Reports from Botswana

Hey everyone!

We reach safely home one month ago, and I have had plenty of time to reflect on my experiences. My time in these two African countries, with highest AIDS prevalence rates, has furthered my interest in Bioengineering and Global Health needs and I can’t wait to pursue this in future graduate studies! Visiting the children at Motswedi and Cheshire opened my eyes to how close Best Buddies is to my heart, and I’m grateful that I got to work with these children. I have no doubt that the doctors, nurses, patients, students, and staffs of these facilities have helped me grow more than I have helped them in the fast 8 weeks. I acknowledge that it is impossible to chronicle every single lesson learned, but an overlying theme I observed is a true sense of passion.

The children at Cheshire taught me to be passionate about education. Despite any physical disabilities, their eagerness to perfect their handwriting and learn how to read their names shows me that if the passion is there, then you will make it a point to overcome any obstacles. Their sincere curiosity to learn is so different than what I have ever observed in children at that age.

The children at Teen Club or at the Clinic recognize that having an HIV positive status does not define their very essence. Just like other teenagers, these teenagers are also artists, baseball players, and determined to study well and become successful nurses, teachers, physicians, and engineers. Like the kids at Cheshire, they do not let the possession of this serious illness (or disability) bury their wishes or interests. They truly value every second of their life so they make the most of their available resources to pursue their dreams.

I would like to thank the doctors at Baylor for their encouragement and guidance (esp. Drs. Ryan, Parth, and Michelle). The trip to Swaziland would not have been possible without the help of Dr. Richard from BIPAI Swaziland, Dr. Ryan, and of course, BTB (Yvette, Drs. RRK and Oden)! Thank you so much for your support in arranging this trip because it was the icing on the cake for the internship experience; we were able to successfully carry out the project we worked on since January!

I also want to extend a huge thanks to the Cheshire Foundation.  The staff was very supportive and welcoming with sincere smiles on their faces always. Many thanks for arranging transport as well because none of the amazing experiences and memories I now have would be possible if I could not even get to Cheshire! I also want to thank Ms. Cindy for allowing me to help her out in the classroom for a few weeks. Cheshire does wonderful work there in building these special, bright, and talented children. I already miss the bubbly smiles these kids carried on their faces and hope to visit them in the coming years.

Overall, I am happy to be home and am truly grateful for this amazing opportunity from God. I will carry these lessons throughout my studies and endeavors. I wanted to end with a picture of the Cheshire students(along with Ms. Cindy and House Mothers) as they were practically climbing on top of me during my last day. I hope it makes you smile as big as I do when I look at it.

Sorry this is so late…

I would like to use this post as my last post and sum up this experience for me personally. To say that my time here was amazing does not even hint at all that I have encountered, learned and lived. This opportunity was more than I ever imagined and I am so grateful to have been chosen among the 10 BTB Student Interns. Being in the two countries hit the hardest by HIV in the whole world has further motivated me to continue pursing my future career goals in science and medicine. Watching all of the children in the clinic was an experience that I will never forget. Most of them are so young that they have not been fully disclosed to their status, nor do they know exactly why they come to visit the doctor so often. They are always so happy and excited to see you and it’s very humbling.

The research center that Harvard School of Public Health built in partnership with the Botswana Ministry of Health is a place truly dedicated to research, education, and diagnostic procedures. I am very lucky to have been able to spend some time there as well.

All of the people, everywhere we went, were more than nice and willing to help us. That is something that I will definitely miss. Botswana is a country that is on its way to greatness and what the country is doing to fight HIV/AIDS is a testament to that. I loved being here and, if given the opportunity, would not hesitate to come here again. I’m glad that we were able to be of help here. I came here eager to get to work and after 8 weeks I am exhausted. But that’s a good thing because that means that I did all that I could do. I just hope that we were able to help out the clinic in some way.

Now on our way back home, I am anxious to see Houston again. I am anxious to eat home cooked meals. I am anxious to see me family. A part of me, though, wishes that I could’ve spent more time exploring all that Botswana has to offer and to meet and build closer relationships with more people. I will never forget this experience and I thank everyone that helped us get there including BTB, Rice Bioengineering, our advisors (Dr. Oden and Dr. RRK), all of the clinic staff at Baylor-Botswana and Baylor Swaziland, Dr. R. Phelps, Dr. Kline, family and friends, and my two project partners without whom AMS would not have been all that it is. A consider it a true blessing to have had this opportunity and I’m sure I will be able to apply lessons learned from my experience to my future endeavors.

Kristen R.

