Managing Type 2 Diabetes in Malawi and Africa

(MTIMA)

A team of clinicians and scientists from Mzuzu Central Hospital, University College Dublin (UCD), Ireland, Queen’s University Belfast (QUB), UK, Imperial College London, UK, and Luke International Norway (LIN), Malawi, have embarked on a collaborative research programme to study T2DM with an aim to prevent morbidity and mortality from this disease.

As part of this collaboration we have obtained ethical approval for a feasibility pilot study which will involve the setting up a Diabetes Registry in Mzuzu Central Hospital. Following patient consent, we aim to collate patient demographic and clinical information, and perform several clinical and diagnostic tests for T2DM and associated complications. These clinical and diagnostic tests are performed as part of routine clinical care in many countries. In addition we will analyse 50 novel biomarkers of cardiac disease in diabetes patients using mass spectrometry. This proposed feasibility pilot study will generate data that will be used to aid the study design of a larger clinical diabetes project for a Horizon 2020, MRC and Wellcome Trust funding applications. The pilot study has 100 patients in Mzuzu Central Hospital, and begun in August 2015. Listed are a selection of photos as part of the MTIMA pilot study preperation efforts.

Funding Agency: ROCHE

PIs: Dr Joe Gallagher (UCD) and Dr Chris Watson (UCD & QUB), Dr John O’Donoghue (ICL)

Combining Leadership and patient Empowerment through intelligent data Access and Remote consultations

(CLEAR Consortium)

CLEAR is aiming to revolutionise the way in which primary care services are delivered internationally in developed and developing countries by developing and integrating, pioneering ICT (Information and communications technology) solutions with a view to generating greater patient healthcare outcomes. CLEAR aims to revolutionise the delivery of primary healthcare services. We define a number of core objectives which will ensure the realisation of this aim. 

1)     Barriers to healthcare

The current model of primary care presents barriers to access and use on a number of levels, logistically, chronologically, socially and financially. The first objective of CLEAR seeks to remove these barriers by offering a new model of care which is convenient to use and will help to inform, empower and provide equitable access to primary care to all (Huxley et al., 2015, Hjelm, 2005, Carter et al., 2018).

2)     Empowerment and self-efficacy

The concurrent access to a data rich portal by both the healthcare professional and patient will facilitate co-creation of ‘shared care’ style healthcare management plans (Hjelm, 2005). Ultimately the overarching goal is improved health outcomes for patients. Engendering empowerment and self-efficacy will serve to motivate patients and maintain engagement with the care plan thereby optimising health outcomes (Choi et al., 2014). 

3)     Data linkage and semantic interoperability and transparent data provenance:

Contemporary pervasive environments generate significant amounts of rich data which is heretofore being lost or under-utilised (Andreu-Perez et al., 2015). CLEAR will provide a solution to harness this rich data, addressing the challenges of data linkage and semantic interoperability and transparent data provenance. The quality of the information created from the data relies on the data quality and so CLEAR will provide a novel data quality framework which will be reliable, traceable and intuitive for all data consumers to use and interpret.

4)     International first data quality framework

The impact of a quality, data-rich, patient-centred, collaborative healthcare solution will have many implications for healthcare on an organisational and national level. The intelligence garnered from the efficient harvesting of quality data will play a critical role in informing policy makers in regard to healthcare and increase efficiency and cost effectiveness in the sector (HIQA, 2018).  

5)     Pioneering dynamic user interface

Finally, the rapid evolution epidemiologically, in medicine and in technology, demands that any developed solution has the capacity to keep pace with and in parallel with these changes to ensure its continued relevance and applicability into the future. The visionary, ambitious objective of CLEAR amalgamates current scientific knowledge with future projections to lead the way to an entirely pioneering model of primary care. Through state-of-the art dynamic user interface and the incorporation of aspects of virtual technology, CLEAR will reach the previously unreachable and offer healthcare in a previously unimaginable way, thereby achieving previously inconceivable outcomes (Althoff et al., 2016, Anderson et al., 2010, Freeman et al., 2017).

References:

• ALTHOFF, T., WHITE, R. W. & HORVITZ, E. 2016. Influence of Pokémon Go on physical activity: study and implications. Journal of medical Internet research, 18.

