Mami

Breast cancer is the leading cause of cancer deaths among women in Nigeria [1] and is expected to increase globally by 46% by 2040[2].

Detection at earlier stages of the disease is recommended for resource-poor settings like Nigeria [3]. However, ³7 in 10 breast cancer patients in Nigeria first present in clinics when the disease has advanced, and available treatments have less benefit and late presentation leads to poor outcomes including premature death [4]. 

Factors related to late presentation include lack of awareness, stigma, perception of diagnosis as a death sentence, inaccessible health facilities, beliefs, and costs [5-7]. Increased awareness through regular breast self-exam (BSE) and clinical breast exam (CBE) and mammography are recommended to improve early detection. In addition Nigeria lacks a population based cancer screening program.

 Although incidence rates (new cases per population) are lower in low-income countries (LICs) compared with high income countries (HICs), death rates are markedly higher [8] in LICs. This suggests that though chances of having the disease are less in a LIC, patients living there are more likely to die from it [8].

Breast health education (BHE) including breast self-examination has been shown to significantly impact on early presentation and clinical downstaging [9].

References            

[1] International Agency for Research on Cancer, GLOBOCAN Factsheet for Nigeria, 2020).  https://gco.iarc.fr/today/data/factsheets/populations/566-nigeria-fact-sheets.pdf 

[2] Heer E et al., The Lancet Global Health, Volume 8, Issue 8 (e1027), 2020.

[3] Yip C.H. et al.,  World Journal of Surgery 39 (3), 686 (2015).

[4] Corbex M. et al.,  The Breast 21 (4), 428 (2012).

[5] Pruitt L. et al, Glob Public Health. 10(3), 331(2015)

[6] Olarewaju, S. O. et al., Jour of Glob Oncol, 5:1-8, 2019

[7] Foerster M, et al., Int J Cancer, 148(2), 340 (2021)

[8] DeSantis C, et al. Cancer Epidemiol Biomarkers Prev 24:1495-1506, 2015

[9] Yang K. et al, J Cancer Educ, 34(6):1225-1230, 2019.

Our solution is Mami a mobile app and SMS service to help women in low-income countries, starting with Nigeria, to identify breast cancer symptoms early and connect with care.

Mami is unique to its competitors as it is the only mobile application that integrates breast health education, visual demonstration in the country’s five major languages, prompts for BSE, symptom log and connects women to navigators (trained healthcare and community workers) for information on accessing care. Importantly, it plugs the gap between women noticing symptoms and seeking help to reduce fears and feelings of stigma.  Our primary aim is to educate and enhance early presentation in symptomatic women.

The mobile app consists of a monthly reminder which is calculated based on the woman’s menstrual status. Next step is to watch a video on how to check the breasts in any of the five major local languages.  This is followed by a step-by-step picture guide on how to check for symptoms with the option to download a record of the check. If an unusual change is noticed, the user has the option to connect with a local navigator (a trained healthcare or community worker who supports on accessing care).

Using a phased approach, a mobile application will be developed for smartphone users in the first phase, and then adapted to non-smart phones using SMS, and Unstructured Supplementary Service Data (USSD).

 The content of Mami will be translated into Nigeria’s major languages (English, Pidgin, Yoruba, Igbo, Hausa) to maximise accessibility and reach to women of different socioeconomic groups, living in rural and urban areas.

Our target users are women living in Nigeria aged 21-55 years with busy lifestyles such that their own health often takes the backseat to other responsibilities. Although most have heard of breast cancer and agree that it is important to check their breasts regularly, they often forget or don’t know how to do a breast self-exam. In addition, 

Approximately 80% (88 million) of the women in Nigeria use mobile phones (smartphones: 46%, non-smartphones: 42%). With a 5% reach (arbitrarily), we could potentially impact 4.4 million women.

We anticipate that integration into the existing healthcare system at the local government level through partnerships would help enhance uptake.

Women in their 30s who have become more aware of the need to take care of their health and may have possibly started raising young children.

 Our users range from young women in tertiary institutions to older women in their 50s with growing businesses or careers who realise that their health is important but often forget the information they received at the last breast cancer awareness campaign they attended or have simply never received any form of breast health education.

Our five key target areas to reach our target users are:

-       Local Health Centres including antenatal and immunisation clinics, and community pharmacies. We anticipate that integration into the existing healthcare system at the local government level through partnerships would help enhance uptake.