I mentioned in an earlier post that I would devote an exhaustive post to our Adherence project, so here it is! Forgive me if I have missed out on anything, so please see Kristen’s earlier posts as well.

Importance of adherence: Now adherence is defined as the extent to which a patient follows their prescribed regimen. Barriers to maintaining good adherence include difficult ARV side effects, no tolerance to the medications, and unavailability of money or transport to maintain the supply of medications.  Inadequate food or water supply, no social support or means of refrigeration for certain medicines and complex timing schedules for administering ARV’s also act as a hindrance to maintaining a good adherence. Poor adherence can lead to progression of the illness, the development of resistance to the medications, increased healthcare costs, and even death. As such, it is important to check a patient’s adherence to their medication at each clinic visit to emphasize to the patient the importance of good adherence and to let the physician know if there are any medical concerns. For example, for a patient with poor adherence, a physician may recommend a viral load and CD4 test to assess whether or not the patient needs a change in drug regimen or whether the patient should be moved to the next line of ARV treatment (of which there are ONLY three lines).

 Current methodology: In Botswana, adherence is measured in each examining room by a nurse. For pill medications, they make a manual count of the actual returned and compare this to the expected return to calculate a percent adherence. The nurse sits alongside the doctor in the examining room and reads out the calculated adherence for each medication to the doctor to be recorded on the Medical chart for the patient. For liquid medications, the nurse rinses out a tall graduated cylinder, labeled for the specific medication, and then pours the remaining liquid medication to determine the milliliters of liquid remaining. Finally, the nurse pours the medication back into the bottle (to return to the patient) and makes a note of the remaining volume for the pharmacy to dispense more. Finally, the cylinder is rinsed again. Since they use large graduated cylinder, there is a greater chance of losing liquids due to their highly viscous nature (i.e. taller cylinder means more surface area for the medication to get stuck to and then more difficult to remove). Moreover, using these graduated cylinders also increases the risk of spilling the liquid medications because it involves pouring medicine from bottle to cylinder and back to the bottle. It is also time-consuming as it involves extra steps of rinsing the cylinders and taking off the bottles caps and popping off the nozzles.

Now in Swaziland, there is an individual adherence room where all patient medications pass through first, before seeing the doctor. Basically, there is one nurse who does the pill counting and assesses the volume of liquid medication remaining. The number of actual pills returned and actual volume of liquid medicine remaining is then recorded on an Adherence Record Sheet and these numbers are also entered by another nurse onto the Electronic Medical Record system (EMR). This Adherence Record Sheet is attached to the patients file and then the patient returns to the waiting room to be called on to see the physician. Within EMR though, adherence is calculated using the following inputs: medication name, date of last clinic visit (entered using a drop-down calendar), doses per day, expected return volume (pill count), actual returned volume (or pill count). Using these inputs, EMR calculates the percent adherence for each medication. After discussing any issues of poor adherence with the patient’s family, the nurse can make notes within EMR that will be visible to the physician as they make notes during the examination. The Clinic here uses a series of smaller medicine measuring cups to determine the volume of liquid medication remaining and as such they lose a smaller volume of medication when measuring adherence each time. Spillage and time are still a problem though. Relying on EMR to calculate adherence is also a downside because EMR fails frequently and the internet connection downstairs is not very stable.

 The Adherence Monitoring System: Interns from last year the Lesotho and Botswana clinic both mentioned that calculating adherence, though necessary, was quite tedious and time-consuming. Thus, our aim was to create a device for the Baylor International Pediatric AIDS Initiative (BIPAI) Clinics that measures adherence to anti-retroviral regimens in a time-efficient manner.

The system consists of two components: 1 Acculab VIC-303 scale and 1 Microsoft Excel computer program. The scale can measure up to 300 grams with 0.001g readability. After calibrating the scale, the average weight of each pill medication, of 1cc of liquid medication, and of the empty liquid medication bottles, must be catalogued into an Excel spreadsheet before using AMS.

The inputs required for the Adherence % Excel program include the present date (automatically updated), date of last clinic visit, medication name, bottle type, initial dosage, doses per day, and the remaining mass reading from the scale. Outputs include the number of days between visits, the recommended dose, the pill count (or volume) remaining, actual dose taken, percent adherence, and the number of pills (or mLs) missing or extra.  We think this program will be especially useful in the event the electronic record system fails. The other Excel program takes the input of medication name, bottle type, and remaining mass to output the number of pills (or  volume of liquid medication) remaining. This program can be used in conjunction with the electronic system to calculate adherence percentage.

