I have been struggling with an eating disorder for the past few years. I am afraid to eat and afraid I will gain weight. The fear is unjustified as I was never overweight. I have weighed the same since I was 12 years old, and I am currently nearing my 25th birthday. Yet, when I see my reflection, I see somebody who is much larger than reality.
I told my therapist that I thought I was fat. She said it was 'body dysmorphia'.
She explained this as a mental health condition where a person is apprehensive about their appearance and suggested I visit a nutritionist. She also told me that this condition was associated with other anxiety disorders and eating disorders. I did not understand what she was saying as I was in denial; I had a problem, to begin with. I wanted a solution without having to address my issues.
Upon visiting my nutritionist, he conducted an in-body scan and told me my body weight was dangerously low.
I disagreed with him.
I felt he was speaking about a different person than the person I saw in the mirror. I felt like the elephant in the room- both literally and figuratively. He then made the simple but revolutionary suggestion to keep a food diary to track what I was eating.
This was a clever way for my nutritionist and me to be on the same page. By recording all my meals, drinks, and snacks, I was able to see what I was eating versus what I was supposed to be eating. Keeping a meal diary was a powerful and non-invasive way for my nutritionist to walk in my shoes for a specific time and understand my eating (and thinking) habits.
No other methodology would have allowed my nutritionist to capture so much contextual and behavioural information on my eating patterns other than a daily detailed food diary.
However, by using a paper and pen, I often forgot (or intentionally did not enter my food entries) as I felt guilty reading what I had eaten or that I had eaten at all.
I also did not have the visual flexibility to express myself through using photos, videos, voice recordings, and screen recordings. The usage of multiple media sources would have allowed my nutritionist to observe my behaviour in real-time and gain a holistic view of my physical and emotional needs.
I confessed to my therapist my deliberate dishonesty in completing the physical food diary and why I had been reluctant to participate in the exercise. My therapist then suggested to my nutritionist and me to transition to a mobile diary study.
Whilst I used a physical diary (paper and pen), a mobile diary study app would have helped my nutritionist and me reach a common ground (and to be on the same page) sooner rather than later.
As a millennial, I wanted to feel like journaling was as easy as Tweeting or posting a picture on Instagram. But at the same time, I wanted to know that the information I provided in a digital diary would be as safe and private as it would have been as my handwritten diary locked in my bedroom cabinet.
Further, a digital food diary study platform with push notifications would have served as a constant reminder to log in my food entries as I constantly check my phone. It would have also made the task of writing a food diary less momentous by transforming my journaling into micro-journaling by allowing me to enter one bite at a time rather than the whole day's worth of meals at once.
Mainly, the digital food diary could help collect the evidence that I was not the elephant in the room, but rather that the elephant in the room was my denied eating disorder.
The elephant in the room
The World Health Organization (WHO) defines maternal health as the health of women during pregnancy, childbirth and the postpartum period.
Worldwide, roughly 800 women die from preventable conditions associated with pregnancy and childbirth every day¹.
A significant amount of these deaths occur in low-resource settings as a result of complications that include high blood pressure, infection, severe bleeding, and issues during birth.
The risk of a woman in a low and middle-income country dying from a maternal-related cause is about 33 times higher in comparison to a woman in a developed nation. Maternal mortality is a health indicator that exposes vast disparities between high and low-income populations.
Today a range of proven and cost-effective solutions are available to prevent the majority of conditions causing maternal and neonatal deaths.
These vary from antibiotics for infections, and sterile blades to cut umbilical cords; as well as point of care diagnostics like test blood glucose, syphilis, and HIV testing for early diagnosis and management of risk factors² ³.
With an array of cost-effective measures, it's visible that the barrier to expanding the access and quality of maternal health in the developing world lies in the availability of frontline health workers that identify risk cases and deliver treatment.
In Ghana, there are 350 deaths per 100,000 deliveries (WHO, 2010), this ranks Ghana 31st in the World Maternal Mortality Index. The chance of a mother losing her life due to pregnancy is 58 times higher in Ghana than in the Netherlands.
The scarcity of skilled gynecologists and midwives in Ghana is a limitation to antenatal care coverage and quality. Not identifying risk factors among patients is a possibility since there is no nation-wide operational model in place. Without a functional system, the gynecologists are reluctant to shift tasks to nurses and even midwives thus limiting their capacity to perform specialist tasks.
The shortage of well-trained health workers is a global issue, but developing countries feel this crisis most acutely. The lack of health workers is the primary limitation in scaling access to healthcare in the low and middle-income countries.
