Translating Traditional Publicity into Community Outreach

Today is day four of the Journey of Hope. So far we have performed awareness talks in four towns. In two of these towns, Gweta and Nata, our talks were done in the town’s kgotla. The kgotla is a gathering place where the chief meets with the town residents to disseminate information. Before departing on the journey midwives from a clinic in Gaborone translated breast cancer awareness pamphlets into Setswana so that all audience members had equal access to this information.

The first talk in Maun had a small turn out even though it was suggested that the turnout in Maun would be the highest of any town. Thus, many of us were disappointed and presumed that the remaining talks would be attended by even fewer community members. It was a bit disheartening to see the limitations of traditional marketing techniques (such as posters in a gas stations), which served to us as another reminder of the importance of flexibility in community work. Knowing the current marketing for the program was not working, we took the initiative to promote the awareness talks in the three proceeding towns: Gweta, Nata, and Francistown. Prior to each talk a group of us, including two members of the Journey of Hope that speak Setswana walked into the community, handed out pamphlets, and encouraged both women and men to attend. The attendance increased and we were able to have great discussions in the smaller towns of Gweta and Nata. The women in Nata were so engaged with the presentation that they ended up requesting clinical breast exams, resulting in over 50 women getting screened after the talk. The simple act of going out and meeting people reflects what we have come to know as an important aspect of Botswana culture-greeting, establishing a relationship and putting a face to a name will open doors for incredible opportunities to learn and grow.

Bridget, Randi & Grace

Pabalelong: Home of Love and Care

Growing old and being ill can be difficult in any country, but in Botswana the challenges are often compounded by lack of facilities to deal with terminally ill and disabled patients. Botswana is unique in the fact that most of the elders in the community are cared for in the homes of their children – there are no retirement homes or nursing homes here. This culture of home-based care for the elderly and terminally ill places a high burden on families that want to care for those loved ones but may be ill-equipped to provide adequate medical care. The families may have limited time, financial resources, and access to medical knowledge, not to mention the fact that they themselves may be in poor health and unable to perform some of the physical activities needed to give sufficient care.

This week we had a chance to work at Pabalelong Hospice: Home of Love and Care, a home for those in ill health and unable to be cared for in their own homes. Opened in 2010, Pabelelong is distinct in that it provides care not only to the elderly and terminally ill, but also to those incapacitated by chronic conditions such as TB, HIV and stroke. The hospice has 12 beds, and is surrounded by a wraparound porch, where patients enjoy sitting in the sun and socializing with visitors. Although the hospice sees many patients pass away during their stays, as opposed to the Western conception of “hospice” they also care for patients who are not terminally ill, but simply need extra care that their family is no longer able to provide.

During our time at Pabalelong we had the privilege of meeting a man by the name of Mr. Andrew – a 70 year old retired farmer who had suffered a stroke, leaving him paralyzed, and unable to communicate. Mr. Andrew was well cared for by staff, and well loved. Mr. Andrew refused to eat or drink at lunch on our first day with him. The nurses were concerned about him, and continued to offer food for the remainder of the afternoon. Near the end of the afternoon, the nurses investigated possible causes for his lack of interest in food or drink and found that his urinary catheter had become infected and was leaking. We assisted the nurses in removing the catheter, cleaning the patient, redressing his wounds, and attempting to provide him some measure of comfort. Despite his inability to talk, it was obvious that Mr. Andrew was in pain and suffering from a fever – a situation that we as nursing students were eager to fix immediately. However, there were no available antibiotics in the hospice, and none could be obtained until the next morning when the village clinic opened. Also, the strongest painkiller available to help Mr. Andrew weather the pain was Tylenol which we had brought with us to the clinic.

You might be asking yourself how this could be possible – a severe urinary tract infection, and no antibiotics or painkillers available? Almost incomprehensible to the American nursing student who is accustomed to stocked supplies of antibiotics from ampicllin to zythromycin, and an entire Pyxis of pain killers on hand for hospice care. While Botswana provides free or low cost drugs to citizens, the center receives no funds to purchase any medical supplies or drugs that are not directly prescribed for a patient. Patients must be seen at a government clinic or hospital to get their medications free. Therefore, if the hospice has an independent physician come in and consult, the prescriptions they write must be bought with hospice funds. In addition, the hospice receives no funds to purchase supplies such as bandages, gloves, IV solutions, or adult diapers. This places the hospice in a precarious situation – both in terms of provision of supplies and care. For example, the hospice is chronically short staffed, as they can only afford to pay two retired nurses, and cannot offer a salary attractive to anyone young enough to work in a hospital.

