More specifically to medical missions is the pharmacy component .... population; 2) Training health workers; 3) rebuilding the health infrastructure; ..... Preparing the labels: The pictogram labels were prepared using online software available .... Drug industry aid for Haiti earthquake relief efforts. in-âPharma technologist.com,.
Lessons learned from The Pictogram Labeling Project in Haiti (PLPH)
Meghana V. Aruru, Ph.D., M.B.A., B. Pharm. Roosevelt University J. Warren Salmon, Ph.D. University of Illinois at Chicago Submitted to: The Business and Health Administration Association (BHAA) Annual Conference 2014
* Our special thanks to colleagues, Sue Walsh, G.W. Douglas, and Leslie Cordes on the Little-‐by-‐Little Medical Mission, without whom this research would not be possible. “Human misery is so appalling nowadays that if we allowed ourselves to dwell on it we should only add imaginary miseries of our own to the real miseries of others without doing them any good.” -GEORGE BERNARD SHAW, letter to Siegfried Trebitsch, Marc, 1940.
ABSTRACT Background: On January 12, 2010, Haiti's catastrophic earthquake killed more than 222,570 citizens with over 1.3 million currently homeless. As a poor developing nation with scarce health resources, Haiti suffers from more than just natural disasters and imported cholera. Disease eradication efforts have been directed at multiple conditions, some for prevention and a few with successes. The Ministry of Health and Population (MOH) requires significant capacity building to commandeer such public health activities and primary care upgrading, plus coordination fitted to the urgently needed interventions. Prior to the earthquake, 46% of Haitians did not have access to healthcare, either due to cost, or lack of care in their area. Since then, Haiti has been inundated by international aid, United Nations assistance forces, and a slew of NGOs working on relief to one of the poorest nations in the world. There is sadly a dearth of literature on continuity-‐of-‐care once medical mission trips leave, or on the follow-‐up of patients who were critically ill and treated by providers during such trips. More specifically to medical missions is the pharmacy component that renders necessary pharmaceutical treatments. Since providing prescriptions is the major therapeutic intervention for patients' ailments, there is a crucial role for professional pharmacy in medical missions. In Haiti, the extent of literacy amongst patients is questionable, with most speaking in Creole and claiming to be able to read and write. However, in the absence of governmental statistics on educational completion and considering Haiti’s past struggles with its education system, it appears more than likely that most of the population would be semi-‐literate at best. Therefore, this project focused on improving the medication labels to incorporate the uncertain literacy though inclusion of pictograms as a means to explain medication use and instructions to patients. Methods: Pictogram labels were developed and distributed for 20% of the formulary. Focus groups were conducted by patients to understand their acceptance of the newer pictogram labels. Results: More than 70% of the patients preferred the newer labels and those who preferred the older, written ones stated their preference due to being familiar with the older labels. Discussion: This pharmacy intervention and subsequent study for the Little-‐By-‐ Little teams at Mountain Top Ministries intended to aid patient medication usage in a small way and to demonstrate the crucial role of pharmacy in medical missions across the globe.
INTRODUCTION One of the poorest nations in the Western hemisphere, Haiti was struck by an earthquake with a magnitude of 7.0 on the Richter scale in January 2010, which destroyed most of its capital of Port Au Prince and surrounding areas. Over 222,000 Haitians were killed, 300,000 were injured, and more than one million persons were displaced, to live without shelter on the tropical island subject to heavy rains, hurricanes, and more environmental decay. The earthquake was estimated to cost the nation $7.8 billion. 1-‐5 International relief was forthcoming from many nations and disparate NGO agencies, but under the circumstances of horrible disaster, much was untimely and inadequate for the massive damage, and the overall effort seemed uncoordinated. Haiti had no adequate medical infrastructure and the weak system that existed was essentially crushed. This forced reliance on international aid and medical missions even more with benefits from governmental coordination more necessary. More than 80% of the Haiti population lives under the poverty line, with 54% living in abject poverty-‐-‐worse since the quake. Since two-‐fifths of all Haitians depend upon the agricultural sector (with small-‐scale farming comprising a majority of the work), the nation remains vulnerable to deforestation and other natural disasters. Approximately 95% of the population is of West African descent with mulattoes and whites comprising around 5%; the official spoken languages are Creole and French. The state religion is Roman Catholicism. As of July 2013, Haiti’s population was
estimated at approximately 9 million. Most residents are between ages 0-‐54 years, with the 55 and over group comprising 9% of the overall population. One-‐third are under 15. The Haitian population is growing at a rate of 0.99% with 23.3-‐ births/1000 population. Life expectancy at birth is merely 62.85 years with females expected to live slightly longer to 64.25 years as compared to males at 61.46 years. An estimated 120,000 Haitians are currently living with HIV/AIDS, much more undetected. The literacy rate stands at less than 50% among both males and females. 5-‐7 As a poor developing nation with scarce health resources, Haiti suffers from more than just natural disasters and imported cholera. Disease eradication efforts have been directed at multiple conditions, some for prevention and a few with successes. "Remarkable progress" has been made at eliminating lymphatic filariasis (elephantiasis, a disabling and costly tropical disease). 8 This required a dosing of two medicines every year, which also protects against intestinal worms.9 Influenza annually strikes poor impoverished peoples hard, more variable in timing and severity.10 Developmental aid addressed children immunizations against, not just cholera, but other childhood illnesses as well. Emergency relief from a few Pharmaceutical firms' donations ($17 million in 2010) needed coordination 11-‐12 but by 2012 a concerted campaign by GAVI Alliance, PAHO, UNICEF, among others aimed at reaching an estimated 95% child vaccination coverage.