To measure adherence for pill medications using AMS, the pills should be transferred into a standard tared container and the remaining mass can be entered into the Excel program. Most patients come in with less than 6 pills so in these instances it is faster for the nurse to just open the bottle and count the number of pills remaining. We decided against cataloguing each pill bottle because this means extra foil, cotton balls, or any other extraneous items would have to first be removed, before placing the bottle on the scale. If these items are not removed, then this can add more variability to the already present variance in empty bottle weights. For example, we found that for one medication, the variance in bottle weights was off by as much as 4 grams, which can throw the remaining pill count off by as much as [4grams/0.15grams (or the weight of the smallest pill)]. For this reason, we decided to just use a standard tared container to weight the mass of remaining pills alone.

To measure adherence for liquid medications using AMS, the bottle cap along with any nozzles should first be removed before placing the bottle containing the liquid medication onto the scale. This mass reading can then be entered into the Excel program to obtain the volume of liquid remaining and percent adherence. For liquid bottles, we wanted to avoid using graduated cylinders and taking out the liquid medication for any reason. Bottle weight variance of empty liquid medication bottles was still a concern but we decided the best way to overcome this was to weigh as many empty bottles as we can, so that the average mass entered into the Excel program is a good representation of the mass distribution.

 Swaziland Results and Stats: As Kristen explained earlier, “the centralized location of measuring adherence in Swaziland makes it much easier to use our device because we only need one device (vs. one for every examining room in the Baylor clinic) and there is an available computer for us to put the program on (vs. in Botswana the doctor is on the only available computer in the room).” 

Once we reach Swaziland, we spent one morning to observe how things ran in the Adherence Room. Soon afterwards, we decided to go ahead and show the nurses how AMS worked. They were very eager and excited about the prospect of not having to move liquids around anymore. Anyhow, for the few liquid medications we tried, AMS seemed to be off by as much as 3 - 20ml. This worried the nurses because for some medications, such as Kaletra, a reading off by 3 milliliters could cause the calculated adherence to be off by 3 doses. The nurses also seemed somewhat weary about using the scale and were quite concerned about what to do in the event of a malfunction. The fact that manufacturers frequently change bottles for liquid medication was also a concern.

We came in the next day and decided to basically re-catalogue all the medications used. We noticed that many of the bottles for both pill and liquid medications were different than those medicines used in Botswana, probably because they came from a different manufacturer. As we were cataloguing, we observed that the weight of 1cc of liquid medication or of the average pill was definitely different than that weight recorded for Botswana; and this could explain the reason why AMS seemed to be 3mls off on the previous day. After some exhaustive cataloguing and more testing, we were very relieved to find out that AMS was returning pill counts to the precise pill (i.e. AMS gives 5.04 when there are 5 pills left OR AMS gives 3.992 when there are 4 pills left). For medications where there were half pills, AMS returned 46.45 pills remaining when there were actually 46.5 pills; thus, AMS is also sensitive to the presence of half pills. A paired t-test results showed there was no significant difference for the remaining pill counts obtained through the manual method or AMS.

Now for liquid medications, AMS also proved promising again as we only observed a deviation between 0.1 to 2.0ml in calculating the volume of liquid medication remaining. A paired t-test results showed there was no significant difference in calculating the volume of liquid medication remaining (p > 0.05) however there WAS a significant difference in the time required to determine the actual volume remaining (p < 0.05). The average time for the manual methods was ~52 seconds while with AMS, this average was much faster at only ~24 seconds. Although AMS was quite accurate in providing the volume of liquid remaining, we recommended that for volumes below 25 milliliters or for medications with doses as low as 1milliliter, it was best to use the manual method since a gap of 2mls with AMS can lead to an adherence percentage off by as much as 2 doses. The effect of 2 doses missing or extra on the calculated adherence percentage depends on a number of factors including the number of days between visits and the initial dosage given. As Kristen mentioned, for the few examples in which we did adjust the volume remaining by 2mls, the adherence percentage only changed by 1%.

Moreover, the nurses in Swaziland were pleased with AMS’s performance last Friday so they are testing it out, alongside their manual method during this work week. Their feedback is quite important to us and we will let you know what they say!

Hello, again from Botswana!

It’s definitely time to update you guys on some of the other going on’s over here Kemly and I are really excited about all everything that we are involved in at the clinic. We told you guys about our chart review projects for Dr. Parth and for Dr. Michelle. Both have gone well and we are excited at the progress that we have made. I think in total we have reviewed 900+ patient charts, definitely an accomplishment that we are proud of.