Our time in Pabalelong touched us, and truly reminded us of why we decided to pursue a career in nursing. Mr. Andrew’s struggle is one that is faced by many patients here, making Pabalelong an important source of community care and support.

Erin, Linden, Grace & Danielle

Flexibility in Cross Cultural Nursing

Recently several of us were placed at the Old Naledi community clinic to work alongside UB students and nurses in their community health rotations. Old Naledi has been blogged about previously, when we spent time in a children’s program, and houses some of the lowest income residents in Gabarone. We spent our clinical day here with eight UB students, one of whom was already a diploma RN, and another who was a diploma NP (?). Many diploma-trained nursing professionals opt to return to nursing school for their nursing degrees. Our objective for clinical was to join the Old Naledi Home Based Care (HBC) RN in her home visits in the community. As mentioned in a previous blogs (Flying Missions), HBC involves meeting patients in their homes for any kind of assistance, which may include hygiene, housekeeping, transportation, groceries, and more. HBC provided by the community clinic, however, is different from Flying Missions in that a trained RN from Old Naledi Clinic makes the patient visits, rather than trained volunteers or caregivers. According to the center for HBC in Gaborone, the Old Naledi RN may be capable of seeing eight patients per day, depending on the acuity or level of need. These HBC RNs help improve patient healthcare in Botswana by providing care for patients who cannot stay in the hospital, do not have sufficient social support, or for other reasons. In the past, HBC was only provided to HIV-positive patients, but has now been expanded to all patients in need.

As we have learned, flexibility is important in the Botswana community, and our agenda for the Old Naledi clinic day changed. Instead, we spent time in the clinic itself observing consultations, injections and wound care. We also spent time at the center for HBC in Gaborone, learning about program standards of care. We also went to Princess Marina Hospital (PMH) for a tour of the wards. The various wards at PMH are very different from the floors at the hospitals in Philadelphia. Each ward was separated into a different building and contained 4-6 open areas with several patient beds in each. Wards were distinctly male or female and surgical or medical and there was also a pediatric ward, delivery ward, and NICU. The patients used communal bathrooms and were lucky to have a curtain to pull around their bed. Most wards did not have hand sanitizer dispensers on the walls and in the pediatric ward several of the sinks were in disrepair.

Our visit to PMH was eye opening, and highlighted many of the things that we may take for granted in the United States. Although the nurses we met lacked supplies we deem essential to daily nursing practice, the true spirit of nursing was visible and trans-cultural. We were welcomed with open arms as we moved throughout the hospital, nurses were able to attend to patients on a deeper level since the usual reliance on technology to monitor patient status is unavailable and patient care is truly the priority with the environment and materials available. Many American healthcare workers we have met ask us incredulously whether we can believe some of the disparities we have observed. The answer is yes-but perhaps we can all learn from the reminder we have gotten from our observations of Botswana nurses and value the cross-cultural ability of a nurse to recognize and respond to a patients’ physical, emotional or spiritual needs to maximize quality of life at unique moments in time.

Posted by Trudy Kao, Bridget Sullivan, Randi O’Neill, & Megan Rogers

Journey of Hope

Breast cancer is a leading killer of women worldwide. In the United States, we all know someone who has been personally affected by breast cancer and research shows that one in eight women will develop breast cancer in their lifetime. Since our early teens doctors have encouraged us to perform monthly self-breast exams, obtain yearly mammograms when we are older, and seek our primary care providers’ guidance if we have concerns. In short we have been armed with knowledge in the fight against breast cancer and awareness in the U.S. is at an all-time high.

However, here in Botswana breast cancer still touches many lives but is often lost in the battle against HIV and TB. Statistics are hard to pin down, and many women are not aware of the risks. Screening is practically non-existent because of a lack of awareness and resources. For example, in the capital city of Gaborone there are only 2 mammography machines. Therefore, if a woman is diagnosed with breast cancer it is often not until the disease has reached a more advanced stage and is difficult to treat effectively.

For the next week we have the opportunity to work with a group of women committed to raising breast cancer awareness throughout Botswana. The Journey of Hope grew from the desire to advocate on behalf of women and to provide to care for those who otherwise could not afford it. The organization is trying to raise $200,000 for women who are unable to afford breast cancer treatment and reconstruction and seeks to educate the public on early breast cancer detection and breast self-examination. To this end, a team of women will be riding 12 Pink Vespa scooters over 1,000K from Maun to Gaborone starting in Maun on August 22 to coincide with a "Sisters for Blisters" fund/awareness raising walk for breast cancer.

