KaziCHAT: Comprehensive Health Assessment Tool

Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality, causing more than 70% of all deaths globally. Of these, three-quarters of deaths occur in low- and middle-income countries (LMICs), as well as up to 80% of premature NCD deaths (death below the age of 70 years). With most of the risk factors preventable through healthy lifestyle behaviours, more emphasis needs to be placed on primary prevention strategies. One way to address this is to incorporate health promotion interventions within already established workplace structures.

Although massive increases in data and analysis have occurred in many fields over the last decade, data is still lacking within LMICs, especially health data. Barriers to health data collection, profiling, and exchange, have been attributed to poor infrastructure, lack of training and insecurity.

The spread of mobile technologies, as well as advancements in their innovative applications to address health priorities, have evolved into a new field known as mHealth. A report published by the WHO in 2011 stated that the use of mobile technologies to support the achievement of health objectives has the potential to transform health services across the globe. The software solution and health platform KaziChat developed here is intended to contribute to the health system of the Eastern Cape, South Africa, and to support the Department of Health in recording relevant medical health parameters at the population level.

The development of KaziCHAT (Kazi- Comprehensive Health Assessment Tool) was driven by the need to simplify health data management within a workplace health intervention program designed for low-resourced school environments. KaziCHAT, followed a user-centred design process to create a responsive web-based health data management solution. The workplace
health promotion program (consisting of a health risk assessment,
lifestyle counselling, and continued follow-up):

is aimed at improving targeted health behaviours, cardiometabolic health risk markers, perceived levels of stress and mental health outcomes. The workplace health intervention, although present only used within school settings, can be scaled and incorporated within other workplace sectors, especially within regional and local governmental departments (such as clinics and healthcare facilities, police and protective services, and the like).

KaziCHAT has the ability to track longitudinal health data and provide a summary to the participant, which can be accessed with an easy-to-use cell phone application. KaziCHAT further allows the interdisciplinary healthcare team to collaborate and share patient data. The KaziCHAT platform has the functionality to store and rate body composition, cardiometabolic risk factors, physical activity and fitness data, psychosocial health, and parasitology data. Each category has various assessment methods, depending on availability within the settings. A random glucose sample or a full glycosylated haemoglobin assessment can be used, depending on availability and need, for example.

Available data within LMICs indicate that the disease profile of people is moving towards a profile seen in more Westernised countries, where more deaths are being attributed to chronic NCDs. As current lower-resourced health challenges, such as child and maternal health, WASH, and the like, have not been completely resolved, populations within LMICs face a double burden of infectious- and non-communicable disease risks.

Lower-resourced settings within LMICs are therefore incredibly vulnerable, and it is exactly here where our solution will be implemented. Due to environmental challenges, health information flow within these settings is not optimal, where a patient for example will not receive their health data in an understandable and preservable way. It is here where the KaziCHAT platform places patients at the centre of their own health data, overcoming the setting-related challenges to receiving and understanding their personal health data and placing them in a position to take action in improving these.

The KaziBantu project, ‘Healthy Schools for Healthy Communities’, is implemented in primary schools in low resourced settings within South Africa’s poorest province, the Eastern Cape. The project aims to promote physical activity and healthy lifestyle behaviour in both schoolchildren, through the KaziKidz toolkit, and their teachers, through KaziHealth, a workplace health intervention program. KaziHealth consists of five steps: risk assessment, health risk profiling, lifestyle coaching, self-monitoring and evaluation of goals achieved. The Kazi- Comprehensive Health Assessment Tool, or KaziCHAT for short, was developed to ease the assessment, profiling, and storage of health and wellness data within KaziHealth. KaziCHAT has the ability to track longitudinal data, and provide a summary to the participant, which can be accessed with an easy-to-use cell phone application. KaziCHAT further allows interdisciplinary healthcare team to collaborate and share patient data.

Therefore, our team from the UNESCO Chair "Physical Activity and Health in Educational Settings" is well positioned to deliver the KaziCHAT solution and supports international collaboration among various UNESCO Chairs through: (i) Research and teaching unit at the University of Basel (Basel, Switzerland) and the Nelson Mandela University (Gqeberha, South Africa) and other universities in sub-Saharan Africa; (ii) An established agreement between UNESCO and the University of Basel; and (iii) A commitment to go beyond disciplinary boundaries and to relate its work to setting specific and global future challenges.

Although LMIC populations have been identified as having a high risk of NCDs, little is known about risk factors present, health behaviours practised and the effectiveness of interventions to improve these. An important gap in the literature will be addressed by examining these risk factors and determining the efficacy of a workplace health intervention programme in primary school settings with the help of the KaziCHAT platform. The ability within the KaziCHAT responsive web solution is to add information about current health conditions / relevancies – COVID-19 for example. Incentivize participation, usage, and goal achievement through gamification can support this process. Now we believe that with KaziCHAT we are at a stage of development where the product is ready for dissemination and can be used, tested and adapted in other settings from LMICs with appropriate needs, while further developed by information technology (IT) experts from the Centre for Community Technologies from the Nelson Mandela University (Gqeberha, South Africa).

