My education and career goals were quickly reshaped after a summer internship in Bangalore, India following my second year of college. When I began my bachelor’s degree in biomedical engineering at the University of Wisconsin-Madison, I envisioned myself someday performing biomechanical analyses of injuries for ESPN. Traveling in India that summer offered a new perspective; this was my first exposure to widespread lack of access to basic amenities and healthcare. My ESPN dreams were easily overthrown.
Since this time I have completed eight semesters of Hindi language study including one more summer in India under the Critical Language Scholarship program. By the time I finished college, I envisioned myself someday combining my new language and engineering skills to solve problems with cultural sensitivity via real community connections. Now, supported by The Fulbright Program, I am beyond thrilled to be carrying out this mission with Barefoot College in Tilonia, India.
Now, several months into my work at Barefoot College, my motivators have changed. One year ago I probably would have said that I am motivated by the challenge of creating low-cost, simple solutions to complex problems in medicine; I probably would have said that my love for technology is what motivates me. This still has truth; however, during my initial months in Tilonia, I have learned that my biggest motivator is belief in the right to quality healthcare for every person. I believe that contextually appropriate technology is a vehicle through which this can be achieved. Working with community health workers every day and seeing them struggle with the tools that are available to them motivates me to work toward providing suitable and efficient diagnostic tools.
During the third year of my PhD I was already planning to move back to India to understand the challenges faced by women in rural India at close quarters. My research on nutrition environment of the mother before and around pregnancy and its impact on adult health has made me think about the relevance of such research and its implications on Indian population. I realized that real impact is only possible once I translate these on to the ground and hence I took what I call my "leap of faith" and applied for a rural development fellowship which would provide me an opportunity to work on health issues.
I was appalled by the issues faced by women and girls. I realized that health issues in these communities can not be isolated from interconnected problems of education, discrimination against women, financial dependency, and poor understanding of rights. I started working on issues which needed the most immediate attention and launched a program called Women Wellness Initiative which works on key areas such as awareness on menstrual, sexual and reproductive health, diagnostic care and malnutrition.
One of the first initiatives was a study of the efficacy and acceptability of traditional nutrition product for alleviation of anemia in rural girls and women. During this study, I realized that the commonly used methods for hemoglobin measurement by the grassroots community health workers were prone to human errors and produced variable results. Devices known to produce accurate results required highly specialized skills and mostly were not affordable. Without a device which can be used by community health workers and produce accurate diagnoses, it is difficult to identify, prevent or cure anemia. In a rural setup, other factors like ease-of-use and affordability play an equally important role.
This was when the idea of either designing a new device based on rural needs, or doing a comparative study to identify the best suited product for rural context was conceived. Hannah's background in biomedical engineering provides us the right expertise to lead the study.
Which point of care (POC) device is most suitable for reliable hemoglobin (Hb) measurement in resource constrained settings? There is currently no consensus from the medical and scientific communities. This lack of clarity has a major impact on the quality of health services that can be provided in rural communities, such as our clinic at Barefoot College. Proper Hb measurement is essential for effectively diagnosing anemia. In children, undiagnosed anemia can lead to impaired neurological, behavioral, and physical development. In mild forms it causes severe fatigue and weakness, which can lead to fatal deterioration of muscle and organ function if left untreated. This particularly significant for reproductive age and pregnant women, as the nutritional demands are higher on her body. If a woman is anemic during pregnancy, the child’s health is also compromised leading to low birth weight and developmental delays.
For all these reasons, it is crucial that the tools for accurate anemia diagnosis are accessible at even remotest levels of healthcare. Unfortunately, there are several complications with existing POC Hb measurement devices in rural clinics like ours at Barefoot College. Of the devices we have in our clinic, we see that many are not used properly, require too many consumables, are highly subjective to user interpretation, do not suit the environmental conditions, or are expensive.
Our study aims to determine an answer to the lingering question - Which point of care (POC) device is most suitable for reliable hemoglobin (Hb) measurement in resource constrained settings? We will be conducting a comparative analysis in which 1200 children in Ajmer District, Rajasthan will be evaluated using six POC Hb measurement devices - four which are minimally invasive (requiring blood draw), two which are non-invasive (requiring no blood) as well as a clinical gold standard hematology analyzer which will be accessed from a nearby hospital. All children in this study will be followed up with nutritional supplementation and subsequent checkups. In addition to comparing accuracy, this study evaluates the various POC devices in terms of cost per test, consumables, required training, device maintenance, and other factors that determine product suitability for rural settings like ours.
