HERA: A Health Platform for Refugees

HERA App is a mobile health (mhealth) intervention designed for Syrian refugees under temporary protection in Turkey, a population of 4 million people.The application was envisioned as a guide and a bridge for refugees, especially women and children, to access healthcare services in Turkey. Increasing demand for preventive services, such as childhood immunizations and antenatal visits, will eventually lead to saving lives, reducing the hospitalization times, and lowering healthcare costs in this population. HERA is an acronym for ‘Health Recording App’ and is the name of a powerful Greek Goddess.

HERA was designed to decrease maternal and infant mortality and morbidity by increasing the uptake of vaccinations and prenatal care. The crucial distinguishing feature of HERA is that it focuses on the demand-side of the care equation: while the majority of healthcare solutions focus on increasing the supply of healthcare, HERA works by increasing the demand for existing health services. To achieve this goal, HERA sends push notifications to users about upcoming important medical appointments. The app also provides information in English, Turkish, and Arabic about the Turkish health and legal system, which is unfamiliar to many refugees. Additionally, users are able to locate nearby medical clinics and to store their personal health records in a secure encrypted location. 

All of our codes for both backend & mobile app v1.0 can be found here: (we are trying to make sure all of our is reproducible and understandable, bare with us!)

https://github.com/hera-for-refugees

Leadership: Team and Advisors

Core Team:

● Aral Sürmeli – Global team management, partnerships, scaling strategy

● Hande Tarcan – In-country team management and technology development

● Sarah Bolongaita – Monitoring and evaluation design and analysis

● Matt Hughsam – Fundraising and scaling strategy

● Erdal Bayraktar & Pınar Erçelik – Pilot coordination and in-country management

Advisory Board:

● App Design Advisor - Prof. Nitika Pai, MD, MPH, PhD. McGill University

○ mHealth expert, created apps for HIV response in African countries

● IT and Scaling Advisor - Prof. Ata Akin, PhD. Acıbadem University

○ Leader of incubation center of Acıbadem University

● Scaling Advisor - Prof. Rifat Atun, MBBS, MBA. Harvard University

○ Global health systems expert, special advisor to Turkish Ministry of Health

● Statistics and Evaluation Advisor - Dr. Figen Demir, MD. Acıbadem University

○ Epidemiology and statistics expert

HERA App description short video: https://youtu.be/uGFLJXlqwBk

HERA App Screenshots:

HERA is a web platform designed increase vaccination and prenatal care uptake of Syrian refugee populations through an innovative mobile solution. Users can track their health, call ambulance, keep electronic health records, navigate to closeby health centers and receive reminders for timely vaccination dates, through an automated calendar system.

You can download it in the app store, it is free!

HERA Project is an open-source web platform, currently offered through a mobile application. People can contribute to our codes since it is publicly available. In addition, anyone can use our codes as a base to their interventions for other populations. In addition, interested parties can contribute to HERA in parallel to our 'needs' described in JOGL. Namely, business development, integration and field tests in other populations, P&R material creation and support, UX / UI design. We are also happy to collaborate with organizations and partners for global health / mobile health grant applications. For collaborations, they can contact Aral Sürmeli through JOGL, or given contact info and discuss how we can work together. The main condition we put forward is that any work related to HERA will be non-profit, meaning the primary aim of any activity will be to improve health of vulnerable populations. We are a group of passionate professionals focused on this aim and always looking for people to share information, guidance and collaboration without any reservation. We are always working on making our work more open for reproductivity and collaboration.

According to the UN, the Syrian refugee crisis is the worst humanitarian crisis since World War

II, with over 10 million people displaced, 60% of whom are women and children. Prenatal care and childhood immunizations are essential services that prevent significant morbidity and mortality. Evidence indicates that timely and complete uptake of these health services is low among Syrian refugees in Turkey, our focus country, and comparable places:

● Less than 50% of pregnant Syrians attend at least four prenatal care visits and only 13-

25% of children are fully-immunized.

● Outbreaks of vaccine-preventable diseases among refugee children are

increasing despite numerous immunization campaigns.

● In Turkey, as few as 59% of Syrian refugee children outside of camps are immunized for

measles.

Even though the Turkish government provides free healthcare to Syrian refugees, studies and

our first-hand experiences indicate that women face many barriers to accessing services for

themselves and their children, including:

● Language barriers, which complicate navigating an unfamiliar, complex health system;

● Competing demands such as managing their family’s numerous other settlement needs;

● Fear of deportation or other consequences if they access health services; and

● Lost or non-existent medical records, which hinder continuity of care.

HERA works as a bridge between Syrian refugee women and children and the Turkish health

system. As an app-based mobile health platform, HERA provides:

● Push notification reminders: Users receive three notifications (a week prior, a day prior,

and the day of their appointment).

● Electronic health record keeping: Users can scan and store medical information and

notes in a cloud-based server, protected by EU-compliant security measures.

● Health facility location finder: Users can locate, view details for nearby health centers.

● Emergency service call: With a single tap, users can call emergency services and the

app announces the location of the caller in Turkish for the emergency service responder.

● Education: Users can access health education and information about the health system.

Once a user downloads and opens the HERA app (available in Arabic, Turkish and English) they are

prompted to enter their health information. The app then automatically calculates the dates for

their four prenatal care visits and remaining immunizations for their children using Turkish vaccination calendar.