In addition to that we have been involved with the Teen Club at the clinic. Teen Club, again, is a group of adolescent patients from the clinic and every fourth Saturday of the month we do activities with them. We have a range of about 70-80 kids that come on these Saturdays. This past Saturday was the June meeting and we took the kids to the Botswana museum. The museum is actually really close, just a couple of streets over from the clinic and the hospital. We split up the kids into groups of three and gave them all worksheets to fill out while touring the museum. The kids with the most answers right would get a prize when we returned to the clinic. When we got back we had lunch with the kids and we were done at around 1:30P. It was a lot of fun and we are sad that we couldn’t have had more Teen Club experiences.

We also have been working on personal, self-identified projects while we have been here. Kemly has been telling you guys about the stuff she is doing at the disability centers and I, as well, have been working on a couple of other projects. I am now spending some time over at the Botswana-Harvard School of Public Health Collaborative Research Center. It’s actually on the same campus as the government hospital, Princess Marina, and the clinic, so it’s very convenient for me to get to. Over there I have been introduced to a number of diagnostic laboratory techniques including DNA PCR to detect HIV infection in infants. I love it over there and cannot wait to learn about the other parts of the lab. I have also be looking at some of the data that we have been collecting on the patients at the clinic and I want to eventually put together an overview/fact sheet about the treatments and demographic backgrounds of the children at the clinic. This plan may not come to fruition though because the completeness of the records that I have access to are not that great, but I will see what kind of information I will be able to come up with.

We have also made some progress with AMS. After a few weeks of going back and forth and getting the right green lights, we have gotten the okay to travel to the Baylor clinic in Swaziland to try and implement there. Our host doctor taking care of us in Botswana actually is new to the Botswana clinic as well, having come from Swaziland himself. He had mentioned the idea of going there once he learned that we were having somewhat of a difficult time implementing our device in the Botswana clinic. In Swaziland they have an actual Adherence Room. This is the room where all of the medications are measured and counted. This happens before the patients go in to see the doctors, and all of the adherences are calculated in this one room. This is much different from in Botswana where all of the patient adherences are done by nurses in each examining room while the patient is in with the doctor. The centralized location of measuring adherence in Swaziland makes it much easier to use our device because we only need one (versus one for every examining room in the Baylor clinic) and there is an available computer for us to put the program on (versus in Botswana the doctor is on the only available computer in the room). So after we contacted the clinic in Swaziland and found that they were open to us coming with our device, we booked flights and packed up to come.

We just arrived in Swaziland last night and we are loving it as well. It is very different from Botswana, particularly with respect to the landscape. Swaziland is very mountainous and has lots and lots of greenery and trees. Botswana is desert, so the land is very flat and there is not very much vegetation. Anyway, Swaziland is very beautiful.

When we got to the clinic this morning everyone was very welcoming and we quickly got acquainted with the main adherence lady. She is very nice and very open to see our idea of measuring medications and counting pills faster. We observed what goes on in the adherence room for the major part of this morning and the biggest thing that we’ve noticed is that the clinic uses a patient database that actually measures the adherence for them. So we just finished up modifying our program to simply calculate the amount of pill or liquid medication left in the bottle (by the same relative mass algorithm), which is the number that they calculate by measuring the medication, to plug into the database. We will start cataloguing the bottles they use here and present everything we’ve done to the adherence head towards the end of the day. If everything goes well we will try it out during the next couple of days and see how that turns out. Kemly and I are really excited. We definitely see how our device would save them lots of time. It’s such a great opportunity to have been able to come out here and try it out and we hope that our device will be able to help them. We will definitely update you guys on how that all goes Until then…

Kristen R.

Ever since my tour 2 weeks ago, I have been visiting Cheshire for few days a week. I am just trying to provide a helping hand but always jotting down potential project ideas, whether engineering, educational, or recreational to do with the children. Hopefully, they will be of use for future students in the BTB program and I will see what I can accomplish while here as well. By the way, the Cheshire staff has been generous enough to give me the position as Teacher’s Assistant to the Special Education teacher in the Residential Classroom for the rest of my stay in Gaborone! Here is a summary of what I did on two of my visits during this past week (Monday and Friday):

I visited Cheshire Foundation on Monday afternoon and got to help the volunteer teacher from the UK, Connie, with the activity she had prepared for a small group of children. She paired me with Patricia (who is beautiful by the way!) so I helped her learn about the different ‘fruits’, or ‘Maungo’ in Setswana. There were pictures of pineapples, tomatoes, cherries, bananas and Portia repeated the name of each fruit after me. I really enjoyed spending this time with the kiddos and think Ms. Connie is doing an amazing service by donating her time and resources to the Foundation.

