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.

According to the World Bank, South Africa is the country with the
largest GINI index (a measure of relative concentration or inequality) resulting from differences between poorer and richer communities of the population (in close proximity). In addition, South Africa is currently challenged by systematic and public inequalities in access to the public health system. Our current and preliminary findings pertaining to teachers in the Eastern Cape revealed that approximately 40% presented with hypertension stages 1, 2 or 3; and close to 90% were classified as overweight or obese, as per body mass index analysis. Elevated total cholesterol levels were observed with a prevalence of nearly 12%. Similarly, the incidence of diabetes was also prevalent, exceeding 10%. 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 from marginalized communities. Barriers to health data collection, profiling, and exchange, have been attributed to poor infrastructure, lack of training and insecurity.

The spread of mobile technologies and 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 in the Eastern Cape, South Africa, and to support the Department of Health among South African marginalized communities in recording and monitoring relevant medical health parameters at the population level, but also to allow to pursue lifestyle changes on an individual 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.

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 water, sanitation and hygiene (WASH), and the like, have not been completely resolved, populations within LMICs face a double burden of infectious- and non-communicable disease risk.

Lower-resourced settings within LMICs are therefore vulnerable. It is here where our solution will be implemented. Due to environmental challenges, health information flow within these settings is not optimal, where e.g. patients 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. Furthermore, the KaziChat platform is used in continuing professional development (CPD) teacher courses, which are accredited by the South African Council for Educators (SACE) and where it is offered to teachers for use in storing and monitoring relevant key health parameters.

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, and stems from a 10-year collaboration between the University of Basel and Nelson Mandela University. The project aims to promote physical activity and healthy lifestyle behaviour in both schoolchildren, through the KaziKidz toolkit, and their teachers, through a workplace health intervention program. The Kazi- Comprehensive Health Assessment Tool, or KaziCHAT for short, was developed to ease the assessment, profiling, and storage of health and wellness data. 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' (which is valid until June 2027) 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 set specific and global future challenges.

The project lead, Distinguished Professor Darelle van Greunen, is recognised as introducing smart technologies to the man in the street. The recognition is not only in the number of successful projects but also in various awards and international acknowledgement for groundbreaking research and application development within Africa.

To date, 400 teachers (each with 400 data points) have made use of the KaziCHAT platform, for two research projects KaziHealth, and for the
KaziHealth sustainability study.  These research projects were limited to one geographical area, namely Gqeberha.

Little is known about NCD risk factors present among marginalised communities in South Africa, health behaviours practised and the effectiveness of interventions for improvement. 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, which worsened during the COVID-19 pandemic, as South Africa put into practice and enforced one of the toughest lockdown globally. Incentivize participation, usage, and goal achievement through gamification can support this process. 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).  As the solution development is based on end-user needs, the solution will benefit from a revision based on the current results and usage.

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 its 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 these 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 and use user-friendly and 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).

The 5-year visions of the UNESCO Chair Team for the future are:

1. Continue and strengthen the link with UNESCO and WHO policy. Close cooperation with UNESCO (especially on 'QPE', 'Fit for Life' and 'Ready to learn and thrive') and existing UNESCO Chairs on relevant programmes and activities.
2. Continue to collect and monitor key medical parameters via the KaziChat platform for scientific analysis at the population level and share epidemiological results with the public health system in the Eastern Cape to enable potential action.
3. Campaign for the recognition of physical education as an essential component of the school curriculum and for the reintroduction of physical education as a stand-alone subject in the South African school system.
4. Promote the inclusion of KaziBantu – 'Healthy Schools for Healthy Communities' as an interdisciplinary project between the Health Sciences Faculty and the Education Faculty at NMU, for the promotion of health and well-being of children and teachers, as well as the implementation and improvement of quality physical education teacher education.

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. 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.

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 South African 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.

The technology solution is in use in specific Nelson Mandela Bay area schools. Evidence of how the solution works and academic publications are listed below:

KaziCHAT Demo

Academic Paper: Digital health solutions to support self-monitoring and self-management of patients

Research publications on the KaziBantu project

Nelson Mandela University has taken various steps to promote inclusivity and transformation. These initiatives include:

Access to Education: The university aims to provide access to quality education for a diverse range of students, including historically disadvantaged individuals. It offers financial aid programs, scholarships, and support services to ensure that students from different backgrounds have an opportunity to pursue higher education.

Curriculum Transformation: The university has been working on curriculum transformation to address social justice, diversity, and inclusivity issues. This includes incorporating diverse perspectives, indigenous knowledge systems, and relevant content into the curriculum to provide a more inclusive and representative education.

Diversity and Equity Policies: Nelson Mandela University has implemented policies and initiatives to promote diversity and equity within its student body and staff. These efforts include affirmative action policies, employment equity programs, and creating an inclusive and supportive campus environment for all individuals.