• ANDERSON, F., ANNETT, M. & BISCHOF, W. F. 2010. Lean on Wii: physical rehabilitation with virtual reality Wii peripherals. Stud Health Technol Inform, 154, 229-34.

• ANDREU-PEREZ, J., LEFF, D. R., IP, H. M. & YANG, G.-Z. 2015. From wearable sensors to smart implants-–toward pervasive and personalized healthcare. IEEE Transactions on Biomedical Engineering, 62, 2750-2762.

• CARTER, M., FLETCHER, E., SANSOM, A., WARREN, F. C. & CAMPBELL, J. L. 2018. Feasibility, acceptability and effectiveness of an online alternative to face-to-face consultation in general practice: a mixed-methods study of webGP in six Devon practices. BMJ Open, 8, e018688.

• CHOI, N. G., HEGEL, M. T., MARTI, C. N., MARINUCCI, M. L., SIRRIANNI, L. & BRUCE, M. L. 2014. Telehealth problem-solving therapy for depressed low-income homebound older adults. The American Journal of Geriatric Psychiatry, 22, 263-271.

• FREEMAN, B., CHAU, J. & MIHRSHAHI, S. 2017. Why the public health sector couldn't create Pokemon Go. Public Health Res Pract, 27.

• HIQA 2018. Guidance on a data quality framework for health and social care. Health Information and Quality Authority.

• HJELM, N. 2005. Benefits and drawbacks of telemedicine. Journal of telemedicine and telecare, 11, 60-70.

• HUXLEY, C. J., ATHERTON, H., WATKINS, J. A. & GRIFFITHS, F. 2015. Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice. Br J Gen Pract, 65, e813-e821.

Supporting LIFE

(AQ4LC)

It is well documented within academia and the general media of the increasing risks associated with poor environmental air quality levels. Numerous studies, including a 2013 assessment of Chinese cities discovered that only 4.1% of the 74 cities monitored, met official air pollution standards in terms of PM2.5, with an annual average PM2.5 value of 72 μg/m3 (Guo et al., 2016). In developing countries there is even a higher burden of indoor air pollution as a high number of biomass stoves are used indoors for cooking (Gupta, 2019)(Smith, 2002). Indoor air pollution increases the risk to upper respiratory tract infections. Studies have shown chronic exposure to biomass smoke-generated indoors can cause a wide range of health effects such as chronic obstructive pulmonary disease (COPD) (Sehgal, Rizwan and Krishnan, 2014)(Neidell, 2004). Asthma is one of the upper respiratory conditions that affect individuals as a result of poor air quality.

When it comes to air quality monitoring and asthma self-management, there are a number of new technologies coming to the market, including, the utilisation of a network of handheld air quality monitors (Dutta et al., 2009) to environment crowd-sensing for asthma management (Vasilateanu, Radu and Buga, 2016) and (Tinschert et al., 2017) on mobile apps for Asthma self-management to the installation of air particle monitors to provide digital coaching to reduce indoor smoking (Hovell et al., 2020). Such technologies combined have the potential to offer greater levels of asthma self-management which may result in a higher standard of living.

Finally, “adequate asthma management depends on an accurate identification of asthma triggers. A review of the literature on trigger perception in asthma shows that individuals vary in their perception of asthma triggers and that the correlation between self-reported asthma triggers and allergy tests is only modest.” (Janssens and Ritz, 2013). Within the Air for LIFE Consortium our initial trial will be looking to assess the impact of using personalised air quality monitors as part of Asthma self-management in both urban and rural settings in Malawi, Africa.

Team members:

Adina Elena Zagoneanu,

Sydney Brannen,

Tarun Das,

Dr Trevor Nichols,

Dr Oisin O’Connell,

Dr Patrick Henn,

Simeon Yosefe,

Hsin-yi Lee,

Joseph Wu,

Prof. Chang-Chuan Chan,

Prof. Sally Chen,

Prof. Richard Costello,

Prof. Joe Gallagher,

Hastings Gondwe,

Dr Griphin Baxter Chirambo,

Dr John O’Donoghue.

References:

• Dutta, P. et al. (2009) ‘Demo abstract: Common sense - Participatory urban sensing using a network of handheld air quality monitors’, Proceedings of the 7th ACM Conference on Embedded Networked Sensor Systems, SenSys 2009, pp. 349–350. doi: 10.1145/1644038.1644095.