Another interesting fact Ms. Connie pointed out though, was that most of these children are from the rural villages; so the fruits or vegetables they are familiar with include sugarcane, oranges, papaya, and mangoes. As such, they had never seen or tasted any of the fruits which we were naming. Ms. Connie has promised to bring a few cherries, tomatoes, bananas, and pineapples so that the children can taste, touch, and see these new fruits. I can’t wait to see the looks on their faces when they taste these new fruits!

As soon as I got to where the kids were assembled on Friday morning, I flashed a big smile at all of them and saw that many still remembered me from my previous visits that week. Patricia used her right arm to prop up her left hand onto the arm rest of her chair and she slowly lifted her left hand and waved at me! JAnna looked backwards to where I was standing and in her own words said, “Hey!” Angel looked over and gave me a big smile too. Other kids from the Wednesday class had huge smiles on their faces too…but nowhere as big as the one on my face.

Once, I got there I realized there were no classes, so I shadowed the therapists in the physiotherapy department instead. On Fridays, the foundation has an outpatient clinic for members of the community to come for free physical therapy treatment. They treat both men and women, of all ages (from 2 yrs to well over 60).

In the first half of session, I observed physical therapy for 3 of the Cheshire children. Each child has a varying degree of physical disability and there were three physical therapists working with the three children. It was amazing to see how excited the children were about being held up by the PT!

For one child, they put extra weights on both of his fraile and skinny legs. Then they propped him on a mattress and helped him do sit-ups and knee bends. Eventually, the PT stood him straight up and let him lean on the walker (it had a board similar to the feeding board of a high-chair so that he could lean his upper body on it). From there, I watched in wonder as this little boy struggled to lift each foot, one before another. Every now and then, he would cross the feet over from exhaustion. I was simply amazed to watch this boy bring himself to travel at least 9 feet across the PT room floor!

Oprah did an equally amazing job too. She was able to pull her own weight out of her wheelchair to hold onto the parallel bars while standing up. From there, she went back and forth across the bars at least TWICE. She crossed each time, with a huge smile on her face, as the PT was saying, “Oprah, you can’t chase me!” Oprah was definitely moving quickly though across those bars and turning at each end was the only thing slowing her down.

By the way all of the children were wheeled into the physical therapy room by their classmate Cage. It was so adorable to see Cage pushing his classmate in a wheelchair that is as tall as him!

What is most remarkable about all these children though is that they never give up. You can really see in their eyes that they would give anything just to stand up straight on their own two legs. I have never seen any group of 7 year olds man their wheelchairs like experts as these children do. Everyday, these kids are truly champions as they do what seems to take the most effort: they try. These kids do not sit back in their chairs and expect to be babied all day long. They want to move around on their own, feed, and clothe themselves. Though they are so young, they do not allow themselves to easily give up. I can’t capture the perseverance (despite any pain) that I see in their face as they struggle to pick up each foot and walk. In the classroom, you can also see that these children are truly curious to learn. They come join the circle with their friends because they are curious to learn what new colors or shapes Ms. Cindy will teach them today, not because they want a candy, toy, or sticker reward. The huge grin on Ms. Cindy’s face and their friend’s applause is more than plenty of a reward for their small accomplishments.

I must also mention though how amazing the physical therapists are as well. They keep providing encouragement and praise to the children for each one of their efforts. As Cindy was trying to hold her head up in front of the mirror, the PT kept saying, “Look up! look up Cindy! Look up at your beautiful eyes!” Moreover, I feel Cheshire has provided a loving environment for these children with the needed motivation and support which will allow them to flourish into their full physical, intellectual, social, and spiritual potentials.

*Note: I have not used the real names of the children*

Sorry this post is a bit late but here is a summary of my notes from a meeting with Billy, the Director of Cheshire Foundation of Botswana – Mogoditshane Rehabilitation Center, Ivy(Training Coordinator), Mbasa (project Coord.) and Sandy (Head Physical Therapist – Outreach Coord.):

 Mogoditshane provides services for children 5- 15 years of age, including accommodation for 35 children and a daycare program for 25 kids. They also provide physiotherapy, occupational therapy, special education classes, and community based rehabilitation (CBR) as well. On Tuesdays and Fridays, there is a small outpatient program where they provide basic medical care at no cost for other members in the community.  CBR provides at home therapy for individuals who are disabled by accidents, HIV/AIDS, or since birth, for over 22 villages. They currently serve 355 people but have helped as many as 2000 individuals. Sandy is the physical therapist who heads Outreach programs and was the one to actually give me a tour of the Center.  