Sustained effective programming and continued outside assistance are necessary but insufficient without a well-‐functioning health care system, which is coming along with clinic and hospital construction and efforts by the government apparatus, along with the populace, for public health. The challenges of STIs (including HIV/AIDS) and increasing unwanted pregnancies-‐-‐both surging post-‐calamities-‐-‐remain problematic. National immunization days seem to work in many countries so it has been tried in Haiti for reaching targeted groups on polio and other childhood diseases. The Ministry of Health and Population (MOH) requires significant capacity building to commandeer such public health activities and primary care upgrading, plus coordination fitted to the urgently needed interventions. If the goal of sustainable development is to be achieved by building capabilities of local groups and coordinating them, Haiti must focus on: 1) Raising the health literacy of the population; 2) Training health workers; 3) rebuilding the health infrastructure; 4) Strengthening the MOH with its partnerships, and 5) Reconstructing a system of clinics and hospitals. In our world of notable climate changes, amidst seriously increasing natural disasters, international crisis response must become a science. Whitworth of the Welcome Trust (Whitworth, 2013, p.9) writes:
“It is imperative to offer shelter, nutrition, sanitation, and medical care to
those suddenly bereft of it. Without aid, humanitarian crises would cause
still greater suffering. Yet admiration for the agencies that deliver relief
should not blind us to the need to ensure that it is well delivered.
Humanitarian responses must be founded on good evidence. The evidence
base, unfortunately, is weak.”
On January 12, 2010, Haiti's catastrophic earthquake killed more than 222,570 citizens with over 1.3 million currently homeless.
13
Earthquakes, typhoons,
tsunamis, volcano eruptions, and other natural disasters remain beyond human control, but all have severe impacts on the nation's total environment. However, Haiti was significantly affected much more so than other nations in the Western hemisphere would have been-‐-‐due to its concentrated urban poverty, governmental unpreparedness, and poor medical infrastructure. For those outside of the destruction, it is difficult to grasp the enormity of severe food, clean water, and shelter shortages. The massive injury exceeded what the limited health facilities-‐-‐ which had not tumbled-‐-‐could begin to handle. Waterways that people were dependent upon for drinking, bathing and clothes washing were polluted, facilitating disease spread. The breakdown of ordinary sanitation became very problematic, even being nowhere ideal beforehand. After disasters, infections of many kinds run rampant. International relief for such large numbers in need becomes patchwork. Desperation for food and clean water, and overcoming added environmental hazards, accompanies the widespread post-‐traumatic stress disorder (PTSD) of the people. Experts in emergency planning and management have pondered over the Haiti situation with some openly criticizing the governance (or the lack thereof) in terms of bringing quicker and steady relief to the unfortunate
survivors. Before the quake, the Ministry of Health (MOH) was decentralized to departments for health planning within a framework of national priorities. Successes back then came with aid from international sources for some forward rebuilding post-‐calamities of earthquake, hurricane, and cholera. 14 The international response was mostly for short-‐term relief, focusing on food, water, medicines, and health care, but slowly helping to strengthen structures for the MOH and its leadership. Needless to say, a disaster of this magnitude (with the following hurricane and UN-‐inspired cholera epidemic) would stress any government and its people to a major degree. Longer-‐term development must meet the challenges of greater resources and determination.