• Guo, Y. et al. (2016) ‘Factors affecting parent’s perception on air quality-from the individual to the community level’, International Journal of Environmental Research and Public Health, 13(5). doi: 10.3390/ijerph13050493.

• Gupta, A. (2019) ‘Where there is smoke: solid fuel externalities, gender, and adult respiratory health in India’, Population and Environment. Springer Netherlands, 41(1), pp. 32–51. doi: 10.1007/s11111-019-00325-6.

• Hovell, M. F. et al. (2020) ‘Randomised controlled trial of real-time feedback and brief coaching to reduce indoor smoking’, Tobacco Control, 29(2), pp. 183–190. doi: 10.1136/tobaccocontrol-2018-054717.

• Janssens, T. and Ritz, T. (2013) ‘Perceived triggers of asthma: Key to symptom perception and management’, Clinical and Experimental Allergy, 43(9), pp. 1000–1008. doi: 10.1111/cea.12138.

• Neidell, M. J. (2004) ‘Air pollution, health, and socio-economic status: The effect of outdoor air quality on childhood asthma’, Journal of Health Economics. North-Holland, 23(6), pp. 1209–1236. doi: 10.1016/j.jhealeco.2004.05.002.

• Sehgal, M., Rizwan, S. A. and Krishnan, A. (2014) ‘Disease burden due to biomass cooking-fuel-related household air pollution among women in India’, Global Health Action. Co-Action Publishing, 7(1), p. 25326. doi: 10.3402/gha.v7.25326.

• Smith, K. R. (2002) ‘Indoor air pollution in developing countries: Recommendations for research’, Indoor Air. Blackwell Munksgaard, 12(3), pp. 198–207. doi: 10.1034/j.1600-0668.2002.01137.x.

• Tinschert, P. et al. (2017) ‘The Potential of Mobile Apps for Improving Asthma Self-Management: A Review of Publicly Available and Well-Adopted Asthma Apps’, JMIR mHealth and uHealth, 5(8), p. e113. doi: 10.2196/mhealth.7177.

• Vasilateanu, A., Radu, I. C. and Buga, A. (2016) ‘Environment crowd-sensing for asthma management’, 2015 E-Health and Bioengineering Conference, EHB 2015. IEEE, pp. 1–4. doi: 10.1109/EHB.2015.7391363.

Mobile Apps and Patient Safety

(MAPS Study)

Risk Assessment using Practical and Innovative Diagnostic Diabetes tools

(RAPID Diabetes Study):

 Mobile IN Development

(MIND Study)

BioTope

(BIOmarkers TO diagnose PnEumonia)

BioTOPE (BIOmarkers TO diagnose PnEumonia)

Title:

Digital Datum Study

Introduction:

Field study research plays an important role in determining the effect of any given intervention e.g. how a smartphone app may assist in diabetes patient self-management, or how a new medication may help to alleviate pain etc. Collecting data during research is a core activity, as such data points help to measure the success or failure of a given intervention. 

This review examines the use of data collection tools in low- and middle-income countries for Randomised Controlled Trials (RCTs). It evaluates the tools based on the Mobile Survey Tool (MST) evaluation framework, considering factors such as functionality, reliability, usability, efficiency, and cost-benefit. The search will be conducted in electronic databases (Pubmed, CINAHL, Web of Science, and EMBASE) and only RCTs conducted in low- and middle-income countries that mention a health-related data collection tool will be included. The PRISMA tool will be used for the systematic review. Two authors will independently screen titles and abstracts for inclusion. The data will be analysed using a narrative synthesis approach. 

The aim of this research is to generate a Data Collection Tool Checklist (DCTC) for all researchers when selecting a suitable data collection tool to conduct research in low- and middle-income countries. Such an approach will assist the research team to be better prepared before undertaking future research studies.

Registrations:

A Systematic Review Investigating the Characteristics of Health-related Data Collection Tools Used in Randomised Controlled Trials in Low- and Middle- Income Countries. Prospero: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=405738

Publications:

Title: “Investigating the characteristics of health-related data collection tools used in randomised controlled trials in low-income and middle-income countries: protocol for a systematic review“ https://doi.org/10.1136/bmjopen-2023-077148

Team members:

Noor Al-Shamaa,

Rithvik Karthikeyan,

Eve Kelly,

Prof. Frances Shiely,

Dr Patrick Henn,

Prof. Titus Divala,

Dr Kayode Philip Fadahunsi,

Dr John O’Donoghue.