They look for the different potentials of individuals with disabilities and then place them in suitable industry jobs through the job placement program. The performance and productivity of these adults is assessed by the employer and the Foundation. However, their success rate after placing these adults has only been 30% because many are forced to resign from their workplace. Why? Because the heads of these jobs clearly need an “attitude change” – Mr. Billy

Cheshire tries to achieve this attitude change through training and sensitization programs where they give an orientation to the members of the medical and general community so they can better understand the issues associated with rehabilitation. 600 to 1000 students per year attend these orientation meetings.

 Through their inclusive Education program, the foundation increases community awareness about the need to integrate children with disabilities and mainstream students within the school system. “Isolation is not the solution,” said Billy, because these children do not deserve ‘sublevel’ education. In fact, some of them are more intelligent than us and their only difficulty may lie then in their access to education (e.g. may be wheel-chair bound but intelligent with no cognitive disabilities).  

Sandy took me to their physiotherapy room where he showed me the active and passive room. In the passive room, there is a therapeutic ultrasound machine, muscle stimulator, and even a hydro collator. Next, he took me to the residential classroom, daycare, and speech therapist office where I got to meet the special education teachers, staff, and the AMAZING kids!

I also got a chance to sit down and talk to Mr. McKinsey, the head of the occupational therapy department. He told me how their main concern is the function of the individual and how to make the person better with whatever abilities they may have despite physical or intellectual impairments. So they make assistive devices for the children so that they can support the weight of their own body in their wheelchairs while keeping their limbs free for use. Many of these devices are made with improvisation or making use of whatever materials are available due to resource constraints. They make corner seats here too (just like in Motswedi)!

Anyhow, after my tour, I decided to send some time with the children. The special education teacher was nice enough to let me read a story to a group of six children, “Tom Thumb.” I read each page in English first, then the teacher translated into Setswana, and then we passed the book around to each child so they could see the picture on the page. By the end of the story, two more kids from the other group had joined us!

So I mentioned few posts back how I heard how about a school for disabled children in Mochudi, as one of the patients we saw with Dr. Michelle 2 weeks ago, was actually a new student to the school. Anyhow, so after some more asking around, I found out the name of this school and made a visit this past Tuesday. Dr.Michelle dropped me off at Motswedi Rehabilitation Center and the first thing she says is, “A wheelchair ramp! We don’t get to see much of those around here!”

I talked to the Director, Nurse Grace, about the school and here is a brief overview. Motswedi Rehabilitation Center opened its doors in 1993 for services, under the umbrella of the Botswana Council for Disabled. The Center provides many services for adults and children with disabilities including community based rehabilitation programs, physiotherapy, day care services, group therapy, stimulation classes, occupational skills training in horticulture, sewing, basic home economics, and carpentry.

Once I told Grace I was from the U.S., she began telling me how grateful she was to the U.S. Army, as they donated two pianos, gym equipment, along with chairs and desks for the classrooms. These donated goods mean a lot to this center especially considering at times they have to use recycled materials to make a walker for the children (i.e. paper Mache walker). Either way, I feel the Center has been especially successful as they have had two children compete and win in the Special Olympics. One child won a bronze in Shanghai and another child won a gold medal when the Games were held in Dublin, Ireland!

Mr.Faquero (a Coordinator) was then nice enough to give me a tour of the Center. We started off with the Stimulation Classroom where children ranging from ages 5 to 8 are taught life skills such as self-grooming and the basics of speech and reading. All the classrooms have three teachers of which at least one is a youngster (~20 yrs old) who has a physical or intellectual disability himself. He or she acts as a teacher’s assistant and guide the children in their school activities as well. I definitely think this is a unique way of teaching that I have not observed in the United States.

In the next classroom, the Reception and Stimulation Classroom, there are the most severely disabled children who cannot do things on their own and thus, they need individual attention. The children are stimulated through drawing, using play dough, music, and art activities. Yes, that’s right: music! When I walked in, the Special Education teacher, Trust, was singing, “Making Melodies in my Heart” with the children; this is a song that one of the children in Teen Club sang during their last gathering.

