2012.3.2.003_LFF_PWID SW MSM_VNM.indd - World Health ...


2012.3.2.003_LFF_PWID SW MSM_VNM.indd - World Health ...

Lessons from the FieldInnovative data tools: a suite for managingpeer outreach to key affected populations inViet NamNguyen Thien Nga, a David Jacka, a Nguyen Van Hai, b Nguyen Kieu Trinh, c Neil Boisen c and Josselyn Neukom dCorrespondences to Nguyen Thien Nga (e-mail: nguyenthie@wpro.who.int or nguyenthienga@yahoo.com).Problem: The paper tools used to monitor outreach work in all major cities in Viet Nam had substantial writing requirementsfor each contact with difficulty maintaining confidentiality.Action: This paper describes the development of a Unique Identifier Code (UIC), a field data collection notebook (databook)and a computer data entry system in Viet Nam. The databook can document 40 individual clients and has space forcommodity distribution, group contacts and needles/syringe collection for each month.Outcome: Field implementation trials of the UIC and databook have been undertaken by more than 160 peer outreachworkers to document their work with people who inject drugs (PWID) and sex workers (SW). Following an expanded trialin Hai Phong province, there have been requests for national circulation of the databook to be used by peer educatorsdocumenting outreach to PWID, SW and men who have sex with men. The standardized UIC and databook, in a variety oflocally adapted formats, have now been introduced in more than 40 of the 63 provinces in Viet Nam.Discussion: This development in Viet Nam is, to our knowledge, the first example of the combination of a confidential UICand an innovative, simple pocket-sized paper instrument with associated customized data-entry software for documentingoutreach.The HIV epidemic in Viet Nam remains in aconcentrated stage with signs that it mayhave begun to stabilize over the last two years.There has been some decrease in HIV prevalenceamong people who inject drugs (PWID) and femalesex workers (SW) in most provinces. According to theViet Nam national 2011 sentinel surveillance, HIVprevalence among PWID and SW remains high, at13.4% and 3%, respectively; Integrated Biologicaland Behavioural Surveillance 2009 data indicate thatprevalence among men who have sex with men (MSM)also remains high at 16.7%. 1 The distribution of HIVcases largely follows the distribution of these threepopulations that are heavily concentrated in urbancentres (though not absent in non-urban communities).The overall adult HIV prevalence (ages 15–49) remainedat 0.45% in 2011. 2Since 2004, projects implementing broadly similarHIV prevention peer outreach targeting PWID andSW have expanded across Viet Nam to 60 provinces forthe Needle Syringe Programme (NSP) and 63 provincesfor condom distribution. 3 These outreach activities,designed to take HIV prevention education, behaviourchange communication and HIV prevention commoditiesinto the networks of key affected populations, havefollowed similar practices under each project, often beingco-located in the same province, district or evencommune, and reaching out to the same networks. Atthe end of 2011, these peer outreach workers numberedin excess of 6200 across the 63 provinces. 3Previous paper instruments to collect client contactdata by peer outreach workers, under the variety ofprojects in Viet Nam, had problems with reliability ofdata recording, confidential monitoring of individuals andrecording of commodity distribution and other services.There exist major practical challenges to harmonizingand collecting data for various coverage indicators at theprovincial and national level while managing the datacollection burden in the field. 4To improve the collection and reporting of theseoutreach data, we document the development of a suiteaWorld Health Organization Country Office, Ha Noi, Viet Nam.bProvincial AIDS Center, Hai Duong, Viet Nam.cIndependent Consultant, Bangkok, Thailand.dPopulation Services International, Ha Noi, Viet Nam.Submitted: 27 April 2012; Published: 30 September 2012doi: 10.5365/wpsar.2012.3.2.003www.wpro.who.int/wpsar WPSAR Vol 3, No 3, 2012 | doi: 10.5365/wpsar.2012.3.2.003 1