Haitian history in context:
Haiti gained its independence from France in 1804, being the richest colony of the French empire at the time due to a combination of cheap land, labor and European capital. However, soon after the revolutionary war that led to its independence, Haiti’s natural commodities – sugar, cotton and banana plantations were destroyed by adverse weather setbacks and poor management, thereby sapping the country’s economy and causing a chronic lack of funds for education. By 1825, as the slavery abolition movement spread, citizens in the United States and Europe decided to recognize Haiti’s independence on the condition that the country would assume all losses suffered by the colonialists and French citizens as a result of the revolution. France demanded that the Haitian government pay them 150 million French francs
as a condition to recognize the new nation. As a result, the Haitian government had to borrow the money from foreign banks, taking 80 years and all of the country’s economic production to pay off the debt. 14 Money that could have been used to develop infrastructure and build roads within the country was instead sent to France. Post-‐independence, Haiti lost its colonialists–-‐meaning teachers, clergy and other valuable professional personnel. In the absence of a good education system and boycott from the international community, Haiti fell further behind. Poverty and destitution are a downward spiral in the developing world, and Haiti was no exception to the rule. The country attracted pirates, shady merchants, and fortune seekers resulting in repeated insurrections, military coups and, social, economic and political instability. 14 NGO nation: By 1971, Haiti was becoming increasingly dependent upon outside NGOs to feed its population and provide health and humanitarian services. Beginning then, the international community shifted policy to providing funding to NGOs as opposed to direct funding to the country in an effort to combat corruption. In the political realm, the Duvalier regimes in Haiti had unsuccessfully tried to reverse this policy. By 1984, the American Voluntary Association estimated the presence of 200-‐300 NGOs in Haiti. By 2010, an estimated record number of over 10,000 NGOs were working in Haiti with only 500 registered officially with the government. 15
Since the quake, it should not be surprising to note the number of NGOs considerably increasing. The issue of NGO involvement (and non-‐governance) is crucial in the context of Haiti’s societal and political development and its current state of affairs. The biggest donor in Haiti is the United States Agency for International Development (USAID), an intergovernmental agency involved in every sector of the Haiti government. USAID sponsors several NGOs working there to provide services on behalf of the Haitian government. USAID had moved to performance-‐based contracting 16 for providing basic services (such as MCH and immunizations) with incentives for meeting targets. It may be noteworthy that the Haitian government has little or no oversight over NGOs. While this may in itself be less problematic (considering the failed governance from past years), caution must be exercised in terms of extending assistance that may lead to a paternalistic attitude toward the country’s residents to perpetuate dependences. One of the biggest challenges lately lies in oversight and coordination of the myriad NGOs working in Haiti. 17 A lack of cooperation and collaboration ensures that during natural disasters emergency management plans usually fail, or at least come up quite short. In fact, consider the situation in Haiti post-‐earthquake: Its only international airport was damaged preventing larger landings, more than a million Haitians were living in makeshift shelters under deplorable conditions longer than 6 months after the quake with no plans to move them despite the fact that over $1 billion was collected in aid relief. 17
Healthcare in Haiti Prior to the earthquake, 46% of Haitians did not have access to healthcare, either due to cost, or lack of care in their area. Since then, Haiti has been inundated by international aid, United Nations assistance forces, and a slew of NGOs working on relief to one of the poorest nations in the world. As if the quake's devastation and a subsequent hurricane didn't inflict sufficient tragedy upon the Haitian people, a cholera epidemic from a U.N. encampment's faulty sanitation swept across the nation affecting 635,000 people (5% of the population); it succumbed an additional 7,500 lives. 18 About 2 million people had been forced to take shelter in scattered overcrowded, filthy camps, easily transmitting the infectious organism. In a country that had spent approximately $58 annually per person prior to the earthquake, the Haitian Ministry of Health (MOH) faced the excessive morbidity resulting from the earthquake and the cholera epidemic-‐-‐with much fewer resources. Cholera is thought to be a preventable and treatable disease 19 but here it spread like wildfire, despite an early world commitment of $230 million to control the unexpected scourge besetting the people. The United Nations' bungled response and then rejection of responsibility to compensate families of the cholera victims riled the people of Haiti. (A 1946 convention granting the U.N. immunity for its actions was claimed, though experts pinpointed the specific cholera organism and identified the Nepalese encampment's unsanitary source). 20-‐21 The South Asian strain has now traveled to the continent's mainland; Mexico became the fourth Western Hemisphere nation to experience an outbreak this past September, 2013. 22
