I was discussing a project that I have with colleagues in Bangladesh to improve awareness about breast cancer and access to care in a rural area. The project actually uses something called mobile health or m-health but the mobile is referring to mobile phones. Our colleagues developed special applications in the Bengali language that are relevant for women in these local villages who have very limited education to guide community health workers using the phones in door to door interviews. It’s a randomised controlled trial, if I can just go into it in a bit of detail, with thirty community health workers, so these are women who have basic high school education from the villages. Two of the groups were randomised to use the phones and one is using paper and pen. So the women with the phones also are able to show door to door the adult women who are agreeing to be interviewed a video testimonial. Women from their own community who have already been to our breast clinic or the local hospital who found out either that their breast lump turned out not to be cancer, so that’s a huge relief and they can learn about breast health that way, or that they had cancer and it was treated effectively and they’re cured. Because most of these women in rural Bangladesh have never heard of anyone surviving cancer of any kind so if you haven’t ever heard of a cancer survivor, why wouldn’t you think it’s a death sentence? So part of our project is actually to do community empowerment and to reduce inequities in health for women but in the meantime the door to door interviews showed that the community health workers who had the phones were much better at getting women to disclose if they had a breast problem and if they did on physical exam, which the health worker did right there and then in the home, they were much more likely to come for care if they were interviewed by a community health worker with a phone.
Now two of the arms had phones, one of the phone arms also included a special day of training in what we call patient navigation. So these CHWs, as we call them, community health workers, were trained to ask questions on social issues and some of the issues around domestic violence that might be preventing them from making decisions for themselves about their health and even to troubleshoot in a very practical way. For example, ‘How can we help you come to clinic?’ ‘Oh, I’ll come to clinic.’ ‘Well I sense that maybe you might have problems coming. Can we come back and talk to you and your husband together? Do you need permission from your mother-in-law? Can we help you with childcare or even bring you to the clinic directly?’ So that extra little one day of training resulted in a much higher rate, I think it’s something like 72% of women in that study arm, who had a breast problem came to the clinic compared with about 50% in the other groups.
Anyway, we’re about to publish this in the Oncologist and I’m looking forward to hearing more about what’s going on at AORTIC. There are many people here who have similar projects, maybe not with the phone or with the CHWs but trying to make an impact on breast cancer in low income countries.
Why was Bangladesh used in this trial and will the trial be rolled out to other countries?
Bangladesh was the choice of location for this, partly just for organic reasons – I’ve already been working in the country for about five years, I co-founded a small breast clinic with a local NGO, that’s information communications for technology for development, ICT4D, called Amader Gram which means ‘Our Village’. So we already had the clinic and it was because we didn’t see enough women coming to the clinic that spawned this idea – how can we make inroads, how can we educate the women in the communities around our clinic and find something innovative that might be a bit more attractive and appealing for the local researchers also to get involved, that sort of thing.
I think there is an interest coming from several countries here in Africa regarding adaptability of our project. Now it has its shortcomings, we weren’t able to track all of the diagnoses and closing that loop from having a symptom to diagnosis to treatment and follow up is absolutely essential for success of a project like this. So we’re trying to see if we can adapt it to other settings but we’re also trying to improve the platform for this model of care so it’s going to be more effective.
There are very few opportunities to fund projects like ours which are not just a non-communicable disease, NCD, but cancer in particular in a lower middle income country. So I’m very grateful to the people at Grand Challenges Canada which is an NGO, we have funding from the Canadian government but it’s an independent body with its own peer review through our Canadian Institute for Health Research, CIHR. They provide small seed grants of $100,000 each for projects that include what they call integrated innovation. So it needs to have an aspect that’s social innovation and business innovation, not just scientific and technical. So it’s a great opportunity; I see more people now applying for these grants related to cancer; they also have a stream for maternal health and for child health etc. but this was a very important opportunity for us.