The KaziBantu project was conducted according to the latest International Conference on Harmonization - Good Clinical Practice (ICH-GCP) and the 1975 Declaration of Helsinki and amendments. The KaziBantu study received ethical approval from the following committees: (1) Nelson Mandela University Research Ethics Committee (Human) on 26 March 2018 (H19-HEA-HMS-003); (2) Eastern Cape Department of Health on 5 June 2018 (EC_201804_007); and (3) Eastern Cape Department of Education on 9 May 2018. The study was further registered with the Ethics Committee Northwest and Central Switzerland (EKNZ) on 1 March 2018 (R-2018-00047). The study was also registered at the International Standard Registered Clinical / Social Study Number registry (ISRCTN) under controlled-trials.com on 11 July 2018 (ISRCTN18485542), and with the International Registered Report Identifier (IRRID) (DERR1-10.2196/14097).

Multiple health assessments can be undertaken by the client and
Health Assessments can be compared with one another in order to show
progress or decline in the clients health results. KaziCHAT has
the capability to compute the values assigned to specific responses on
questions asked in the assessment questionnaires and to classify the
outcomes as either low, moderate or as high-risk levels. Some of the
values that are measured during the clients health assessment are blood
pressure, cholesterol and body mass index. The visual presentation of
the results is in an on-screen dashboard, which is colour coded in the
formation of traffic lights to make the interpretation of the data
easier and to indicate the risk level in a very relatable manner.

KaziHealth is a mobile solution that is linked to KaziCHAT. Users can import their risk profiles from the KaziCHAT solution onto their mobile phones and generate their own risk profiles, based on specific data inputs. The App then assists the users in managing their health risks themselves. KaziHealth can also be used as a standalone application and can be downloaded from the Google Play Store. The application can therefor be downloaded and utilised by persons whom are not part of the KaziCHAT assessment. The mobile application also contains modules on how to manage a persons health risk such as blood pressure, weight, cholesterol and blood glucose level by linking to information about nutrition, exercise and health habits.

We use innovative technology for our translations that can combine machine learning with human work from a scientist or medical professional. This enables culturally relevant translations that facilitate two-way conversations between teachers and scientists or medical professionals. The KaziCHAT online health-platform is designed for low-resourced environment:

• Run off tablet / cell phone;
• Low internet usage;
• Sever storage;
• Easy to learn /use / user friendly / intuitive interface;
• Bull in error prevention (skip logic, defined data types);
• Use what you have principle, there for very flexible, allow entry level health profile to be generated / versatility; and
• Easy to implement (star using at any low-resourced healthcare facility).

Our 5-year vision is to unlock the potential of educators from the Eastern Cape in South Africa to support health and its prevention through the KaziCHAT platform where the need is greatest. The numbers of users of KaziCHAT and interest of end users will be monitored, in our case, of teachers with health problems. We plan to achieve this by: i) seeking working relationships with government-related institutions in South Africa such as the Eastern Cape Department of Health; ii) generally increasing the number of our institutional partnerships, including state and federal governments, school districts, non-profit educational institutions as well as international organisations; and iii) activating teacher communities in different regions of South Africa. KaziCHAT will be disseminated where the need is greatest. We foresee this especially in semi-urban and rural areas of South Africa.

Our vision and mission is:

• Physical Activity is key to promote health and wellbeing;
• Learning this at a young age will have long lasting effects throughout the whole life; and
• Especially people from low- and middle-income countries carry a double burden by communicable and non-communicable diseases.

Strategic goals of the UNESCO Chair on "Physical Activity and Health In Educational Settings":

Sustainable Development Goal 3:

• Ensure healthy lives and promote wellbeing for all at all ages; 
• Contribute against the spread of NCDs in people from marginalized communities in middle-to-low-income countries; and 
• Support teachers from disadvantaged communities in middle-to-low-income countries to lead an active life (and avoid the further spread of NCDs).

Sustainable Development Goal 4:

• Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all; 
• Providing study materials for primary school teachers - the KaziKidz teaching material - to contribute to health literacy; and 
• To offer teachers a health program - KaziHealth: Teachers' health promotion programme - that will contribute to improving clinically relevant health parameters.

The unprecedented spread of mobile technologies as well as advancements in their innovative applications to address health priorities, have evolved into a new field of eHealth, known as mHealth. A report published by the WHO in 2011 stated that the use of mobile and wireless technologies to support the achievement of health objectives has the potential to transform the face of health service delivery across the globe. A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services and the continued growth in coverage of mobile cellular networks.

It is against this background that an eHealth solution called KaziCHAT (Kazi- Comprehensive Health Assessment Tool) and a mobile application called KaziHealth, were developed to support a workplace health promotion program (consisting of a health risk assessment, lifestyle counselling, and continued follow-up) and aid in determine the intervention’s effectiveness on targeted health behaviours, cardiometabolic health risk markers, perceived levels of stress and mental health outcomes. We therefore see the opportunity to operate in the research field of digital health and perceive a great potential to support the governmental health institutions in South Africa.