Understandably under the health conditions of the island, weak disease surveillance and case tracking, inadequate purified water distribution, latrine building, and more, led to the particular pattern of the cholera epidemiology. News descriptions of the response detailed the ensuing chaos also among the humanitarian and health agencies trying to cope with it. 23 The epidemic did, however, eventually spurred forth sewer and water improvements on the island according to the American Journal of Tropical Medicine. 24 The problem with Haiti’s healthcare system is that it never existed, nor has a functional health care system ever been implemented. The nation's first line of defense is primary care by the Medical NGOs (such as Medicines Sans Frontieres among others) run medical camps that may be faith-‐ or charity-‐based, or both. Currently, the public health care system is woefully inadequate–-‐insufficient medical staff, support, outreach, facilities, equipment and treatments, with little promise expected over the near future. 25 Before the earthquake, the Haitian Ministry of Public Health and Population had begun to transition to a national system, to corral groups using a variety of plans. USAID funding enabled some coordination and cooperation in the delivery of services through a network of 147 public and private sites to approximately 45% of the Haitian population. 17
Current shortages of professionals and facilities are not new to Haiti. In 2005, there were 1949 doctors working in the Haitian health sector, with only 730 in the public sector. World Health Organization (WHO) approximates this to 3 doctors, 1 nurse and 8 hospital beds per 10,000 Haitians. WHO’s target is 23 health professionals per 10,000 population.5-‐7 Adding to the beleaguered health system is the fact that a number of health professionals perished in the quake, so the previous statistics have worsened. Fewer doctors and nurses translate to less attended births, lower childhood immunization rates, less treatment of tuberculosis, malaria, HIV/AIDS, and other communicable diseases, amidst increased wait times for the very ill and injured, and long perhaps deadly delays at the few secondary and tertiary level facilities. In other developing countries, previous disasters have led to overcrowded living conditions, poor sanitation, and environmental degradation-‐–resulting in outbreaks of cholera, hepatitis, tetanus, bacterial dysentery, and upper respiratory infections. Vector borne illnesses (such as malaria and dengue fever) can take up to 8 weeks to begin and peal several weeks later. With more than a million Haitians exposed to living outdoors overcrowded near fetid environmental conditions, it is estimated that the rural prevalence of malaria and dengue may be 2-‐3%, meaning an additional 60,000 cases in Port-‐Au-‐Prince alone. 1-‐7 It is also estimated that, with the resultant trauma (including missing limbs), the long-‐term morbidity would significantly increase mortality rates from traumatic
injury for up to 40 years. Long-‐term recovery also rests upon the ability to re-‐ establish most of the workforce-‐-‐an extremely challenging proposition given the lack of adequate healthcare-‐-‐thereby threatening economic revival for the country. 26 In
the meantime, this bleak portrayal sees the nation slowly inching toward
increased governance and what may hopefully be improvements in public health for its citizenry. Then a prospect for economic revival may come from direct foreign investments.
27
In the meanwhile, NGOs continue to provide health and
humanitarian services through partnerships with local sites. In the context of this study, we have partnered with and focused upon one such Medical Mission, Little-‐By-‐Little (LBL) that was begun in Chicago, Illinois with the intent of improving the primary care of Haitians living in the village of Gramothe and their neighbors. LBL has traveled to Haiti to serve the Gramothe community over the last decade.
NGO Medical Missions
Most NGO’s have some type of health service provision through a faith-‐ or charity-‐ based mission. Popularly known as Medical Mission trips, the Nobel Prize winning Medicines Sans Frontieres (MSF) has pioneered this kind of initiative on a worldwide scale. MSF has historically accomplished much in numerous nations besieged by both war and natural disasters. Medical Missions often involve multidisciplinary teams of healthcare professionals and non-‐professionals who travel to the country to provide health services.
Review of the scientific literature enlightens medical mission trip outcomes in terms of individual provider narratives, numbers of patients seen, treated, etc. There is sadly a dearth of literature on continuity-‐of-‐care once medical mission trips leave, or on the follow-‐up of patients who were critically ill and treated by providers during such trips. Nevertheless, the noble intentions of those who participate and provide care cannot be overlooked, and in fact must be praised. More specifically to medical missions is the pharmacy component that renders necessary pharmaceutical treatments. Since providing prescriptions is the major therapeutic intervention for patients' ailments, there is a crucial role for professional pharmacy in medical missions.
Role of pharmacy in medical missions
Pharmacy is a very well established arena of work activity in all developed countries and in some developing countries. However, the general absence of professional pharmacists on many medical missions may impede efficient use of medications provided to patients from very limited formularies on tight budgets. Issues of waste, expiration, non-‐use or misuse of medications on these trips are significant concerns with little discussion thereof in the literature. One major concern when dealing with patients, regardless of their culture or nationality, is the appropriate usage of medications often combined for multiple disease conditions in powerful potentially hazardous mixes.
