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A new interface for community health work

By Elizabeth Liu

Many challenges face global health organizations when it comes to community health work in foreign countries, not the least being the disconnect between the needs on the ground and what outside aid perceives the needs to be. I came to better understand this divide while at the Wellbody Clinic in Kono District, Sierra Leone this summer.


The Wellbody Clinic complements the government-run hospital healthcare delivery system in war-torn Kono District. It’s been a decade since the end of the devastating civil war, but the infrastructure — electricity, sanitation, education, healthcare — has yet to recover.

Despite incentives such as free health care for pregnant women and children under five, many locals are still reluctant to visit the clinic, due to costs and stigma. I went with a group of Princeton students to pilot a program that would train Community Health Workers on diagnosing patients with the aid of smart phone technology and a software program called Sana. Our goal was to teach them how best to canvas the villages for patients that needed testing or referrals, to keep a comprehensive record of patient histories and to detect diseases early.

The concept behind the Sana mobile software is quite straightforward. A CHW records the patient’s information — name, age, gender — uses the camera on the phone to take pictures of rashes and problem areas, and checks off symptoms. The software logic uses the symptoms to come up with recommendations, such as to make free referral to the clinic or to administer a malaria test. In a country where doctors and medical resources are in shortage, a smartphone program that mimics what doctors do when diagnosing a patient in the absence of stool and blood samples could become a powerful tool.

When we began house visits, testing the HIV and malaria procedures, new problems arose. Recording patients’ names was a difficulty. Most of the villagers were illiterate and didn’t know how to spell their own names. More troubling was the attitude of dependence. The calls of “White man, white man!” and kids asking for money would follow us wherever we went. Similarly, villagers that were not ill would claim to have symptoms when they saw the “white man” with the CHWs.

The input from the CHWs facilitated the project. In between sessions of training and role-playing, they laughed at my efforts to learn Krio, the common language in Sierra Leone. But when they shared their music and talked about the obstacles in education, channels of communication opened. It was one of the CHWs that brought our attention to the AIDS stigma and being circumvented when asking questions about sexual partners and condom use. Yet another suggested that to not have false positives to questions asked, the CHWs had to be more discerning of patient answers and use their hands-on training. Hence, I learned the importance of teaching locals the tools to help themselves in the long term, but of also working with them to make sure what we wanted to implement was rooted in pragmatism and actual needs on the ground.

Despite all the difficulties with the phones, there were clear benefits. Since CHWs are asked to document all home visits on the phones and keep detailed records, the phones made the CHWs accountable for actually visiting the patients. Furthermore, when fully redone, the screening will have comprehensive questions that prompt referrals for different sets of symptoms. With patients coming into the clinic already on record for needing further testing for specific diseases, some of the burden placed on nurses and doctors will be reduced. Lastly, as a CHW noted, since phones hold such an exalted place in the community’s mind, simply using the phones as a diagnostic tool is bringing legitimacy and excitement to going to the clinic. How long that enthusiasm will last depends on the how well implemented and cohesive the program is.


Ultimately can a software program stand in for human diagnosticians? Of course not, since technology is only a tool to be used as an aid and not a crutch. Though the smartphone shows promise in terms of treatment management and HIV/TB medication follow-up on side effects, the phones, like any tool, should not become a misleading authority in the face of common sense. By reaching more people in rural communities with fewer doctors, it’s valuable for the CHWs to use the phones as a guide but to also keep in mind the personal hands-on aspect of community health.

Elizabeth Liu is an ecology and evolutionary biology major from Fremont, Calif. She can be reached at eltwo@princeton.edu.

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