We hypothesize that even if one POC device under evaluation outperforms the others, it likely still has flaws which could be addressed with an improved technology. Overall, the study aims to accomplish the following:
- Determine which of the existing POC devices is most suitable for use in a rural, resource-constrained setting
- Better understand the shortcomings of existing devices and recommend design criteria for a new POC device which is optimized for use in a rural, resource-constrained setting
Why is this important?
India has the highest rates of undernutrition in the world; in Rajasthan alone, children under five experience stunting and muscle wasting at 36.5% and 14.2% respectively. This is directly linked to the extremely high rates of anemia seen in the country: nearly 40% of the total population, and around 50% of all women have Hb levels below the healthy range. Though there can be many causes for anemia, the most common is due to nutrition deficiency. Difficulty in making proper diagnosis further perpetuates the problem. Symptoms are often not apparent until the condition becomes severe, at which point the consequences are tremendous. Anemia is the second leading cause of maternal death in Asia and accounts for 20% of all maternal deaths worldwide. Anemic children experience impaired behavioral and cognitive development in addition to physical consequences such as stunting and muscle wasting. This condition constitutes the intergenerational cycle of poor health in women and girls: anemic mothers give birth to low birth weight babies who experience stunting and wasting during childhood, grow into malnourished adolescents before becoming anemic mothers themselves and the cycle continues. Making accurate and efficient diagnoses will enable health workers to properly prescribe an intervention, such as locally accepted nutritional supplementation. Such an intervention will effectively break this intergenerational cycle, but can only be prescribed when a health worker is equipped to make an accurate diagnosis.
To take steps toward solving this problem, we are evaluating six different POC devices and comparing against a clinical gold standard. We are making this multi-way comparison based on more than diagnostic accuracy alone; we aim to understand overall suitability of each device for this specific setting according to several metrics.
Who will benefit?
This project will most directly benefit community health workers and pathologists. This study will give them confidence in the tools they are using to work; they will be able to do their jobs knowing they can trust their equipment. Of course, improving health workers' ability to provide quality service will then benefit the patients they serve. In this project, those patients are the 1200 children for whom we will be performing quarterly checkups. We hope that the benefit will extend beyond our reach to any patient in a rural setting with limited access to health services.
There will be additional benefit to our community in particular. Barefoot College health workers and pathologists will be conducting all the health camps required to collect data and will undergo many hours of training and practice to prepare. All camps are being conducted by them so that we can best understand the true use cases of each device. The whole process of carrying out this study will also serve to build the capacity of our team at Barefoot College.
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BudgetThe funds raised here will be used to purchase required materials, to pay the salaries of health workers who are conducting the health camps, to purchase two new devices we want to include in the comparison but do not currently have in our clinic, to cover travel expenses, and to purchase a specimen cooler.
Phlebotomy Workshop with BD
In resource constrained situations, such as in many rural health centers, syringes are used for venous blood drawing. While in some cases there are advantages to this, there are many more drawbacks. First and foremost, syringes are designed for injection, not for withdrawal. The gage of the needle is small and the drawing pressure is dependent on the speed at which the operator draws the plunger. Since this is inconsistent with venous pressure, it causes damage to cells as they are drawn from the vein and through the needle. Another major concern with use of a syringe is the high risk for needle stick to the health worker when transferring the sample from the syringe to a collection tube.
To mitigate these risks and optimize the quality of our venous blood samples, we have chosen to move forward with BD Vacutainer products. We have specifically chosen the push button blood collection set, which has a short length needle (0.75in) optimal for patients with thin veins, such as children. Representatives from BD had visited our Tilonia clinic back in May for an initial demo and information session. This week a representative from BD returned with a dummy arm and conducted a phlebotomy workshop for the staff to practice venipuncture with their new tools.
We started with a refresher information session and then moved forward to practice on the dummy arm. After the staff felt comfortable on the dummy, they moved ahead to conduct venipuncture on one another. I also volunteered as a subject and I must say, Kishore ji did a very smooth job! We plan to continue practicing with our new products until all the health workers are confident.