While most practitioners can satisfactorily explain directions on taking medications to patients (assuming language and cultural barriers), comprehension by patients remains questionable (even in the United States), let alone resource-‐poor Haiti. Issues of non-‐adherence, misuse, and incorrect use may be significant in the context of stemming infection spread (e.g., tuberculosis, malaria, cholera, typhoid, HIV/AIDS, etc.). Incorrect use of medications may likely result in mild to severe side effects and/or poisoning, thereby creating further new downstream mortality and morbidity. Today with the newer emphasis on clinical pharmacy in PharmD curricula, a different sort of professional is here, and these professional skills can vitally complement medical missions going abroad as PharmD students embrace new horizons for the roles internationally. Currently, most pharmacists become employees in corporate chain drug stores and PBMs, but there are small numbers who seek to distinguish themselves by being committed to underserved communities, bringing to vulnerable populations needed pharmacy services inspired by the worldwide professional movement for pharmaceutical care. Drug Topics reported on pharmacists connected to the Friends of the Children of Haiti out of Peoria, Illinois, who responded quickly after the quake. 28 The work in Haiti by the Little-‐by-‐Little Foundation has begun to show how medical missions can be reinvigorated by the addition of pharmacy professional expertise to establish not just a new clinical role, but an administrative pharmacy contribution of
knowledge of laws, regulations, drug supply issues (from counterfeits through purchasing from various sources), standards of practice, disease management strategies, advocacy, and pharmacy operations. Pharmaceuticals and the use of pharmaceuticals are crucial ingredients to medical missions for underserved populations, particularly in developing nations; to the same degree, pharmacy is an added crucial ingredient. Most patients seen by professionals on medical missions are suffering from infectious and parasitic illnesses that when easily treated by modern medicine can be effective, when the drugs are available, continuous, and properly taken. Moreover, aging cohorts abroad are increasingly encountered, and they face cardiovascular ailments, diabetes, cancer, and rheumatic diseases, among other chronic degenerative ailments. Western pharmaceuticals can be worthwhile in alleviating suffering for these clinical conditions in earlier stages, and thus prolong life. Yet, the literature is quite scant in the former category of pharmaceuticals within medical missions, and not much is recognized for the necessary contributions pharmacists can bring to enhancing medical missions through their professional expertise in pharmacy management systems and appropriate drug use. Generally, physicians and nurses seem to undergo a different kind of socialization in patient-‐centered care than pharmacy education has historically provided. This
professional socialization seems to instill greater social commitment for underserved communities, both here and abroad. Previously, pharmacists underwent basic science training in their B.S. degree programs, and only now are curricula beginning to emerge, particularly in advanced economies, with a strong clinical pharmacy direction. Old time pharmacists sought careers as shopkeepers running their own independent community pharmacies, pharmaceutical industry workers, or in corporate drug store chains. Pharmacist involvement with physicians and nurses in one medical mission will be detailed here since we found no suitable literature on pharmacy and the use of pharmaceuticals in medical missions, even though countless numbers of trips have been carrying Western treatments to poor, developing nations over past decades to positively (and unfortunately sometimes negatively) affect the health of communities. Western pharmaceuticals can be powerful and dangerous when not prescribed, dispensed and consumed appropriately. 29 Moreover, Western pharmaceuticals are very costly additions and can be a financial burden on medical missions who seek to demonstrate good results from their efforts. There are a number of issues that arise that could be better understood in order to enhance outcomes in the communities served, as well as avoid problems and increase the efficiency of the operations.
In Haiti, the extent of literacy amongst patients is questionable, with most speaking in Creole and claiming to be able to read and write. However, in the absence of governmental statistics on educational completion and considering Haiti’s past struggles with its education system, it appears more than likely that most of the population would be semi-‐literate at best. As such, when medications are provided to these patients, despite well meaning intent and counseling, they may likely not be used appropriately, which can create sequelae beyond what medical missions had addressed. Patient comprehension (or the lack thereof) is not exclusively a developing country phenomenon. In the United States, most Americans read at the 5th grade level and a national study on health literacy revealed that 48% of Americans had below basic literacy. Therefore, the purpose of this pharmacy intervention and study was to work toward improving patient comprehension of their medications with to serve to (hopefully) improve health outcomes as intended by the medical and nursing professionals.
