the sender is

48. More support on Health Ambassador Program CVDs impose severe costs on the health-care system but there is not enough present emphasis to combat this A Health Ambassador Program does this: Primary control and prevention of CVD risk factors helps strengthen, rather than compete, with health-care interventions for other diseases Essential to move to programs in that focus on risk factor prevention and initiatives for health promotion at every level (individual, family, community and national).

49. Capital costs (land, site development, Woolly Pockets) total $4.0MM to build 640 “Hearty Gardens” over 4 years Capital Cost Analysis for the 4-year “Hearty Garden” Construction Plan

50. Labor and material costs to build 640 “Hearty Gardens” total $2.8MM over 4 years Variable Cost Analysis for the 4-year “Hearty Garden” Construction Plan