-       Social media platforms

-       Health focused charities/NGOs

-       Community groups e.g., markets, faith groups, social and career networks.

-       Media platforms –Newspaper/ magazine adverts/feature articles

I was born and raised in Nigeria and began my career in the country and most of the team members have lived in Nigeria for most of their lives. We are from different cultures of the country ethnicities bring a rich diversity of perspectives to the work. To further understand the problem of late presentation, and poor screening uptake, I began by speaking with women and healthcare professionals in the country starting with those in my personal network. Following this we conducted a survey to understand their knowledge and attitudes towards breast cancer screening. The finding s from the survey and further conversations informed the design of the mobile app. After developing the prototype, another group of women in Nigeria from different parts of the country tested it and provided anonymised feedback.

Every member of our team has worked/volunteered on health projects in rural and urban areas of Nigeria or other countries in sub–Saharan Africa, engaging with communities of diverse cultures. We are using our experiences in planning and executing Mami.

Currently, we have 26 users who tested the app and a waiting list of 61 subscribers.

This would enable us to complete the development of Mami, and strengthen our operations as we roll-out in Nigeria, and enhance our brand strategy as we plan to establish the first set of partnerships with collaborators and sponsor(s). The award will also provide access to other networks and funding opportunities, that will help us grow and scale to other African countries through partnerships. In addition, Solve can potentially provide us with grant funding, credibility, and help build exposure. I would like to receive mentorship, financial training, learn negotiation skills, build networks and marketing strategies that would enable me to lead the organisation effectively and sustainably. I would also like to learn how to build an organisational culture that promotes growth and development in the lives of all the team members.  

Mami is unique to its competitors as it is the only platform that integrates breast health education, visual demonstration, prompts for BSE, symptom log and connects women to navigators for information on accessing care. Importantly, it plugs the gap between women noticing symptoms and seeking help to reduce fears and feelings of stigma.  Our primary aim is to educate and enhance early presentation in symptomatic women.

In the next one year, our goal is to reach 400,000 women with at least 70% using the app consistently over the time period. In the next 5 years, our goal is to reach 4.4 million women in sub Saharan Africa and other low income countries through partnerships with other organisations and governments.  

Currently at least 7 in 10 (70%) breast cancer patients in Nigeria present at the late stage and our goal is to reduce this by half to 3 in 10 in five years.

The impact of Mami on users will be measured by evaluating: 

- Increase in the knowledge of symptoms and risk factors of breast cancer symptoms 
- increase frequency of breast self-examination among users.
- Increase uptake of breast cancer screening including annual clinical breast examination and mammograms/ultrasound for those who are eligible.

We will also continue to assess the users' experiences through interviews and open-ended questions.  Our evaluation framework will be one of the key pillars on which we will base our deployment. This will ensure that as we roll out, we are tracking the right data that will guide us in assessing these. We will continue to evaluate the impact and incorporate updates based on the feedback we receive through an iterative process.

Metrics 

1.       Number of users

2.       User retention rate (we aim for 70%)

3.       Users who notice symptoms and connect with navigators.

4.       Number of users interested in screening services.

Providing breast health education to women in Nigeria and facilitating access to information on where they can find appropriate care, would promote health screening behaviour and attitudes, and empower those with symptoms to seek medical help early to enhance early detection and treatment uptake if needed. This would consequently improve outcomes as early detection increases the chances of survival. 

In Nigeria, health care payments are predominantly out-of-pocket, so breast cancer has further socioeconomic implications such as patients’ inability to work and disruption to the work of relatives who provide care.  Breast cancer affects women at the prime of their lives and can potentially plunge the whole family into poverty so diagnosis and treatment uptake at the early stage of the disease is crucial.

The visual demonstration in local languages will enable Users to access the information in a language that they understand and engage with. Adapting the Mami software to non-smart phones ensures that no woman is left behind and enhances early detection across socioeconomic levels. Bridging the gaps potentially results in reduced inequities in outcomes in a society where the woman may not be the key decision maker on her health. 

Enhancing early detection impacts the woman’s health; the wellbeing, security and stability of her children/dependents, community stability, and economic production of a country.

Assumptions: 

Women are willing to learn about breast health education including information on breast cancer in a way that is accessible, convenient, and confidential. 
They would be willing to screen for breast cancer.
They have mobile phones and will be willing to use the mobile phones to book cancer screening services.

