Since my last post, we have reached many milestones and confronted many unique difficulties. There’s much to convey, so I’ll jump right in!
Milestone #1: Finalizing Study Design and Conducting Baseline Survey
Since our arrival in Kurnool, we have become attuned to the many nuances of life in Kurnool and have modified our study design accordingly. In order to separate out the effects of solely the SMS Reminders on vaccination coverage from SMS Reminders + Link Volunteer follow-up for those children who are not vaccinated on time, we added a third arm to our original study. Now, we are: 1) surveying 250 mothers with the baseline survey as our control group; 2) enrolling another 250 mothers-to-be in Intervention Arm A: SMS Reminders; and 3) enrolling a third set of 250 mothers in Intervention Arm B: SMS Reminders + Link Volunteer follow-up. We decided to select 16 of the 50 electoral wards in Kurnool Town based on the proportion of urban “slum” (54%) and “non-slum” (46%) populations, according to the government definition of slum, which includes indicators such as crowding, water supply, and sanitation. Our sample population therefore should be representative of the population of Kurnool Town in terms of socio-economic status.
One of our primary goals during our two months was to design and conduct a baseline survey of the immunization records of children between one and two years of age. Conducting the baseline survey was a complex step-by-step process. After determining the types of questions that should be asked with the help of our friends from Kurnool Medical School, we had our trusty TIKA Assistant and Volunteer Coordinator Murali translate the packed five-page baseline survey forms for us with instructions on how to conduct the survey. Through a stroke of luck, friendship, and serendipitous timing, the Principal of the Government Nursing School gave us access to her second-year nursing students who were required to complete two weeks of community service work precisely during our scheduled baseline data collection time. We trained roughly 30 nursing students* in conducting surveys of mothers with children between 12 and 23 months of age and with access to a cell phone, and had Chandana the nurse from the TIKA Centre review vaccination schedules and their importance. We accompanied the students to two wards not included in our catchment area in order to test the survey and modified the questions according to their experiences and suggestions. We also modified our baseline survey according to local trends. For example, since married women usually travel to their mother’s house for a month or two during the first year after they give birth, we added a provision to allow those women to be included in the study. At last, with a final stamp of approval on the content of the surveys from several partners, we began collecting baseline survey information. Though a tedious process, our nursing students managed to brave the scorching heat every morning for two weeks in order to complete the baseline survey in all 16 wards. We are very grateful to them for their hard work and dedication, and to their Principal Ms. Asmat for her constant support – and for feeding us sweets whenever we stumbled into the Nursing School without having had breakfast and appearing as if we hadn’t slept in days.
We are happy to report that we have nearly finished this portion of the project.
Kurnool Highlight: Floods & Strikes
From the moment we landed in India, we have yet to experience a dull week. Kurnool is famous for devastating floods, which, two years ago, destroyed much of the town’s infrastructure. Though on a much smaller scale, we were given a little taste of the flood life when we woke up one morning ankle-deep in a good two inches of water covering the majority of our apartment floor. The spectacle that ensued was quite the experience, with neighbours wading through what appeared to be chlorinated water to figure out the cause of the flood. As it turns out, a water tap that dispenses clean – thankfully – drinking water only between 6:30am and 7:30am and only on some undetermined days of the week had been left on and our sink wasn’t able to handle the volume of water! Given that this was near the beginning of our stay, our suitcases were still unpacked – I found all my clothes and belongings dripping wet and turned everything possible in the apartment into clothes hangers. Luckily Priyanka’s room remained a dry safe haven for us while we dealt with the mess. Our neighbours also helped us, using any tools possible tools to scoop, sweep, drag, and drain the water from our submerged apartment until it was able to air dry on its own. We quickly developed a reputation as the foreign girls who had managed to flood their apartment. What an experience!
Since then, the weeks have only grown more eventful, with senior medical students striking to receive stipends that had been withheld for three months and succeeding in locating and procuring the funds, as well as protesting teachers getting their students to link arms and block traffic on a busy street.
Milestone #2: Ethics approval
After countless weeks and days spent in pursuit of local Institutional Review Board approval, including trying to re-create an Ethics Committee at Kurnool Medical College, camping out outside the Principal’s office for hours at a time daily for two weeks, meeting various professors and experts, and discussing our prospects inside and out, we came to the conclusion that there was not an IRB to be found in Kurnool. Since we’re on a strict timeline, searching for one in other cities would have been too lengthy a process. In the end, with the advice of a professor from undergrad (Thank you Prof. Brynen!), we sought ethics approval from the Government, and in particular the District Medical & Health Officer in charge of overseeing all health-related matters in the District of Kurnool. He, along with the District Immunization Officer and the District representative of the National Rural Health Mission, were impressed with the initiative and after reviewing our documents gave us permission to carry out our the surveys required for our study as well as ethical approval.