Little-‐By-‐Little Medical Mission trips:
Little-‐By-‐Little, (LBL) a not-‐for-‐profit Chicago-‐based NGO has worked in the Village of Gramothe, Haiti for the past decade to provide health and humanitarian services to the villagers of surrounding communities. It is affiliated with Mountain Top Ministries, a Haitian Catholic agency that provides the facilities and some staffing support. The area was not as severely affected the earthquake as Port-‐Au-‐Prince.
Pharmacy is a crucial component of these medical mission trips and the lack of trained pharmacists has been an impediment toward efficiently delivering care. As such, a collaborative project was developed to identify key factors to improve comprehension among patients so that they would take their medications as prescribed by the practitioners. A large part of the problem is that most patients are illiterate or semi-‐literate, so it is very difficult to measure comprehension while on-‐site. The practitioners rely on patients to take their medications correctly and follow-‐up generally cannot occur. LBL visits Mountain Top Ministries (MTM) to provide care to the villagers of Gramothe and surrounding areas four times a year. The teams are diverse with various healthcare (physicians, family nurse clinicians, pharmacists, and students) and non-‐professionals volunteering their time and expertise. LBL typically serves anywhere between 500-‐1000 patients each day during their mission trip. The teams fill an average of 3-‐4 medications per patient (vitamins, antibiotics, analgesics, anti-‐ worming RXs, etc.). Most teams provide a 30-‐day supply for maintenance medications and vitamins. Pregnant or lactating women are provided a 3-‐month supply of prenatal vitamins. The spring team provides a 3-‐month supply to cover the summer when there is no team available. Beyond the LBL teams, other Medical Mission teams visit the MTM facility in between. On a typical trip, patients arrive to the clinic and wait for their turn. Each patient that has been seen by the clinic has a dossier (patient record) of diagnosis,
treatments, medications, etc. Once, the physician has checked a patient, they are asked to proceed to the pharmacy window where technicians dispense their medication after checking with the pharmacist for accuracy. The dossier is updated and the patient is informed about the proper use of the medication (i.e. when to take it, how to take the medication, other explanation points, etc.). It is important to note in this context that the Health Ministry of Haiti does not recognize Pharmacists as healthcare providers nor is there any education for pharmacy training in the country. Most of the healthcare providers on medical mission trips are traditionally physicians, nurses, social workers, students who are in training, etc., but few trips have regularly recorded the presence of pharmacists. While pharmacists may remain in the background on many medical mission trips internationally, their expertise and training is an important component of a patient’s health care process. Medications are an integral component of most interventions, and, as such, it is extremely important as well as challenging to ensure that patients not only understand proper usage of medications, but also adhere to their prescribed regimens for improved outcomes. Therefore, this project focused on improving the medication labels to incorporate the uncertain literacy though inclusion of pictograms as a means to explain medication use and instructions to patients.
The Pictogram Labeling Project for Haiti (PLPH):
Phase I: Pictograms are a great method to relay information to people who may have questionable levels of literacy. Pictograms are often used in other fields (e.g., education, sociology, etc.) to conduct research or provide information that will be better understood. As such, this project was conceived and developed to improve patient understanding of medication labels. About 20% of LBL’s drug formulary was converted to pictogram labels and piloted through a small study in May 2013. The primary objective of this study was to identify key elements on the medication labeling that could be converted to pictograms and to pilot test the pictograms with existing patients. Preparing the labels: The pictogram labels were prepared using online software available through the International Pharmaceutical Federation (FIP). All the pictograms were developed in English and translated to Creole through a certified translator. Each label contained pictures on how to use the medication accompanied by directions in Creole. (See picture 1)
Picture 1: Doxycycline pictogram Creole label
The
pictogram
labels
were printed and dispensed with medications during the Spring 2013 mission trip. RESULTS Focus group: A focus group was conducted with patients to identify key issues with the newer pictogram labels and to evaluate acceptance of the new labels. 167 patients participated in the study. 16 (10%) of the patients declared they couldn’t read while 5 (3%) were visually impaired. For the pictogram label study, 11 patients refuse to answer questions and their data was removed from the analysis. 42 (27%) of 156 patients preferred the old, written labels while 114 (73%) preferred the new pictogram labels. 69% of the patients preferred the writing while 27% preferred the pictures with only 5% reporting they preferred both. Participants were asked whether about their reasons for preferring the old labels and those are presented below (see Table 1).