Next, I got to see the physiotherapy center where assessment, referral, and treatment occurs for individuals referred to the Center by CBR, hospital, clinic, or caregivers themselves. I noticed a treadmill which was donated, but has never been used because it doesn’t work. In addition to few exercise bikes, there was an empty swimming pool that had been drained for the past three years due to some malfunction, so the physiotherapy department could no longer provide hydrotherapy to the children. There was also one computer in the physiotherapy office…but it wasn’t working either.

Mr. Faquero took me to the meal hall and kitchen where few adolescents with disabilities were learning basic home economic skills. They stand side by side the chef and helping to prepare breakfast, lunch, and dinner. The center not only provides services for the 89 children that reside there, but also for children from nearby villages who cannot afford breakfast. He also showed me what corner seat was…basically it looks like a specialized high-chair for disabled children who cannot support the weight of their own head. The chair has a ‘corner’ backboard that prevents the child’s head from rocking back and forth.

In the handicraft classroom, there were teenagers learning how to sow simple door mats, baskets, place mats, etc. There were about 14 students in this classroom including the one boy that I had seen at the hospital with Dr. Michelle two weeks ago. He waved at me with a big smile so I am assuming he recognized me!

In the carpentry shop, fourteen boys and one girl were busily making a bed frame for an order of beds placed few weeks prior. The two teachers showed me the ‘lab practicals’ the students have to complete including making simple window frames or other designs based off of a pencil sketch. She also showed me their storeroom where there were many tables, shelves, chairs, and even a rocking horse.

The dorms are very simple with a bed, dresser, and nightstand for each child, but this is the amazing part: each bed, dresser, and nightstand was made by the child himself, in the carpentry workshop as their beginning projects. The children even tie-dyed the pieces of cloth that now hang as their curtains. THIS IS AMAZING and completely blows my mind away.

Finally, I got to meet the 8 horticulture students who were cultivating mangoes, papaya, broccoli, garlic, beet root, onions, etc.. The students in the carpentry and horticulture classes are all taught basic marketing skills so that they can earn a small stipend for themselves. Each student starts off with 50 Pula and they are given a bank account at the local post office. Grace says that the income for three of the students has grown to as much as 300 Pula! This reminds me of a small microfinance venture which I think is a great idea for empowering individuals with disabilities. Even a small source of income based on their sales can provide a greater degree of independence for these individuals within their community.

Anyhow, I think the Center does a great job of helping these children and adults in spite of whatever resource constraints may exist. The masterpieces in the carpentry shop, beautiful handicrafts, and array of vegetables in the garden, are all evidence of the true talent within these children. The Motto at Motswedi is “Give me a Chance to Try” and I have no doubt that Motswedi has given these children a chance at living independent lives while carrying huge smiles on their faces.

Painting on Motswedi Wall:Kids of all Cultures Holding Hands - even children in wheelchairs

A Corner Seat

Rocking Horse created by one of the talented Motswedi Children

The Horticulture Garden

Hey Everyone!

Sorry it’s been so long since I’ve posted. Everything is going great! We are already a month through, and it doesn’t seem like we’ve been here that long. So far in the clinic we’ve been really busy helping the docs with their chart reviews (see Kemly’s earlier post for the description of what we’re exactly gathering). Cumulatively we have reviewed over 700 charts, so needless to say we aren’t bored! We’re having a great time doing that.

As far as AMS is concerned, as we get permission to continue doing certain aspects of our study, we do them. So far, we are pretty sure the our device works for measuring pill medications. The only thing is that the patients aren’t given that many pills extra so the amount that they bring back is very small. Thus, it takes little to no time to count the pills and to the math. Decreasing the amount of time it takes to do this by 50% may not be as feasible as we imagined seeing as though the process is already done relatively fast. With liquids we ran into a minor problem. We didn’t realize the amount of variance that accompanied each type of medication bottle. With the same exact bottles we found that there was as much as 4 grams difference between the two. At first we catalogued the medication bottles by weighing the entire bottle, and subtracting from it the weight of the liquid inside (based on how much we catalogued one cc (or one mL) of medication to weight). We are afraid that this may also not be accurate enough, so we discussed measuring the bottles another way. This includes cleaning out old medicine bottles and rinsing them, letting them dry, and taking an average weight of at least three bottles. We will let you guys know how well this works out as well. For now, we are also awaiting word to try and implement our device at the Baylor clinic in Swaziland. The way they run their adherence checks is much more similar to what we had envisioned when we created our device and may be of more help there. Here, at the Baylor clinic in Botswana, the implementation of a device like ours may not necessarily make the current situation any better. We will keep you posted on any new developments with our device.

