By Min Dai
The SCUBY project is conducted during a special time: although focusing on chronic diseases, it is inevitably implemented and realised together with the COVID pandemic in many different ways. Five of our very kind colleagues from all the four participating countries took the time for the interview, to speak about how the SCUBY team took a part in the COVID response, what are the most impressions, how the team has been influenced and learned from the pandemic:
Josefien Van Olmen, SCUBY Project Director and professor, University of Antwerp, Belgium
Katrien Danhieux, SCUBY Researcher and PhD researcher, University of Antwerp, Belgium
Por Ir, SCUBY Principal Investigator and Deputy Director, National Institute of Public Health, Cambodia
Črt Zavrnik, SCUBY Researcher and Healthcare Researcher, Community Health Centre Ljubljana, Slovenia
Kerstin Klipstein-Grobusch, SCUBY Principal Investigator and Associate Professor, University Medical Center Utrecht, The Netherlands
1. Have you and other members in the team taken up a particular role in the COVID response? Can you describe it?
Josefien:“We were overviewing the entire situation.”
Josefien mentions Katrien’s early role in the field at one of the triage centres, which lasted for at least a year and is very visible in the research and gives many insights; her own role as a member of the Antwerp COVID advisory board, the oversight body of the entire epidemic in the metropolitan and surrounding areas of Antwerp; the many COVID related patients that Roy has seen in his general practice; Veerle and Edwin’s inventory on the effect on international students, a research fed the university action plans.
Katrien shares her experience in the triage centre from the first wave of the epidemic with other colleagues from the university, her service in the nursing/care home during the second wave, where most of the deaths happened; and her general GP practice afterwards and service at the vaccination centre. She also speaks about the role of prof. Roy Remmen, prof. Josefien Van Omen connected with the government’s efforts to address the COVID crisis in Belgium.
Por: “We are the first public institute with PCR test in the country.”
NIPH-SCUBY team members are involved with hotspot screening (PCR and RDT), logistic management as well as data management.
Por describes the important role of SCUBY team Cambodia, as part of the National Institute of Public Health, in all the main areas of the COVID-19 response including sample collection and testing; contact investigation; training and technical supervision; and support in the policy and strategy development. A couple of senior members of the team joined working groups and contributed to the policy and strategy development for Cambodia. A large part of the SCUBY team are the staff of NIPH laboratory, the first public health facility able to perform PCR tests which plays a very important role in testing and training. Por speaks about his vice-chair role in the COVID training working group where he coordinates many training programs including the last one in progress on how to manage severe cases of COVID, in collaboration with the national hospital; and his role as a member of a sub-committee on training and COVID-19 vaccination technical supervision. All the NIPH members including the SCUBY team support COVID-19 data management, data entry, data analysis, cleaning, mostly about daily-updated lab testing; these are usually done in the evenings and weekends.
Črt: “We the GPs are carrying out the vaccination exclusively.”
Črt talks about his role as a specialist in family medicine at the first line of the “battle” against COVID_19, to adapt quickly to a different way of working and to ensure health facilities remained as “white zones”. In addition, the GPs have also taken on some completely new COVID-19 specific roles: to be actively involved in the SWAB unit and COVID-19 outpatient clinics, and to carry out exclusively the entire process of vaccination organization and implementation in Slovenia. He also describes the role of Antonija Poplas Susic, SCUBY PI, as the head of Community Health Centre Ljubljana to ensure ongoing coordination between national stakeholders and providers so that all work processes can run smoothly at all times (COVID-19 vaccination, ambulance, SWAB units, emergency department, etc.), and with constant adaptations due to the ever-changing national policies and guidelines. Majda Mori Lukancic, SCUBY Researcher and a nurse working with a diabetologist in a diabetes outpatient clinic, noted that their workload has increased greatly due to the significant deterioration of many diabetic patients; she also reports that the COVID-19 pandemic has also greatly affected her work process - many physical examinations have been replaced by remote treatments, and an increased incidence of diabetic complications has also been noted in recent months (e.g., the incidence of diabetic foot ulcers has approximately tripled).
2. What has made most impressions to you?
Josefien is mostly impressed by the gigantic energy which could be mobilized and how people on all fronts – from within the population, politicians, managers - could convey and join in a common course to fight the epidemic, and how a clear and common goal and a “pressure cooker” phenomenon can make things possible, which gives a lesson for future reform for more gradual transitions.
Katrien: “I will never forget the face of my first patient at the triage centre.”
Testing at a triage center in Antwerp, 2020 ©VRT, Michaël Torfs. Source
Katrien talks about her unforgettable memory of the anxious face of her very first patient, a young girl she met in the triage centre, and the heavy but warm and collaborative teamwork in the nursing/care homes.
Por: “Cambodia is among the most vaccinated countries in Asia”.
Por is mostly satisfied with what the government has done: the commitment, the performance, and the ability to control the outbreaks in communities from overwhelming the health system. During this process in which he is directly involved, he is impressed with the great amount of work and achievements: the quality of NIPH’s quality is recognized worldwide, heavy training programs are being conducted, and he is now involved in the vaccination campaign, supporting the policy development and supervising the quality of activities. From all these activities, he thinks it is a great opportunity not only to help the country but also to learn from the world, especially for the junior staff to learn the system and how to respond.