Objectives:

• Increase uptake of timely vaccination in refugee communities.
• Increase uptake of prenatal care in refugee women.
• Prevent amenable mortality and morbidity due to migration and related social determinants of health.

HERA App screens: https://www.youtube.com/watch?v=KNbKPzypWPA

HERA differs from majority of global health interventions as it focuses on demand instead of supply to bridge the demand gap. In addition, HERA is designed specifically as a behavior nudge system for users to prioritize preventive health services, mainly uptake of vaccination and prenatal care. It is complementary to systems already in place, increasing their effectiveness by acting as a push factor.

To our knowledge, HERA is the first mhealth approach to increase uptake of vaccinations via a reminder algorithm while also providing vital health and healthcare access information primarily targeting refugee populations.

HERA's proof of concept phase is finishing in January 2020. Transition to scale is planned as two pronged operation. International and national scale up. Progress to date in international scale up is registering as a non-profit in US and moving business development activities overseas. International scale up is to be continued via HERA Inc. in Boston / MA. While national scale up eventually leads to complete integration to MoH's health activities towards refugees, to date, we started the protocol to incorporate HERA in local MoH owned primary healthcare centers. Long term strategy plan is presented in impact strategy part. Specific needs are described as below:

1- IT support: In order for HERA to be more adaptable to specific needs of different refugee populations, we require IT partners.

2- Animation Video: One feedback we received from our current users was that they were not sure about how to use the app in a useful way. We indluded addition of an explainer animation video for our scale up plans.

3- International partners for joint grant applications: Since mhealth is relatively new sector in medicine, there is hype and following financial support from different grantors. However we require other organizations to apply together and implement HERA in different settings.

4- Adaptation of HERA to an 'open sourced - open science' basis: With the start of our involvement in JOGL Program, we devoted some of our efforts to making HERA more open and available to other people to use, further develop and comment. We require an advisory group on this issue to increase HERA's openness as a project.

HERA is especially designed to complement systems that are already in place. In Turkey, registered Syrian refugees (%99.9) are entitled to free healthcare by Ministry of Health(MoH), the biggest healthcare provider for Syrian refugees. HERA utilizes this supply opportunity by guiding through the healthcare system while prioritizing preventive care access.

Syrian refugee population is the biggest and most important stakeholder of HERA project. We have made the utmost effort to ensure they are part of all decision making process' since the beginning. HERA was designed hand in hand with refugees and we implemented a routine feedback and evaluation procedures since 2018. Specific features of HERA are decided with them.

International NGOs and UN organizations play an important role in HERA's international scale up. As the need for refugee care increases around the world and in Turkey, many organizations are looking for local partners, such as HERA, to work together in the local context.

These are conservative estimation of our impact calculations using the literature and our capacity. Overall scale up and impact:



Environmental considerations and impact: HERA offers a digital way to carry health records, vaccination calendars and scheduling through mobile phones. Therefore its environmental impact is estimated to be minimal.

Social considerations and impact: HERA is designed hand in hand with the target population and their healthcare point of contacts. Primary meetings, qualitative analysis and other short term protocols are initiated before the design of intervention itself. In addition, certain field protocols are incorporated to respond in adverse situations that our target group can experience. As an example, though not the primary aim of the project, project team received training on domestic violence and created protocols to react in any disclosed situations or suspicions in the field.

IRB approval and accountability: HERA project incorporates a formal scientific study protocol and received IRB approval from the beginning. We believe ethical approval and conducting a formal study are ways to ensure that we are accountable to our target population and research community.

Our code of conduct can be found under documents.

HERA's transition to scale has 2 seperate strategies symbolising in country and international scale up. Sustainability and business development strategies are in parallel with both scale up strategies.

1-In-country Scale Up: Scale up of HERA in Turkey is mainly focused in uptake of and integration to routine MoH provided healthcare services for Syrian refugees. As the sole provider for this population, MoH has started integrating similar digital interventions for Turkish population. Our strategy includes buy-in from local MoH migrant clinics and then nationwide integration to ehealth services. (Sustainability and business strategy presented in the graphic.)

2-International Scale Up: International scale up focuses mainly on uptake by international refugee response organizations such as UNHCR, WHO and other INGOs. (Sustainability and business strategy presented in the graphic.)

Innovation centers: HERA is part of international innovation programs such as Harvard ILabs and JOGL. One of the many benefits is to utilize their vast network to increase our visibility and possiblity of cooperation with other groups.

Refugee populations: As our biggest stakeholder in HERA, we are constantly doing social media campaigns to increase awareness on importance of vaccination and how HERA can be helpful to refugee populations.

Turkish population trials: An important factor in dissemination is acceptance of host country and the officials. In order to increase uptake and decrease resistance, we undertook study protocols to offer HERA to the host population in Istanbul through MoH run primary care centers.

Grassroot organizations: They are the organizations that are in the closest contact to refugee populations. Since 2018, we made agreements with 22 grassroots and currently helping them incorporate HERA in their activities for their populations.

HERA has been funded by Grand Challenges Canada in 2018 for 95.500 CAD for proof of concept study. Currently we are nearing the end of funding and seeking transition to scale funding through NIH (National Intsitutes of Health) and global health grants.