Hyderabad Highlights: Bandhs & Separatist Struggles
On the day of a scheduled trip to Hyderabad, we discovered the separatists in northern Andhra Pradesh had masterfully orchestrated a “Bandh”, or a closure on all public services. Employees refused to work until their demands were met, buses and trains were not running, cars were being turned around before reaching Hyderabad, and it seemed virtually impossible to make it to the city. In Hyderabad, the Bandh translated into gas price hikes and expensive limited mobility options. We were determined however, and though it took some last-minute planning and thinking on-the-fly, we managed to nab a couple seats on the only mode of transport to the city: a 3pm train. This 3pm train turned out to be a great treat, with a constant supply of chai, samosas, and a variety of other snacks. In typical P/N fashion, since we hadn’t eaten earlier in the day, we enjoyed this train ride to the fullest.
Milestone #3: Enrollment Begins
The final piece required to begin the project has begun – enrolment of pregnant mothers scheduled to give birth during the six month window between August 15th and February 15th. We will follow these mothers through the first year of their child’s life and send them reminders at five points throughout the year. As we waited for the final custom changes to PatientView, we decided that the women recruited as Link Volunteers through contacts at the government Anganwadi mother-and-child centres were capable enough to collect data using a form on mobile phones that we would provide (See Priyanka’s post for more info!). This system will have streamlined the process of data entry and analysis, helping both with the PatientView reminders and with the study.
While nearly everyone has a cell phone and uses it for phone calls, a concern for us has been literacy as well as mobile literacy of the mothers receiving the reminders. We are expecting to find that those who have “mobile literacy” – i.e. the ability to send and receive SMS messages comfortably – will have a high degree of literacy. On the other hand, it seems that areas with low literacy levels also are less likely to use SMS. We have allowed the system to accept SMS messages containing accurate Dates of Birth and Dates Taken for vaccines in order to measure the likelihood and possibly ability of parents to use SMS to self-report.
Creating and translating our enrolment survey followed a similar process as the baseline, though this time we were careful to add a detailed two-sided sheet including a consent form and all possible information a pregnant woman enrolled in the study would need to know, including vaccination schedule, schedule of reminders, closest government health centre, and helpline contact numbers.
As was the case during the baseline, we did find a couple interesting cultural nuances with this survey. The most confounding and memorable was certainly a question we hadn’t thought twice about since including it in the enrollment form: Gender of the Unborn Child. We received a call from our Project Assistant Murali stating that he had “some doubts” about the enrollment questionnaire and confusedly proceeded to ask us how we could pose such a question. We just couldn’t figure out why he thought the idea simply ridiculous; logically, a mother giving birth within the next six months would have been to a doctor, and many would have an idea of the gender of their baby, right? Wrong. As it turns out, what hadn’t occurred to us – and though some of you may know this, you can’t say I told you so until you’re in this position! – disclosing the gender of a foetus is illegal in order to prevent female foeticide and other family issues prior to birth. Of course it seemed absurd to ask such a question given this context, and after a very puzzling conversation, with Murali having trouble understanding our confusion (“But how could they know the gender?!”), we all had a good laugh.
Event of the Week: Being locked out of our apartment
On the evening of a very busy day, with more appointments pending before the day was through, we returned home to drop off our bags only to find our key not working. We called the watchman who procured some coconut oil, which was used to coat the key in hopes of loosening the jammed lock. Neighbours gathered from across the hall, from other floors, and eventually from adjacent apartments. Ultimately, the oil wound up all over the lock, the door, and the hands and clothes of all who attempted to struggle with the key, and locked the door further for all we know. We also had some technology needs at that precise moment, so Priyanka spread our laptops on the floor outside the apartment to make progress on that front, while I borrowed a giant screwdriver from the neighbours and began prying the windows open. We had just managed to break open the windows and were engaged in removing the screws from the metal grate inside when students from Kurnool Medical College who had heard about our predicament showed up and kicked the door in. The neighbours gathered around, each testing the lock for his or herself. Once they were satisfied that it was now working, they wished us a safe night after a few words of advice. We’re now known as the foreign girls with the only flooded apartment who also cannot unlock their door. It was quite the spectacle, a scene from a movie almost. On the plus side, we finally met the neighbours.