In addition to these things, Kemly and I have both been exploring ways to create a project of our own. These ideas are still very much under development, so as they become more concrete we will let you guys in on what they are. Thanks so much for keeping up with us!

Kristen R. 

We worked on 3 different projects for the Clinic this week, including:

1.) Chart Review for Dr. Parth. You may be wondering what we are looking for in all these charts…well Dr.Parth is interested in studying the correlation between ARV regimens and the onset of thrombocytopenia, anemia, and neutropenia in Pediatric HIV Treatment. So this means, going through the charts of all the patients at the PIDC (Pediatric Infectious Disease Clinic) at the COE, and looking for factors such as the ANC (absolute neutrophil count), MCV (Mean corpuscular volume), Hb level, CD4, and viral load present as the patient progresses through the prescribed regimen. We also make note of whether the patient received iron, a blood transfusion, platelets, or of any changes in therapy as well. The weight of the patient during the course of visits is also recorded so that we can test whether malnutrition is a confounding factor in the loss of red blood cells, neutrophils, or thrombocytes, while on HAART (or highly-active antiretroviral treatment). Kristen and I have completed well over 400 charts and I’ll definitely share any results as soon as this project comes along.

2.) We also began another chart review for PAC doctor, Dr. Michelle. Her focus is on PMTCT (Prevention of Mother to Child Transmission) and we have been going through charts of Clinic patients started on HAART in 2006 to 2008, in particular. For these children, we are making note of whether the mother received PMTCT and whether the child has been able to achieve viral suppression on the same 1^st line HAART regimen. We are also making note of the age at which HAART is initiated and the progression of the illness (i.e. CD4, VL, CD4 clinical category) so we can make assess whether or not the observed trend is independent or dependent of these variables.   

3.) Dr. Ryan also asked us to help complete a Bereavement Survey for the Botswana Baylor COE that was to be returned to the administration back home. In short, the survey questions the types of support groups currently available at the COE and their activities (whether groups for teens, children, caregivers, or the clinic staff itself). It questions the need for a possible Bereavement training or educational program for clinic staff/physicians who work with grieving patients or for the patients themselves. And why would this even be a need? Well, many of the COE patients do experience grief due to loss of a close relative, and this can directly impact the patients’ self-esteem, medication adherence, and thus affect progression of the illness as well.

Adherence Project: I plan to share a detailed discussion of the project objective and study results objective in a future post, so I will not go into too many specifics now but to say that we are in the middle of our efficacy study (to see if the device calculates the adherence percentage correctly) and results look promising so far. We had a few bumps when it came to measuring adherence for pills but quickly realized the solution. Just by ‘eyeballing’ the numbers(will share statistical test results in future post), I can safely say the device works for measuring adherence to pill medications, but we are still working on the liquids.

Personal Project Update: I got a chance to talk to Mary (Nurse in charge of Teen Club) about my personal project idea and I’ll just say that this talk was encouraging and went over well. I am kind of keeping this idea a surprise until I am for sure it will go through…but I’ll give you guys a hint: think Mochudi and Kemly loves Best Buddies and Teen Club!

Teen Club is amazing!!!!!!!!!!!!! The age group ranges from 13 to 18 and there were probably 80 teens present. It was cool to see some of the kids I had seen around the Clinic again (even a 17yr old, whose adherence I measured on the previous Friday was there) and most of the PAC doctors were present as well. While they were assembled in the classroom upstairs and waiting for the speaker to arrive, a Peace Corp volunteer (Ed) invited kids to tell a joke or sing a song. It was so awesome to see that each child would come to the front of the classroom and begin a Gospel Christian Song, which soon the rest of the kids would join in clapping and singing along. It was something really special to be apart of.

Eventually the admissions representative from the University of Botswana (UB) came and she talked to the children about the different degree programs they offered and of the requirements to gain entry into each program. Next, the kids were divided into three groups and we walked towards UB. UB students gave us a tour of the University which is massive and beautiful by the way. Kristen and I plan to visit again so I’ll post pictures then. Anyhow I think the teens enjoyed the outing from the smiles on their faces and lunch time was fun too.

Not only does Teen Club share educational opportunities or teach the importance of medication adherence or safe sex to these afflicted children, but I feel it functions more as a club for these unique kids to make friends – and we all know friends are the one thing we can’t live without. Imagine what life would be like without someone to share your experiences, whether happy or sad. Helping to build friendships is very important to me, which makes Best Buddies and Teen Club amazing organizations! The next Teen Club gathering will be at the end of this month and I am really looking forward to meeting with this talented and bright group of teenagers, again.