We are honored to be included in this effort and will be accompanying them on their ride to provide informational talks at each village stop. We will teach local women about risk factors, self-exam techniques, signs and symptoms, and what to do if they have concerns. Megan and Danielle were thrilled to be on the national radio this afternoon to help spread the message and answer questions. Although we would love to keep you updated, we may be in remote areas without internet access and will post as we are able and share our stories when we return. Our posse of pink Vespas will be giving talks in the following towns:

· Saturday August 21st in Maun
· Sunday August 22nd Blisters for Sisters Charity Walk in Maun
· Monday August 23rd in Gweta and Nata
· Tuesday August 24th in Francistown
· Wednesday August 25th in Serowe
· Friday August 27th returning to Gaborone

For more information, see the American Cancer Society (http://www.cancer.org/Cancer/BreastCancer/index) and follow us on Facebook (http://www.facebook.com/event.php?eid=125310307496277&ref=mf).

Posted by Penn Nurses in Botswana

Cervical Cancer in Botswana

As we have noted in previous postings, Botswana has a high HIV prevalence rate, especially among women of childbearing age. Today, we went to a reproductive health clinic that serves this population at a local hospital. Women from within and outside of Gaborone come to this clinic for services which are not as readily available elsewhere. Most of the women we saw ranged from 20 to 40 years of age, and were visiting either for a follow-up from a previous treatment, were referred to the clinic due to an abnormal Pap smear, or were there to receive treatment. The clinic usually sees around 10 women each day; however, some women cancel their appointments due to issues such as transportation costs.

The most common cancer among women in Botswana is cervical cancer. Unlike in the U.S. where cervical cancer is regularly screened for with Pap smears and easily treated in early stages, in Botswana women are more likely to die from cervical cancer. Women with both HIV and cervical cancer tend to have more severe cases of cervical cancer than those without HIV. While Pap smears are available for free with government funding, women may not obtain them because of fears about pelvic exams or having a result that requires treatment. Additionally, treatments such as LEEP procedures, colposcopies, and biopsies are more difficult to obtain here with long waiting lists for appointments, a lack of providers trained in these procedures, and delayed results from out-sourced laboratories.

While we were at the clinic, we had the opportunity to observe treatments in the examination room. In comparison to other clinics in Gaborone, this particular clinic appeared to have more access to medical supplies, such as gloves and hand sanitizer. They even have access to an autoclave for sterilizing equipment. The healthcare providers seemed cognizant of maintaining sanitization procedures, and attempted to be thorough with cleaning the equipment between each patient. However, with our frame of reference in the U.S., we were struck by the differences in sanitization procedures. For instance, we emphasize disposing single-use supplies. This clinic would reuse items such as sheets with each patient as opposed to laundering them with every use. We felt uncomfortable observing their cleaning procedures coming from U.S. healthcare institutions. Where we would have changed the sheets, they attempted to clean them with disinfectant spray, leaving visible stains. Perhaps with better funding and access to supplies, this clinic would have the ability to improve their level of sanitation.

In terms of patient privacy, we also experienced a cultural difference. Whereas in the U.S. where we have government policies guaranteeing patient privacy and a standard of practice to not interrupt during patient examinations, such expectations do not seem to be as prevalent here. For example, during pelvic exams the door was frequently opened without warning and staff entered and exited freely, such that the woman was sometimes exposed. To us this felt like a major privacy violation and would make the patient feel very uncomfortable, but the patients did not seem bothered or surprised. We thought this was an important learning experience since we need to respect their cultural norms.

Posted by Trudy Kao and Erin Schelar

Otsogile jang? --How are you?

Mmopane, a small village approximately 15km outside of Gaborone, is located in the Kweneng District of Botswana and boasts a population of around 5,000. The town of Mmopane is sprawling and without clear boundaries - there are no streets signs apparent and as visitors it was hard to find our way to the location of the Mmopane Day Care Center. The day care was held inside one of the community churches where the chairs were pushed aside for the children’s play space. The building appeared old, with no heat and sparse lighting. The temperature that day was about 50 degrees and most children wore hats and gloves while inside. The lack of heat and electricity was not uncommon in other houses in the area as well. Houses in the area were in various stages of construction. Some consisted of cinderblock walls and tin roofs, some were huts, and others were constructed of scrap metal and wood. Various “tuck” shops, or small stands that sell fruit, candies, and phone cards, lined street corners and we passed several bars while driving. The village does not have a fire department but does have a police department, a health outpost with four nurses, a primary school, ten churches both traditional and Christian based, and three grocery stores. Transport buses called “combis” travel to the village from Gaborone during the winter months, but during summer months transportation is hard to find due to the dirt roads that are difficult to maneuver after heavy rains. There were no parks or recreation areas apparent in the village and it was unclear whether or not there were any public works facilities. Many residents of Mmopane struggle to find and maintain employment and often rely heavily on monetary support from the Botswana government.