Title:

An international feasibility study protocol evaluating the appropriateness of podcasts to improve the knowledge and awareness of selected health topics amongst undergraduate general nursing students

Study population:

The study will collect information from undergraduate general nursing students from four universities which are located across, Malawi, South Africa and Ireland.

Methods:

We want to investigate if listening to podcasts impacts undergraduate nursing students' knowledge and awareness of global health issues. Six podcasts in total were designed and created for the study based on a global health issue or disease. Only two of the six podcasts will be used in this research. The two podcasts we have chosen for our study are gestational diabetes and mental health. There will be a survey to be completed before listening to the podcast and the same survey will be completed after listening to the podcasts. We will compare the survey results to see if there is any positive change in the answers after listening to the podcasts.

Ethics:

The study received ethical approval from the University College Cork Ethics Committee (SREC) (ID 2022-027A1) which will also cover the University of Galway in Ireland, the Mzuzu University Research Ethics Committee (MREC) (ID MZUNIREC/DOR/23/28) and in South Africa, the Inter-Faculty Research Ethics Committee (IFREC) of the University of Fort Hare (ID CIL002-21).

Publications:

Denny, A., Curtin, B., Taylor-Robinson, S., Chirambo, G.B., Cilliers, L., Wu, T.S.J., O'Meara, C., Booth, R. and O'Donoghue, J., 2024. Evaluating the Appropriateness of Podcasts to Improve the Knowledge and Awareness of Selected Health Topics Among Undergraduate General Nursing Students: Protocol for an International Feasibility Study. JMIR Research Protocols, 13(1), p.e50735. link.

Listen to any of our podcasts on:

Pregnancy:

• (Spotify): https://spotifyanchor-web.app.link/e/S6Zn61t4ZAb

• (Youtube): https://youtu.be/i_t4EnwS6PE

Malnutrition:

• (Spotify): https://spotifyanchor-web.app.link/e/IaMls0v4ZAb

• (YouTube): https://youtu.be/nGPLkCwmmkA

Mental health:

• (Spotify): https://spotifyanchor-web.app.link/e/LBLzuUpu4yb

• (YouTube): https://www.youtube.com/watch?v=ymydfZw52v4

Gestational diabetes:

• (Spotify): https://spotifyanchor-web.app.link/e/TaSmfTpu4yb

• (YouTube): https://www.youtube.com/watch?v=ed4Qmh_LzhU

Cervical cancer:

• (Spotify): https://spotifyanchor-web.app.link/e/tJC8DoG4ZAb

• (YouTube): https://youtu.be/_qpkP9sUaEU

HIV/AIDS:

• (Spotify) https://spotifyanchor-web.app.link/e/uOE0ePMc8Ab

• (YouTube) https://youtu.be/7QdjHAArEwA  

Team Members:

Alanna Denny

Brian Curtin

Prof. Simon Taylor Robinson

Dr. Griphin Baxter Chirambo

Prof. Liezel Ciliers

Dr. Ciara O’Meara

Prof. Richard Booth

Dr. Joseph Wu

Dr. John O’Donoghue

A selection of PRIME Study Participants and Recording Sessions

Introduction:

The Kufikira project is a survey-based study exploring whether websites could be useful in improving the knowledge, attitude, practice and engagement that type 2 diabetic patients in Mzuzu, Malawi have regarding their illness. Kufikira means “engagement” in the Tumbuka language and it is the title of the project due to the exploration of how websites can be used to engage a population with more barriers to internet access (such as Malawi). In addition to type 2 diabetics, other stakeholders in the Mzuzu area (such as NGO employees, the general public, Mzuzu University students and healthcare professionals) will also be recruited. Overall, this study will showcase whether health promotion through websites can benefit countries that still have barriers to widespread internet access.

Methods and analysis:

Three data collection tools will be utilised across five groups to assess the impact of a diabetes-based website. The groups are 1) T2DM patients located in Mzuzu (n=99), 2) Luke International employees (NGO) (n=36), 3) general undergraduate/post-graduate students in Mzuzu University (n=94), 4) the general public of Mzuzu (n=100) and 5) healthcare professionals (n=90). The data collection tools are 1) a survey, based on the KAP (Knowledge, Attitude and Practice) framework. This will elucidate the knowledge and attitude that participants have towards diabetes. In addition, diabetic patients will be given a more complete version of the survey that will measure any changes in practice 2) the second survey is modelled around the WEQ (Website Evaluation Questionnaire) survey. It will provide information on how participants feel about the navigation, content, and layout of the website and 3)Google analytics data will be used to explore what strategies are best to engage individuals with the website.

