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It has been an exciting month for the Sayana Press team in Uganda – and, tangentially, an exciting month for me!

After successfully launching a nationwide scale up of the provider-injected Sayana Press drug in 2016, the PATH team has been focusing on introducing self-injection. After several months observing self-injection in four target districts, the team set out to conduct an evaluation with the goals of, 1) finding out whether self-injection is working for women in rural areas and 2) learning which variation is most cost-effective.

I joined the team as they were wrapping up their first phase of the evaluation: interviewing the providers who were training women to self-inject. In the second half of my internship, we were busy preparing to launch the second half of the evaluation: interviewing users themselves. Throughout both phases, the team also facilitated monitoring visits at each site to support the field teams. It turns out, starting when I did was a perfect time! I was able to observe the launches of both phases as well as join the team in the field for monitoring visits and jump in on some trainings.

One of the trainings was conducted in July. I joined the team’s Scale-Up Manager, Edson Twesigye, to travel to Mayuge district in Eastern Uganda to orient new providers to the program and “train the trainers” in self-injection. We visited two facilities, Kityeyera Health Center IV: a bustling, district-level referral clinic/hospital, and Muggi Health Center III, a sleepier, more rural center still serving a fairly large population. Observing how Edson facilitated the training sessions offered a lot of insight into PATH’s training methodology, and I enjoyed the chance to also facilitate my own sessions as well. I spoke to the groups about the procedure for using the self-injection register, a reporting tool developed by the team to ensure accurate data collection. The team had found in other sessions that the register was sometimes confusing for providers and was being filled improperly, particularly a few vital questions. I enjoyed the chance to discuss their challenges with them and we were able to clarify several key points. This exercise was an informative opportunity to improve my understanding of data collection tools, especially as we focused on data entry at the point of service delivery.

A key component of training is reviewing and practicing the self-injection procedure with each training team. Self-injection is a 10-step process which is led by a “job aid” – a series of pictures, each with a corresponding instruction, that guides a user through prep up to completion of the injection. There are four critical steps: mixing the solution by shaking the vial, activating the device, pinching the skin at the injection site (abdomen or thigh) to make a “tent”, and then pressing the reservoir slowly to inject the drug. It was exciting and illuminating to watch the training team in action!

After returning to Kampala from Mayuge I joined the team in completing our remaining duties to prepare for Phase II of the evaluation: client survey administration. This training offered even further opportunities for observation, learning and practice. Overall, I had an amazing internship with the PATH team in Uganda. I look forward to following the Sayana Press project further and delving into the results of the evaluations!

-Kirsten

 

I do not want to exaggerate when I say this, but visiting San Miguel de Allende (San Miguel), Mexico, for the first time was magical. This small city is the second colonial city that I am visiting for my practicum about the impact of Western retiree immigration in Latin American cities. San Miguel has a deep history tied to the Mexican revolution, silver trade, and powerful Spanish families, but it’s fascinating how the words of American writer Stirling Dickinson were what attracted Westerners to this baroque city: “There was enough light for me to see the Parish church sticking out of the mist. I thought ‘My God, what a sight! What a place!’ I said to myself at that moment, ‘I’m going to stay here.’”

I share this brief overview of San Miguel’s charm because it illustrates how easy it is to overlook the concerns of the city and the surrounding communities. Look beyond the beautiful architecture and breathtaking views of the highlands and it becomes clear that the city has been operating for outsiders for a couple of decades. While the locals have either been forced to move to the outskirts of the city or leave the area altogether, the economy has largely catered to American and Canadian retirees who desire the amenities and culinary taste of their home countries while wanting that performative element of a more colorful culture. Of course, because of the retiree’s persistence and economic power, they are also the reason why San Miguel has the largest concentration of non-governmental organizations in Mexico, working to solve or mitigate problems related to natural preservation, animal abandonment, children’s vision, water quality, and over a hundred more issues.

Through my qualitative research in San Miguel I have gathered that the presence of retiree immigrants has morphed the social determinants of health for the community in a manner that benefits some while harming others. If you ask any key stakeholder in San Miguel what they think about retiree migration and the effects on the community, they will likely say that the retirees have been the best thing to happen to San Miguel because they have created jobs, have demanded better services, instituted a culture of volunteerism, and have helped San Miguel become one of the most desirable cities to visit in the world. These stakeholders might be government officials, real estate agents, or geriatric specialists, but they often also own other commercial businesses catered to retirees and tourists in general. If you ask people who operate outside of these circles (like a store owner in a predominantly low-income Mexican neighborhood), you will hear how difficult it is to afford living in San Miguel with stagnant wages. Those jobs that the retirees created, like housekeeping and gardening, do not pay enough to maintain families. There are families who owned homes in the center of town for generations and have been offered thousands of dollars to move elsewhere, and so they do, but they move to the outskirts of the city that may or may not have reliable municipal services. With the city’s water quality concerns of high fluoride and arsenic levels—especially in the outskirts of the city where the government must ship well water for distribution—you’re seeing teenagers experiencing early onset osteoporosis and children with developmental delays, among other health concerns.

I feel like there is more to this story than we have the capacity to capture in this exploratory project, and with only one week left in San Miguel, I am hoping there is enough time to properly share the story of the community.

-Karla

Hello everyone!

It’s been quite the adventure since my last post. I went back into the field for the questionnaire portion of our field assessment. This part of the project was more interactive, which I enjoyed. For this blog post, I wanted to share with you two main lessons I learned in the field and working with MAZA overall.

Lesson 1. Leave your expectations and fantasies out the door before you enter any new community, venture, job, anywhere.

I realized my first day in the field that my idea of what it would be was very much glorified. I had received words of advice and told what to expect from my preceptor, Nana, but that didn’t prepare me for the actual act of being in the field. For many years, before embarking on this MPH journey, I had created a fantasy of what working in the “field” in public health would be like, and this was not it. It was tedious, and I thought to myself: “maybe I’m not built for this.” But then days 2 and 3 came and I got to learn the communities I was in and it seemed a little less like work every day. I was built for this after all, and it was only when I had set aside my expectations that I began to enjoy it.

Lesson 2. Be aware of what your presence in a new community may represent, of the privilege you have to be working in that community, and its implications.

Be cautious entering into a community you’re not a part of – whether your work requires physical interaction with others or not. The first part of my field work required little interactions with community members outside of MAZA drivers, and that’s when I felt most out of place. I didn’t speak much because my work at the time didn’t require it and I didn’t speak any of the languages, and that’s what made me stick out the most. And though the community members were welcoming of our field assessment as they were familiar with the MAZA team members I was with, there were moments where I couldn’t help but feel intrusive. I had to make conscious effort of my presence in each community to gain perspective and for a more enriching experience.

For the past few weeks, I’ve been back in Accra working on the not so adventurous things like completing a literature review, analyzing data, and writing. I look forward to seeing how this project makes an impact on MAZA’s program in northern Ghana.

Thank you all for the opportunity to share my experiences with you.

Best,

Edith