Task shifting is the process of moving or delegating specific tasks to less specialized health workers. By restructuring the workflow in this form, task shifting makes better use of the available human resources. For instance, when physicians are in low numbers, a trained nurse can often prescribe and dispense antiretroviral therapy or medication to treat pain and fever or a community health worker can provide basic life support.
Further, community health workers can potentially deliver a wide range of services, such as evaluating risk factors and referral for treatment; therefore relieving the requirement for qualified nurses. Preparing a new community health worker requires between one week and 12 months depending on the skills needed. This is considerably less than the three years, on average, that is demanded to train a fully qualified nurse.
This process increases the pool of human resource rapidly. Also, it has the benefit of strengthening the link between the health facility and the population and produces new jobs and commercial opportunities⁴.
West African Lead, ALMA Youth Advisory Council/Zero Malaria Champion
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Most pregnancies are uncomplicated and do not need gynecologist attention. Only a small amount of pregnancies develop complications and risks. Not identifying and treating these issues lead to high morbidity and maternal mortality rates.
Shifting maternal healthcare from gynecologists to midwives and nurses results as a direct way of reducing pressure on the scarce specialist resources. This enables the specialist to apply his expertise and skills to patients that need it most.
PharmAccess Foundation, with the support of the Dutch Ministry of Foreign Affairs, has launched Woman360: a franchise network of private clinics and hospitals which seek to scale the access and quality of antenatal care in Ghana⁵.
Well-trained midwives working from spoke clinics are providing quality and affordable maternal healthcare to pregnant women in coordination with hub hospitals. The midwives work in coordination with the hub hospital and can refer risk cases for a gynecologist's evaluation and treatment⁶.
For task shifting to work, two things must occur. First, lesser skilled health workers have to identify risk cases adequately. Second, there has to be a higher level available for referral.
In the Woman360 clinics, the midwives maintain the medical history of the patients on paper records for local regulatory needs. Without a shared electronic health record between the clinics and the hospitals, coordination and monitoring would be a manual and slow task. Also, there is the chance that risk cases are not correctly identified and therefore not referred to a specialist.
Here is where Teamscope has entered to fill in this gap and allow the hub and clinics to work in collaboration. The midwives use an electronic case report form (eCRF) on the Teamscope mobile app to capture critical clinical parameters of each patient. The app supports the midwives work by displaying visual alerts when a patient has any of the risk factors.
When a patient requires a referral, the gynecologist and his assistant receive a notification. This allows them to be coordinated with the clinics and review the patient’s medical data before she arrives.
Teamscope's web application provides the managing team with real-time reporting on the number of pregnant women seen treated per clinic, as well as statistical analysis on any of the clinical parameters collected at the clinics.
In the last 20 years, the world's maternal death ratio has seen a 44 percent drop – a tremendous achievement. But despite these advances, every day roughly 800 women still lose their lives from complications linked to pregnancy or childbirth. This is approximately one woman every two minutes.
Also, for every woman who dies, 20 or 30 encounter infections, disabilities, and injuries. The majority of these fatalities and conditions are entirely preventable.
Task shifting result to be a well-fit way to expand the reach of antenatal health care, especially in African countries where there is a scarcity of gynecologists.
The widespread consensus is that task shifting is an effectual way to scale risk prevention and the provision of essential treatments. However, proper management, support, supervision distinguish the initiatives that are successful.
Electronic Data Capture (EDC) software such as Teamscope serve as an aid for health workers when providing care to patients, a monitoring tool for specialists to review risk cases and a reporting platform for stakeholders to track the reach and effectiveness of these interventions.
Dear Digital Diary,
I realized that there is an unquestionable comfort in being misunderstood. For to be understood, one must peel off all the emotional layers and be exposed.
This requires both vulnerability and strength. I guess by using a physical diary (a paper and a pen), I never felt like what I was saying was analyzed or judged. But I also never thought I was understood.
Paper does not talk back.Using a daily digital diary has required emotional strength. It has required the need to trust and the need to provide information to be helped and understood.
Using a daily diary has needed less time and effort than a physical diary as I am prompted to interact through mobile notifications. I also no longer relay information from memory, but rather the medical or personal insights I enter are real-time behaviours and experiences.
The interaction is more organic. I also must confess this technology has allowed me to see patterns in my behaviour that I would have otherwise never noticed. I trust that the data I enter is safe as it is password protected. I also trust that I am safe because my doctor and nutritionist can view my records in real-time.
Also, with the data entered being more objective and diverse through pictures and voice recordings, my treatment plan has been better suited to my needs.
No more elephants in this room