Ethics and dissemination:

Ethics approval was obtained from the Malawi Research Ethics Committee. Results will be disseminated through peer review journals and scientific conferences.

Acknowledgements:

The authors thank the participants and the public of Mzuzu, in advance of their assistance in completing this study.

Team Members:

Kareem Choucair

Griphin Baxter Chirambo

Patrick Henn:

Billy Harry Chitete

Rebecca W Mtegha:

Joseph Wu

Hsin-yi Lee

Philip Fadahunsi 

John O’Donoghue

During the tumultuous days of the COVID-19 pandemic, Malawi's Ministry of Health exhibited remarkable foresight and agility by deploying digital tools to enhance its response efforts. Despite being one of the world's poorest countries, Malawi swiftly harnessed the power of technology to support the Public Health Institute of Malawi (PHIM) and the general population through the One Health Surveillance Platform (OHSP) and WhatsApp Chatbot tools, respectively. Notably, Malawi achieved a pioneering milestone by becoming the first African nation to deploy digital COVID-19 vaccination certificates.

In September 2023, Malawi received crucial funding from the Research Investment for Global Health Technology Foundation’s (RIGHT Foundation) "Evidence Generation Award (EGA)" to undertake the PAMODZI COVID-19 Study ("PAMODZI" meaning "together" in Chichewa, Malawi's official language). This national-level study employs a mixed-methods approach to assess the impact of OHSP and Chatbot tools during the country's COVID-19 response, shedding light on the effectiveness of digital solutions in strengthening healthcare infrastructure during the pandemic.

 This study will go through five core stages:

Stage 1: Illuminating Digital Solutions and the OHSP Usage

The study commences with a comprehensive Delphi Study involving 40 expert panel participants, including representatives from the Ministry of Health (MOH), Public Health Information Management (PHIM), border health officials, and Integrated Disease Surveillance and Response (IDSR) stakeholders. This stage delves into Malawi's COVID response Digital Solutions/Services Architecture and the utilization of OHSP during the pandemic. It features face-to-face roundtable discussions and digital iterations via email to capture nuanced insights.

Stage 2: Engaging Health Service Providers and the General Population

Building on the insights from Stage 1, the study develops a national survey aimed at involving health service providers and the general population. This inclusive approach reaches out to various participants through patient and health advocacy groups across Malawi, with a total engagement target of 670 participants.

Stage 3: Unlocking Insights Through Retrospective Data Analysis

This stage focuses on a retrospective analysis of operational and service data collected by the Ministry of Health Chatbot tool. It encompasses diverse facets such as health education, risk communication, COVID-19 surveillance, vaccine-related information, and self-reporting data. Impressively, the Chatbot engaged with approximately 10,000 members of the Malawian community during the pandemic's peak.

Stage 4: Engaging Stakeholders Through a Collaborative Workshop

After data analysis, a two-day workshop brings together 40 panel members, representing the Ministry of Health and the general public. This unique gathering facilitates rigorous discussion and evaluation of the Chatbot tool's role in supporting Ministry of Health Officials and the public.

Stage 5: Informing Policy and Disseminating Findings

In the final stage, the study's findings culminate in a comprehensive report and policy recommendations. These insights are presented to the national-level Digital Health Technical Working Group within the Ministry of Health, guiding future strategies for digital health solutions in Malawi.

The PAMODZI COVID-19 Study represents a significant leap forward in understanding the impact of digital tools on healthcare responses during the COVID-19 pandemic in Malawi. Through stakeholder engagement, thorough assessments, and widespread dissemination of findings, this initiative paves the way for more effective healthcare solutions within the country and beyond.

This research is led by Luke International (LIN) in collaboration with the Malawi Ministry of Health (MoH), Public Health Institute of Malawi (PHIM), Mzuzu University (MZUNI), Malawi eHealth Research Center (MERC) and University College Cork (UCC).

Funding for this research is provided by the RIGHT Foundation.

Timeline: September 2023 to August 2024.