Črt is impressed by the huge impact of COVID-19 infection on all aspects of our daily lives (health care, work processes, social and psychological aspects, etc.), and is aware and concerned about all the late effects of this pandemic besides the macro-economic and psycho-social aspects, the exacerbation of chronic diseases, delayed detection of complications, and overlooked malignancies. He is also very impressed with how efficiently they have adapted to this health crisis at the meso and micro levels of healthcare, and he is very positive about their future management of all the other challenges.
3. How did your work for the COVID response influence your work for SCUBY?
Josefien:“The network is strengthened, and trust and confidence are built.”
Josefien thinks the work strengthened the network of actors we collaborate with. Trust and confidence are built for future themes. A deeper understanding of the situation in the field at all levels, from the neighbourhood work to the ministerial decisions. It has halted the works we were doing with stakeholders on progressing the roadmap on SCUBY, but we used the time of that “delay” to consolidate collected evidence. It is true that COVID eats up time, also because, especially in the first phase, it had such a strong “pull” factor: it was an emergency, everybody wanted to contribute. The challenge for all of us - in general - is to balance the engagement with multiple roles, both during the crisis and when the situation is cooling down.
Katrien felt the challenge very much in the beginning due to her heavy engagement early in the COVID response, but now it is more balanced between working for SCUBY and meeting patients and colleagues since she has to work from home most of the time.
Por experiences both positive and negative influences. The negative ones include direct ones such as the diverted time and attention, and indirect ones mostly related to the impossibility and delay in the participation of stakeholders. The positive ones include the fact that the COVID situation highlights clearly the lack of services in certain groups (e.g., people with chronic diseases), and the importance to make access to services for those groups and to create opportunities to interact with policymakers.
Črt outlines the physical and mental exhaustion of the SCUBY team due to their additional duties. On a separate note, there are now fewer face-to-face meetings; online meetings have become the new reality instead. Although there are disadvantages, online meetings simplify organization as the team members come from different parts of Slovenia. On work package 4 (Monitoring and Health Information System), for which Crt is responsible in Slovenia, the COVID-19 pandemic has had little impact. Data collection and analysis went smoothly as no on-site data collection was necessary.
Kerstin: “We develop new ways of communication.”
SCUBY consortium meeting 7-9th June 2021 in a hybrid formula
Kerstin highlights that the important COVID-19 pandemic response tasks of many of our stakeholders led to delays in the development of scale-up roadmaps for integrated chronic care for hypertension and diabetes mellitus type 2 in all implementation countries – Cambodia, Slovenia and Belgium. The team experienced limited stakeholder engagement and face-to-face interactions within and across countries. This complicated communications, at least initially. Over time, the team developed new ways for effective project and stakeholder communications with increasing experience (and expertise) in the use of online technology platforms. Flexibility and the ability to adapt and experiment allowed the team to embrace the opportunities that technology offers. Online patient consultation, for example, has been shown to work and to be a valuable tool to empower patients to self-manage.
4. Did the COVID pandemic and response give you any lessons for SCUBY?
Josefien: “The covid response showed how we can collaborate from the ground and scale up; it was bottom-up!”
Josefien suggests that SCUBY can use better the bottom-up approach shown in the COVID response. In SCUBY there is still a divide between the people who are implementing projects and things in the field and talking about how the legislation and financing are hindering scale-up, and the people who are actually thinking about reform and data. In the COVID response process, such a divide was largely reduced, and things could be more easily integrated although a lot of meetings took place. We need to continue building such bridges to connect the projects and decision-making at different levels.
Katrien: “The manual doesn’t match the productive material… decisions have to be made at one level.”
Katrien thinks the COVID response addresses the problems in the current health care sector explicitly. While SCUBY defines the problem in Belgium within the division of responsibilities over the different governments, COVID made it clearer. A vivid example took place in the testing at a nursing/care home during the first wave, when the federal government, responsible for the hospitals, provided the testing material, and the Flemish government, responsible for the prevention and vaccination, provided the operation manual which did not match the testing materials. It echoes the same problem that happens in chronic care, which highlights the need for better coordination at different levels.
Por: “It is also an opportunity.”
Por emphasises the opportunity brought by COVID to transfer messages and evidence to policymakers. Another lesson is about capacity building and learning for the SCUBY staff. SCUBY is not only for SCUBY but also for the health system in Cambodia; it focuses on chronic diseases, but it also has a cross-cutting effect to the health system. Through engagement in the COVID response, we understand better the situation of access to chronic diseases during the COVID period and maybe also in the next emergencies; we can also understand better how policymakers, both at the country and international levels, look at infectious diseases as compared to non-communicable diseases.
Črt emphasized the importance of constant presence of competent health workers and their interventions for the stability of patients with chronic diseases. The lack of health care along with other factors (e.g., stress and social isolation) has led to worsening of diseases and increased incidence of complications in many patients. Therefore, it is critical to recognize the importance of empowering patients and supporting their self-management. The final but no less important lesson is that together, with the right attitude and invested energy, we can overcome challenges on the way to our (common) goal.
Kerstin looks forward to using the effective project and stakeholder online communication methods developed during the COVID-19 period to complement face-to-face engagement in the post-COVID-19 era.