Table 1: Percentage of participants preferring old, written labels Reason
% Prefer old, written labels
Understanding Simplicity Familiarity Unspecified Other
28% 50% 8% 14% 10%
In the pilot study, it appeared that a majority of the patients preferred the newer, pictogram labels to the old, written ones. However, the rollout and implementation of future labels depends upon providers’ acceptance and willingness to incorporate the newer labels into their patient education and communication while on the ground in Haiti. Our study team plans to test the pictogram project at other sites in
Haiti to further assess both practitioner and patient acceptance and how it may be helping the provision of medication usage. DISCUSSION
Health outcomes in primary care in Haiti are of critical concern due to a lack of capacity for referral for systematic interventions. NGOs have varying levels of expertise, care and provisions to offer to the Haitian people, and, without a unifying system to document and monitor the range of interventions, it is impossible to effectively assess the impact of the vast amount of good work done. Nevertheless, several agencies have implemented pay-‐for-‐performance (including the USAID) with some success. It is increasingly important to discuss healthcare outcomes in terms of mortality, morbidity, and changes in live births, availability of services, facilities, and infrastructure in conversations on Haiti. Quality measures and efficiency in resource use are powerful indicators of any healthcare system, but especially so in an impoverished system besieged by various entities and diverse stakeholders whose efforts may at times contradict one another, and create unintentional harm. This can be easily observed with the cholera situation in Haiti. 30 Notably a Cuban medical delegation helped to mobilize health officials and lessened the death toll near Mirebalais. 31 NGOs serve a critical purpose in the absence of established governmental structures, however, the issue of empowering Haitians to take care of their own
remains critical. It must be noted that in 2010, the Associated Press reported that less than one cent of each dollar of U.S. earthquake relief was going to the U.S. government. It may be so that the relationships between NGOs and their donors tends to undermine the Haitian people’s right to self-‐determination, while the organizations continue to benefit from the poverty they are entrusted to fight. In 2010, the top 10 NGOs made U.S. $8 billion, thereby leading many critics to emphatically state that poverty in Haiti may be becoming a business. While the historical presence of the Little-‐By-‐Little volunteers represents an overall valiant effort of interventions that are constantly being upgrading, other efforts inside Haiti have led observers to be skeptical of what may be behind their presence and their effectiveness. 32-‐37 The reconstruction of Haiti needs capacity building from within, and NGOs, while performing essential work, must collaborate, not compete, with each other to fully empower the Haitian people. The earthquake did not damage the revolutionary spirit and independence of the Haitian people. As a result, Haitian grassroots movements have sprung to work within the communities they came from. It is important for NGOs and the Haitian grassroots organizations to seek cooperation to reach out and build thriving communities. Overcoming the adversary of destruction and disease will be no easy task, but our hopes are surely there for advancement. This pharmacy intervention and subsequent study for the Little-‐By-‐Little teams at Mountain Top Ministries intended to aid patient medication usage in a small way
and to demonstrate the crucial role of pharmacy in medical missions across the globe. Contextualizing the Haiti situation reveals great needs for populations faced with natural disasters and inadequate health acre delivery systems.