Innovative data tools to manage peer outreach programme in Viet NamNga et al.of innovative data tools for managing peer outreach toPWID, SW and MSM in Viet Nam.CONTEXTThe tools in use for peer outreach at the beginning ofthis project in 2008 were extremely varied, comprisingpaper notebooks of A5, A4 or even larger sizes. Thedata collected were loosely standardized but oftenincluded name, address, birthdate, mobile number andsignatures for each contact where free commodities(needles/syringes, condoms) were distributed. Someprojects attempted to use code numbers or namesincluding codes for frequency of contact. Most outreachworkers had their own informal notebooks from whichthey transferred data into official project books at homeat the end of each day. These paper systems ofteninvolved serious breaches of client confidentiality andgave supervisory staff false confidence in the system’sprotection against service contact fraud and diversion ofcommodities.The data collected by outreach workers weretransferred to summary sheets at the district level, andboth the number of contacts and of individuals werecollated for provincial reports. There was no system toavoid double counting of individuals by different outreachworkers or services, or for the accurate collating of totalmonthly individuals reached. The summary outreachdata were usually collated on paper at each ProvincialAIDS Center (PAC) from the district reports, for hardcopytransmission to Central Project Management Units inHa Noi, as well as for entry into the Ministry of Healthonline HIV reporting system.ACTIONDevelopment of the Unique Identifier Code(UIC)In 2008, Population Services International (PSI) inViet Nam initiated development of a Unique IdentifierCode (UIC) for their programmes with PWID and SW inViet Nam. 5,6 PSI undertook a test of several proposedUICs on large databases of names in university lists(>4000 student names in two cities) to identify thesequence of likely initials and numbers able to begenerated from an individual’s family name, location andage that could generate a de-identifying code with lowduplication rates (less than 2.5% for example).The aim of the search for such a unique identifierwas to find a code that could be generated consistentlyby clients which would preserve their confidentialityand protect their privacy, yet which contained somedata useful for client contact analysis (such as age andgender) and which could readily be standardized acrossseveral client services. The use of UIC would enableremoval of double-counted clients and creation of moreaccurate coverage numerators.Of the codes tested by PSI, a nine-digit easily selfgeneratedcode using letters and numbers was identifiedwith a duplication rate of less than 1.5% in all cities and0.9% overall. In collaboration with several developmentpartners and the Viet Nam Authority of HIV/AIDS Controlthis code was refined to 10 digits incorporating thestandard Ministry of Health three-letter code for each ofthe 63 provinces. The UIC could be collected over timeas familiarity and trust developed; initially a nicknamewas used by the outreach worker.The final field-tested code agreed as the nationalstandard contains:(1) the first two letters of the father’s familiar orcommon name;(2) the first two letters of the mother’s familiar orcommon name;(3) the three letter code for the province of birth;(4) a code for identified gender (M = 1, F = 2); and(5) the last two digits of the year of birth.Development of the databookIn a parallel process, a standardized data collection toolfor the outreach workers (the databook) was developed.This process began with the collection and analysisof many outreach data collection tools from acrossthe country and region. It was agreed that the newtool should be pocket-sized; be able to track at least40 individual clients; require a minimum of written penstrokes to record each contact; and facilitate monitoringof outreach worker client workloads, service coverageand service intensity.The initial versions of the databook were based onsmall handbooks used in a small number of provinces2WPSAR Vol 3, No 3, 2012 | doi: 10.5365/wpsar.2012.3.2.003www.wpro.who.int/wpsar