These women have access to mobile phone with the capacity to house the app.
Women will be willing to follow the instructions on the app for breast self-examination when they are reminded and shown how to do it. Users would be willing to go for screening tests if they are eligible and to connect with navigators on information on where to access care. 

Enhancing breast health education will improve the knowledge and attitudes of women to improve breast cancer screening behaviour. 

Mami app is composed of a mobile application and a web based back end. The mobile application is built on Flutter by Google which is a cross-platform technology that serves applications to android, iOS, Windows and Web. The mobile application uses SQLite as the database for the mobile part. The web-based back end of the solution is based on ASP.NET Core which is a Microsoft’s web framework for developing web applications for different operating systems. It is supported by a PostgreSQL database. The mobile application communicates with the server via HTTPS connection to ensure that data transmission throughout the system is secured.

Features and User Pathway:

The mobile app provides the users with monthly reminder which is calculated based on the woman’s menstrual status; in women with regular periods the breasts may feel different at certain times of the month. For those with either irregular periods, peri-menopausal or in menopause, there is the option to select an arbitrary date for reminders. The application also has video instructions on how to check the breasts in one of the major local languages. 

This is followed by a step-by-step picture guide on symptoms to check for and how to check for them. The user has the option to download a record of their monthly checks which they can share with their doctor; this feature was repeatedly requested for during the first app testing phase, so we have now incorporated it. If an unusual change is noticed, the user has the option to connect with a local navigator (a trained healthcare or community worker who can provide information on accessing care). We would be monitoring the navigator through our workflow to ensure the user has reported to a clinic to be examined as well as any further diagnostic tests as determined by the doctor. When a user indicates a positive symptom while using the app, they will receive a notification to remind them to contact their doctor and to indicate if they have done so. It would also provide a reminder for women aged above 40 who are deemed eligible by their doctors to go for their yearly mammogram screening.

By becoming familiar with what one’s breasts look and feel like, the user can easily notice when there’s an unusual change and promptly report to a doctor.

We are committed to ensuring that team members are from diverse backgrounds and that we an inclusive work culture. To ensure this, we have put an Equality and Diversity policy in place which every team member is required to read during the onboarding

Our aim is to ensure that all team members (employees, freelancers, volunteers, and job applicants) are given equal opportunity and that our organisation is representative of all sections of society. Each employee will be respected and valued and able to give their best as a result.

This policy reinforces our commitment to providing equality and fairness to all in our recruitment/employment and not provide less favourable facilities or treatment on the grounds of age, caring responsibilities, disability, family situation, gender expression, gender identity, gender reassignment, marriage and civil partnership, pregnancy and maternity, race including ethnic origin, colour, nationality and national origin, religion or belief, sex, sexual orientation, socio-economic background, or the effects of the period/menopause.

 All employees and volunteers, no matter whether they are part-time, full-time, or temporary, will be treated fairly and with respect. When CupArise CIO selects candidates for employment, volunteering, promotion, training, or any other benefit, it will be based on their aptitude and ability.

 All employees and volunteers will be given help and encouragement to develop their full potential and utilise their unique talents. Therefore, the skills and resources of our organisation will be fully utilised, and we will maximise the efficiency of our whole workforce.

Our business model is B2B2C model. 

Our key customers are women:

EARLY ADOPTERS

Women aged 30 – 40 years whose health often takes the backseat to their responsibilities. Although most have heard of breast cancer and agree that it is important to check their breasts regularly, they often forget or don’t know how to do a breast self-exam. Characteristics include:

-        Busy lifestyles

-        Use Facebook, Instagram

-        Have kids or thinking about having kids

-        Health conscious

-        Sexually active

Services: Breast health information, information on accessing healthcare locally

Services through partner organisations: Cancer screening services and clinical consultations. 

Mami would be available free of charge to users and will be funded via two streams using the B2B2C model. These include sponsorship by corporate organisations and commissions (10% - 15%) earned from services offered by partner organisations, which are booked through the mobile app e.g. mammogram, ultrasound, and clinical consultations. As we gain traction, we plan to enable adverts on the mobile app as a further funding stream; these will be adverts by organisations whose values align with ours. In addition, we will explore earning commissions on payment for a type of service/utility e.g., health insurance through the app.

We are still in the process of applying for grants, preparing to approach corporate organisations for sponsorships and exploring our proposed financial models.