REFERENCES 1. The World factbook. Available at: https://www.cia.gov/library/publications/the-‐ world-‐factbook/geos/ha.html 2. Haitian healthcare: A follow-‐up. World Health Organization. Available at: http://www.who.int/features/2011/haiti/en/ 3. Haiti’s struggling healthcare system. Available at: http://newint.org/blog/2013/02/25/haiti-‐healthcare/ 4. United Nations Development Programme (UNDP). 2007/2008 Human Development Report. Geneva: 2008. 5. Basic Health Indicator Database: Haiti. Pan American Health Organization (PAHO); 2000. Available at: http://www.paho.org/English/SHA/coredata/tabulator/newTabulator.htm 6. Haiti Health Cluster Bulletin # 30. Pan American Health Organization (PAHO). 2011 7. Central Intelligence Agency, The World Factbook -‐-‐ Haiti, Washington, DC: U.S. Government Printing Office, 2012. 8. Parry W. Cholera epidemic that began in Haiti continues to kill elsewhere. Huffington Post. 2013 9. Janvier, B. Bernadin, A., & Obidegwu, I. Haiti initiative brings hope for elimination of elephantiasis. The Guardian. 2013. Available at: www. theguardian.com/global-‐ development-‐professionals-‐network/2013/aug/21/haiti-‐initiative-‐hope-‐ elephantiasis 10. Bresee, J, Hayden, F.G. Epidemic Influenza-‐Responding to the expected but predictable. New England J Medicine. 2013; 368:589-‐592. 11. Drug industry aid for Haiti earthquake relief efforts. in-‐Pharma technologist.com, 2010. Available at: http://www.in-‐ pharmatechnologist.com/content/view/print/274537. 12. Pharma leads the way in help for Haiti. PharmaManufacturing.com. 2010; 19:13. 13. Koontz H, Ransom CN. Haiti dominates earthquake fatalities in 2010. U. S. Geological Survey. Available at: http://www.usgs.gov/newsroom/article.asp?ID=2679 14. Auxila P. A Healthy future for Haiti. J Int. Peace Oper. 2010; 5(6): 17-‐32. 15. Rebuilding Haiti: Dreaming beyond the rubble. The Economist. 2013. 16. Eichler R, Auxila P, Pollock J. Output based healthcare: Paying for performance in Haiti. World Bank. 2001. Available at: https://openknowledge.worldbank.org/handle/10986/11370 17. Pierre-‐Louis F. Earthquakes, Non governmental organizations, and Governance in Haiti. J Black Studies. 2011; 42(2): 186-‐202 18. First, do no harm. The Economist. 2012, p. 41-‐42. 19. Waldman, R.J., Mintz, E.D., Papowitz, H.E. The cure for cholera-‐-‐Improving access to safe water and sanitation. New England J Medicine. 2013; 368:592-‐594. 20. Lall R.R. UN will not compensate Haiti cholera victims, Ban Ki Moon tells president. The Guardian. 2013. 21. Panchang, D. Waiting for helicopters? Cholera, prejudice and the right to water. Other Worlds. 2012, 13: 39. Available at: http://truthout.org/news/item/10154-‐ waiting-‐for-‐helicopters? -‐cholera-‐prejudice-‐and-‐the-‐right-‐to-‐water-‐in-‐haiti? tmpl. 22. Knox, R. Haitian cholera strain spreads to Mexico. NPR shots. October 23, 2013, Available at: www.npr/blogs/health/2013/1023/239803803890/haitian-‐cholera-‐ strain-‐spreads-‐to-‐mainland-‐with-‐mexico-‐outbreak 23. Sontag, D. Rebuilding in Haiti lags after billions in post-‐quake aid. New York Times. 2012.
24. Tinder, P. Cholera epidemic drives public health progress in Haiti. Vaccine News Daily. 2013. Available at: vaccinenewsdaily.com/medical_countermeasures/327815-‐cholera-‐epidemic-‐ drives-‐public-‐health-‐progress-‐in-‐haiti/ 25. Porter, C. Porter: Haiti's cholera a story of failed leadership and politics. The Star. 2012. Available at: http:viewFreeUse.act?fuid=MTY1NzM4OTQ%3D. 26. Sontag. D. In Haiti, global failures on a cholera epidemic. New York Times. 2012. 27. Still waiting. The Economist. 2013; p.27-‐28. 28. Lowery. US pharmacists aid stricken Haitians. Drug Topics. May 2010, p. 29. 29. Manasse H. The care in Pharmaceutical Care. J Pharm Teaching. 1992; 3 (3): 39-‐52 30. Barzlay, E.J., Schaad, N., Magliore, R., Mung, K.S. Boncy, J. et al. Cholera surveillance during the Haiti epidemic-‐-‐The first 2 years. New England J Medicine. 2013. 31. Archibold, R.C. Cuba takes lead role in Haiti's cholera fight. New York Times. 2011, p 4. 32. Panchang, D. Withholding water: Cholera, prejudice and the right to water in Haiti. Other Worlds. 2012, 12: 58. Available at: http://truthout.org/news/item/9532-‐ withholding-‐water-‐cholera-‐prejudice-‐and-‐the-‐right-‐to-‐water-‐in-‐haiti?tmpl. 33. Panchang, D. Withholding water: Cholera, prejudice and the right to water in Haiti. Other Worlds. 2012, 12: 58. Available at: http://truthout.org/news/item/9532-‐ withholding-‐water-‐cholera-‐prejudice-‐and-‐the-‐right-‐to-‐water-‐in-‐haiti?tmpl. 34. Wilentz, A. Letter from Haiti. The Nation. 2013, p. 21-‐26. 35. DeGennaro, V. Jr, DeGennaro, V., Ginzburg, E. Haiti's dilemma: how to incorporate foreign health professionals to assist in short-‐term recovery while capacity building for the future. J Public Health 33(3): 459-‐461, January, 2011. 36. Nichols, M. U.N. says will not pay Haiti cholera compensation claims. Business and Financial News. Reuters. 2013. Available at: http://www.reuters.com/assets/print?aid=USBRE91K19020130221. 37. What Haiti is owed: Editorial. The Nation. February 8, 2010, p.4-‐5.