Nga et al.Innovative data tools to manage peer outreach programme in Viet NamFigure 1. The key innovation of the databook: a pair of individual client contact pages, Viet NamDAILY CONTACTUIC(Or Code name/client nickname__________________ Birth Year____ M/F)Date Location N&S Free condom Other products* Referral EIC123456789101112131415Location type Client type Products1. Hotspot 1. IDU 1. Sterile water2. EE 2. Street-based SWs 2. Social marketing condom3. Public place 3. IDU SWs 3. N&S voucher4. Private house 4. EE-based SWs 4. Lubricant5. Fixed site 5. MSM o. Other6. Polyclinic 6. IDU MSM * Record product coded on the7. Commune o. Otherleft side of the quantity of thato. Otherproduct on the right side.From outside area Client type: _______________________New to PEDate Location N&S Free condom Other products* Referral EIC16171819202122232425262728293031ReferralsIEC topics/materials1. VCT 1. Safe injection2. Health service 2. Safe sex3. STI 3. HIV4. MMT 4. MMT5. ARV/HIV OPC o. Other6. TB7. DICo. Otherin Viet Nam by Burnet Institute, other project toolsand data sheets from several NSPs in Australia in theearly 2000s. Several refinements were field-tested inHai Duong province by PAC, but all required an excessivenumber of pen strokes to accurately record client fieldcontacts.An innovative adjustment was made to theprototypes in 2009 with the restructuring of the databookinto client pages, each divided into lines for 31 days, anda client index at the front, to quickly direct the workerto the relevant pages for known or new individuals(Figure 1). The tool also allowed for documentationof outreach activities including distribution of needles/syringes, sterile water, condoms, lubricant and other HIVprevention commodities.The databook thus evolved into an inexpensiveA6-size pocket recording book of around 45 pages permonth (Figure 2) with:(1) two pages with lists of provincial codes and theUIC structure;(2) two pages for the index of individual clients;(3) 40 daily contact pages for 40 individual clients(one client per page pair);(4) one group contact page;(5) one needle syringe collection page;(6) one daily summary page; and(7) one weekly summary page.The 40 pairs of pages devoted to documenting up to40 clients each month provide single-digit number keysfor recording common commodities and referral services.This number of client pages is adjustable according tothe average and maximum number of individual clientseach outreach worker is likely to see each month.Following extensive field testing, the innovativedatabook was introduced through a series of participatorytraining courses for health system supervisors and peeroutreach workers in five provinces.Development of data management systemThe final component of the outreach worker suite of toolswas a tailored freeware database built on the MicrosoftAccess platform by one of the authors (NB). It is fullyconsistent with the data collected in the new databookand with the health system environment and reportingstructure in Viet Nam, and was based on similar clientwww.wpro.who.int/wpsar WPSAR Vol 3, No 3, 2012 | doi: 10.5365/wpsar.2012.3.2.003 3

Innovative data tools to manage peer outreach programme in Viet NamNga et al.Figure 2. Structure of the outreach data collection book, Viet NamNeedle syringe collection Group contact Daily contact Daily summaryIndex Weekly summaryNotesUIC code key service databases developed for use in China andMyanmar. 7The new software allows bilingual entry,interpretation and export of data. It is easy-to-use andrequires minimal keystrokes. The use of UIC and thedata-entry software enables provinces and projects toenter data at a district or provincial level, to monitorfrequency of contacts with clients and to provide reportsdocumenting clients contacted each month, quarter oryear. The software is now at an advanced stage of fieldtesting in three provinces in Viet Nam.In the absence of a full computerized database atany site, accurate identification of double-counted clientscan be undertaken at the district or provincial level bycreating simple alphabetical lists of all the collected UICby month and cumulative by year.OUTCOMEFeedback from the development of UIC found it to beeasily generated and remembered by the clients, withretained confidentiality. It has been consistently providedover time in several provinces with no perception ofrelease of personal information. 8 Within the first monthof the pilot, full UIC were collected for 55% of SW and100% of PWID, with the remainder collected usingthe nickname. Because most peer outreach workersknow their clients well, the majority of UIC were easilycollected – particularly for PWID and MSM outreach. Inthe absence of a full UIC, the nickname is vital.Peer outreach workers in the pilot phase of thedatabook reported that it was easy to document clientcontacts with a minimum of pen strokes, and they coulduse nicknames or a full UIC. At the end of every day and4WPSAR Vol 3, No 3, 2012 | doi: 10.5365/wpsar.2012.3.2.003www.wpro.who.int/wpsar