Overall aim:

The aim of KaziCHAT is to promote and thereby strengthen digital health care in selected disadvantaged areas of South Africa and to support the health system in Nelson Mandela Bay of the Eastern Cape.

Emerging needs for change:

Stakeholders in schools point out that there is a need for health-promoting in-service training for teachers, both in-service training for those who have been trained and initial training for those who have not. In terms of in-service training, our evaluation found that there is a clear need for medical in-service training and promoting awareness of NCDs.

Process of change:

(i) Further KaziHealth education opportunities for teachers via an accredited Short Learning Programme (SLP) by SACE (South African Council for Educators) (pre-requisite is close to finality);
(ii) Further education on the KaziCHAT online health platform (pre-requisite and is available);
(iii) To record the further needs of the end users and setting and environment specific needs (will be elaborated);
(iV) Adaption of the KaziCHAT online health platform (will be elaborated); and
(V) Partial and gradual handover of the software infrastructure to government institutions such as the Department of Health (will be continuously elaborated).

This entire process is always accompanied by various minuted meetings with representatives of the different stakeholders. Always with the overarching goal in the background to jointly achieve sustainability in the project's objective: "To sustainably anchor KaziCHAT in the South African health system".

The development of KaziCHAT (Kazi- Comprehensive Health Assessment Tool) is driven by the need to simplify health data management within a workplace health intervention program designed for low-resourced school environments. KaziCHAT, followed a user-centred design process [1] to create a responsive web-based [2] health data management solution. The data in KaziCHAT is subject to the Data Protection Act, belongs to the owner and may only be used for scientific purposes. Access can be given by the research team along with login details against a confidentiality agreement.

KaziCHAT is a responsive web solution and assesses, profiles and stores longitudinal health data to:

• Simplify access to health data in under-resourced settings;
• Assist participants in understanding personal health data;
• Promote patient education (along with mHealth KaziHealth mobile app); and
• Promote interdisciplinary among healthcare providers (pharmacists, nurses, exercise specialists (Biokineticist), psychologists, dieticians, researchers, etc.) with centralized health data capturing, storage, and long-term tracking.

[1] User-centred design (UCD) is a framework that refers to a design process that places the end-user and their needs at the centre of each phase of the design process. Understanding the user, their demands, priorities, and experiences when using the product are the focus during design, which leads to increased product usefulness and usability, resulting in higher end-user satisfaction.

[2] A responsive web solution refers to web design that responds effectively to user behaviour and the environment, depending on the size of the screen, the orientation, and the platform. The technology allows automatic responding to suit the user's preference and eliminates the need for district design for individual devices, ensuring better usability and satisfaction.

Scientists from the Nelson Mandela University (Gqeberha, South Africa), the University of Basel (Basel, Switzerland) and the Swiss Tropical and Public Health Institute (Basel, Switzerland).

Our research team is subject to the guidelines of the Nelson Mandela University (Gqeberha, South Africa), the University of Basel (Basel, Switzerland) and the Swiss Tropical and Public Health Institute (Basel, Switzerland) regarding the incorporation of diversity, equity, and inclusivity (DEI) in or work and are guided by optimism, partnership, open innovation, human-centered solutions, and inclusive technology. We are committed to anti-racism in all the work we do. Furthermore, our work ethics is inferior to the latest International Conference on Harmonization - Good Clinical Practice (ICH-GCP) and the 1975 Declaration of Helsinki and amendments.

In order to meet the needs of the socially lower population strata of South Africa, the use of KaziCHAT shall be and remain free of charge. This should, however, strengthen the attractiveness of the health platform and have a supporting effect on medical counseling for the end users.

Further development will be carried out by professional IT staff from the Centre of Information Technology from the Nelson Mandela University and support will be provided by experienced medically trained scientists, also from either the Nelson Mandela University (Gqeberha, South Africa), the University of Basel (Basel, Switzerland) or the Swiss Tropical and Public Health Institute (Basel, Switzerland).

Sustainable revenue models will be focused on partnerships and collaboration. Nelson Mandela University positions itself as an institution in-service-of-society and uses public-private partnerships to achieve its goals. Partnerships with Telcos, pharmaceutical other relevant industries will be beneficial to the success of the project growth.

KaziCHAT is aimed at supporting the Department of Basic
Education as well as the Department of Health in achieving the eHealth
and mHealth strategies of South Africa. The aim in the long run is to
allow the respective government departments to take ownership of the
solution and the outcomes and incorporate the outcomes into best
practices and policy guidelines.

The KaziBantu project has received start-up funding of more than 1 million Swiss francs and has thus supported scientific research over several years and contributed to various research articles in peer reviewed international journals. The research output during the last years has also been documented in the UNESCO Chair's research news.