The day care center itself serves about 35 children five days a week. These children range in age from three to six and most are orphans or vulnerable children. The center originally grew out of a HIV support group that met weekly so the vast majority of children have parents who are either living with, or have passed away from HIV. We performed health assessments on these children one morning early this week and were amazed at how quietly and respectfully the children sat as they waited in line for their assessments. It was a refreshing change from our previous experiences at day care centers we have spent time in at home-there was no crying, fighting, or complaining while they waited for over two hours, even as others ate their breakfast after completing their assessments. The majority of children presented with common colds, some skin irritations, and swollen lymph nodes but for the most part they were healthy and happy. We feel that it was a mutually beneficial exchange in that we were able to hone our assessment skills and simultaneously helped to identify health concerns in the children. Although issues were identified in a handful of the children it is unclear whether or not they will have the opportunity to receive follow-up care – a situation that is frustrating for any health practitioner, and that we have struggled with since arriving in Botswana. After assessing one child with an extensive fungal rash on his face and arms we determined that we will return with antifungal cream so that the teachers at the day care can treat this child on an ongoing basis. While this is a small action, it is one way that we can contribute to a positive health outcome.

All in all we felt extremely comfortable and accepted in this community. The children and teachers were extremely welcoming and even sang and danced for us after all assessments were finished. One desire that the teachers voiced was the need for a first aid kit which we plan to provide for them with money that we raised in the United States. See video!!

Posted by: Danielle Altares and Randi O'Neill

Serenity in Mmopane

“God, grant me the serenity
To accept the things I cannot change;
Courage to change the things I can;
And wisdom to know the difference”

We kept in mind this prayer as four of us drove to the rural village of Mmopane, 15 km outside of Gaborone. We teamed up with Flying Missions in conjunction with Tirisanyo Catholic Commission to connect with home health care volunteers in the community. The day was spent walking along winding dirt paths leading to the local health post and visiting among residents of Mmopane. The village has one Christian church, one health post and one primary school. The home health care volunteers were originally from Mmopane earn approximately one US dollar each day for their services. We were extremely fortunate to be paired with these women; their wisdom and knowledge of the cultural norms enabled us to use our clinical knowledge and feel welcomed into patients’ homes. We would not have had the impact we did in the community if it were not for these important liaisons.

While we worked with the Tirisanyo organization last week, today was our first day doing home visits and we did not know what to expect. We were all excited for the experience but also felt apprehensive. The four of us split into pairs and each went with two homecare volunteers to their visits. The cultural importance of introductions was again highlighted and we all found ourselves following the volunteers’ lead. Following our visits, the four of us sat down and spoke about our thoughts and concluded that our emotional responses to this experience was one of the more significant aspects of this clinical site.

One of the most significant feelings was fear of contracting TB. All four of us visited at least one patient who had been diagnosed with TB and while on treatment, adherence to medication could always be an issue. Within a new culture, we struggled with whether to be compliant with American standards of care such as whether to wear gloves or put on a respirator mask.

Another concern of ours was the patient’s ability to commute to the clinic...while physically close to the community, sandy paths and mobility assistive devices prohibit some of these patients from visiting the clinic. Megan and Linden visited an elderly woman who had a stroke two years ago and found her sitting in her own soil on a thin mattress. The woman’s entire right side had been paralyzed from her stroke so she was not able to move independently however she also did not have any disposable underwear to aid with her incontinence. Although we arranged for an ambulance to bring her to the clinic, we had to leave Mmopane without knowing the outcome.

Meeting patients in healthcare settings that are controlled through family decisions as opposed to settings that are controlled by health standards, we struggled with a conflict between two worlds. Normal recommendations such as appropriate nutrition guidelines are based on assumptions that patients have what we interpret as basic necessities (a place to cook, food to eat, access to medical supplies). We were forced to change our recommendations and rely on our observational skills. For instance, when asking patients about their appetite, we had to look around the home and observe whether there was any food in the home to begin with.

No matter how much or how little we helped the patients or their families, they were all so gracious for our presence and any assistance or assessment skills we could offer. All in all, we were grateful for the opportunity to leave feeling as though we learned far more than what we gave.

Posted By: Linden Spital, Megan Rogers, Bridget Sullivan and Grace Oppenheim.