Nga et al.Innovative data tools to manage peer outreach programme in Viet Namevery week, the outreach workers could easily total thecommodities they distributed and activities conducted inthe summary pages. For ease of supervision, the bookprovides at a glance an accurate measure of individualscontacted each month plus a good impression of intensityand nature of client contacts.Although the databook may seem wastefulof paper or space, the benefits of ease of use,clarity, speed and accuracy, and the avoidance of thetranscription of data burden generously outweigh thisdownside. The databook requires 12 books per yearper outreach worker and therefore the programme costis dependent on the quality of paper (12 A4 pages perbook) and the size of print runs.Post-implementation supervision of the outreachteam leaders and workers has been used to ensureconsistent recording detail and appropriate and accuraterecording of UIC and service content. The databook hasbeen readily used by low literacy peer outreach workers.It is fortunate that the ability to write letters and numbersis near universal in Viet Nam, which allows for easyrecording of codes by peer outreach workers. There maybe difficulties in less literate sub-populations.Comprehensive training modules have beendeveloped for use of UIC and the databook. All trainings,usually lasting one day, have been conducted inVietnamese with systematic use of group discussion,examples and paper exercises. The databook, in avariety of (minimally) locally adapted formats, and thestandardized UIC has now been adopted by two largedonor-funded harm reduction projects, and are nowprogressively being used by outreach workers in morethan 40 of the 63 provinces in Viet Nam.During the expanded trial in Hai Phong there wasconsiderable interest expressed by programme managersfrom other provinces for national propagation of thesetools for their ease of documenting peer outreach to PWID,SW and MSM, and the distribution of commodities.The software to manage the wealth of data collectedby the outreach workers is also slowly being rolled out,yet programme managers can, using the databook, UICand a simple spreadsheet, generate accurate clientservice data and low technology client lists to removedouble counting.DISCUSSIONThis suite of tools for effective management anddocumentation of peer outreach client contacts inViet Nam is, to our knowledge, the first exampleof the combination of confidential UIC and aninnovative, inexpensive pocket-sized paper instrumentwith associated customized data-entry software fordocumenting outreach.Initial reservations about obtaining UIC informationfrom key affected populations, limited literacy of thepeer outreach workers and coding difficulties have beenovercome by the extremely hands-on nature of the trainingprocess and the follow-up supervision that emphasizestechniques for stepwise collection of UIC over time.Collection of the complete UIC was consistently moredifficult from more mobile venue-based SW than otherclient groups.In a new country context, rigorous testing of aproposed UIC using a large, detailed database of nameswill be necessary to ensure that the duplication rate ofthe code remains low (recommended less than 5%) withthe training tailored to the local situation and literacy.Conflicts of interestsNone declared.FundingFunding for this research and field trial activities hasbeen provided from a number of organizations includingthe Swedish International Development Agency, UnitedStates President’s Fund for AIDS Relief, the UnitedKingdom Department for International Development,the Norwegian Agency for Development Cooperation,the World Bank, the Australian Agency for InternationalDevelopment and the Government of Viet Nam NationalTarget Programme for HIV.References:1. Results from the HIV/STI Integrated Biological and BehavioralSurveillance in Vietnam – Round II, 2009. Ha Noi, NationalInstitute of Hygiene and Epidemiology, 2012 [in press].2. Viet Nam AIDS Response Progress Report 2012. Ha Noi,National Committee for AIDS, Drugs and Prostitution Preventionand Control, 2012 (http://www.unaids.org/en/dataanalysis/www.wpro.who.int/wpsar WPSAR Vol 3, No 3, 2012 | doi: 10.5365/wpsar.2012.3.2.003 5

Innovative data tools to manage peer outreach programme in Viet NamNga et al.knowyourresponse/countryprogressreports/2012countries/ce_VN_Narrative_Report.pdf, accessed on 25 August 2012).3. Unpublished D28 reports. Vietnam Authority for HIV/AIDS Control,2012.4. Sharma M, Burrows D, Bluthenthal RN. Improving coverage andscale-up of HIV prevention, treatment and care for injecting drugusers: moving the agenda forward. The International Journalon Drug Policy, 2008, 19 (Suppl 1):1–4. doi:10.1016/j.drugpo.2007.12.008 pmid:182624035. Unique Identifier Code - DDRP Best Practice Collection. Almaty,Alliance for Open Society International, 2007 (http://www.aidsprojects.com/wp-content/themes/apmg-1.0.1/documents/UIC_Eng.pdf, accessed August 2012)6. Gray R, Hoffman L. Tracking coverage on the silk road: time toturn theory into practice. The International Journal on Drug Policy,2008, 19 Suppl 1;15–24. doi:10.1016/j.drugpo.2007.12.011pmid:182618957. Baldwin S, Boisen N, Power R. Managing information: usingsystematic data collection to estimate process and impactindicators related to harm reduction services in Myanmar. TheInternational Journal on Drug Policy, 2008, 19 Suppl 1;74–79.doi:10.1016/j.drugpo.2007.12.005 pmid:182812058. Measurable results: targeting sex workers in Vietnam. Washington,Population Services International, 2010 (http://www.psi.org/sites/default/files/Vietnamsw_idusFactsheet.pdf, accessed on26 April 2012) and other unpublished meeting reports over2010.6WPSAR Vol 3, No 3, 2012 | doi: 10.5365/wpsar.2012.3.2.003www.wpro.who.int/wpsar

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