Community Engagement: The university engages with the local community and partners with various stakeholders to address social issues and contribute to community development. This includes collaborative research projects, community outreach programs, and knowledge exchange initiatives that aim to uplift marginalized communities.

Transformation Initiatives: Nelson Mandela University has launched specific transformation initiatives to address historical imbalances and promote social justice. These initiatives may include mentorship programs, leadership development opportunities, and platforms for dialogue on social issues.

To gain more detailed and up-to-date information about Nelson Mandela University's specific policies, initiatives, and impact, it is recommended to visit its official website, review its strategic plans, and explore relevant reports or publications.

The University and all research entities are firmly rooted in the institution's vision, mission and values. One of the core values is Respect for Diversity:

• We reflect and serve diverse regional, national and global communities.
• We promote an open society where critical scholarship and the expression of a multiplicity of opinions and ideas are actively encouraged.
• We foster an environment in which diversity is appreciated, respected and celebrated.
• We foster a culture that welcomes and respects diverse identities, heritages and life experiences.

As a research and engagement entity at a university, we typically operate under a specific business model that supports our activities and sustains our operations. The following elements are commonly found in the business model:

Research Grants and Contracts: One primary source of revenue for the Centre for Community Technologies (CCT) is obtaining grants and contracts from external funding sources such as government agencies, private foundations, corporations, or other organizations. These funds support our research projects and engagement initiatives undertaken by the CCT.

Consulting and Services: The CCT offers consulting services to external clients, including businesses, government agencies, non-profit organizations, and other academic institutions. These services include research collaborations, specialized expertise, data analysis, policy development, and training programs. Consulting fees and service contracts contribute to the revenue stream.

Sponsorships and Donations: Partnerships with industry, philanthropic organizations, alumni, and other benefactors are an important component of the business model. These sponsorships and donations support specific research projects, scholarships, fellowships, or infrastructure development.

Training and Education Programs: The CCT offer specialized training programs, workshops, continuing education courses, or professional development opportunities. These programs target industry professionals, government employees, or individuals seeking to enhance their skills and knowledge. Tuition fees and enrollment charges contribute to revenue generation.

Collaborative Projects and Consortia: The CCT engages in collaborative research projects and consortia with other academic institutions, industry partners, government agencies, and non-profit organizations. These collaborations often involve shared funding and resources, enabling the CCT to participate in larger-scale projects that may attract more substantial grants and contracts.

Expertise and Thought Leadership: The CCT has established itself as a reputable source of expertise and thought leadership in its specific research domains focusing on Africa's low-resourced areas. This leads to opportunities for providing expert opinions, participating in policy discussions, contributing to industry reports, and attracting media attention, enhancing the CCT's visibility and reputation.

To make the CCT financially sustainable, we developed a comprehensive strategy to generate revenue and manage expenses effectively. Some aspects of the strategy include:

Diversify Funding Sources: to diversify funding by actively pursuing grants, contracts, sponsorships, donations, consulting services, technology transfer, and other revenue streams. This reduces dependence on any single source and creates a more stable financial foundation.

Pursue Competitive Grants and Contracts: Actively pursue competitive research grants and contracts from government agencies, foundations, and industry partners. We use a proactive approach to identify funding opportunities, develop compelling proposals, and build strong collaborations. Success in obtaining competitive funding enhances the financial sustainability of the entity.

Foster Industry Partnerships: Establish strong relationships with industry partners through collaborative research projects, technology transfer, and consulting services. Engage in industry-sponsored research and contract research.

Offer Fee-based Services and Consulting: To leverage the expertise within the CCT to provide fee-based services and consulting to external clients. This includes specialized research collaborations, data analysis, policy development, training programs, and expert opinions.

Promote Continuing Education and Professional Development: To develop and offer training programs, workshops, and continuing education courses that cater to industry professionals, government employees, and individuals seeking to enhance their skills. These programs generate revenue through tuition fees and provide opportunities for networking and collaboration.

Optimize Resource Allocation: The management committee efficiently allocates resources to maximize the impact of research initiatives while minimizing costs. It regularly assesses the effectiveness and efficiency of research projects, infrastructure utilization, and administrative processes. It also identifies areas where resources can be redirected or streamlined to ensure optimal use of available funds.

Enhance Visibility and Reputation: The CCT strives to cultivate a strong reputation for excellence in research and engagement within the academic and broader communities. It promotes the achievements and impact of the research entity through publications, conferences, media engagement, and thought leadership activities.

The funding amounts to approximately USD1.5m over the five years. Detail on amounts available upon request. Below is a list of some funders over the past five years:

• Novartis Foundation
• Technology Innovation Agency
• Discovery Foundation
• Department of Science and Innovation
• Department of Health
• European Union H2020
• European Union Erasmus+
• South African Medical Research Council
• Fogarty Grant
• UNICEF
• National Research Foundation
• WHO
• Pfizer South Africa
• Janssen Pharmaceuticals 
• UTFORSK Norway