Development and evaluation of a mobile application for case management of small and sick newborns in Bangladesh

Abstract

Background: In low-income settings, community health workers (CHWs) are frequently the first point of contact for newborns. Mobile technology may aid health workers in classifying illness and providing referral and management guidance for newborn care. This study evaluates the potential for mobile health technology to improve diagnosis and case management of newborns in Bangladesh.

Methods: A mobile application based on Bangladesh's Comprehensive Newborn Care Package national guidelines (mCNCP) was developed to aid CHWs in identifying and managing small and sick infants. After a 2-day training, CHWs assessed newborns at Sylhet Osmani Medical College Hospital and in the Projahnmo research site (Sylhet, Bangladesh) using either mCNCP or a comparable paper form (pCNCP), similar to standard IMCI-formatted paper forms. CHWs were randomized to conduct a block of ~ 6 newborn assessments starting with either mCNCP or pCNCP, then switched to the alternate method. Physicians using mCNCP served as gold standard assessors. CHW performance with mCNCP and pCNCP were compared using chi-squared tests of independence for equality of proportions, and logistic regressions clustered by CHW.

Results: Two hundred seven total CHW assessments were completed on 101 enrolled infants. mCNCP assessments were more often fully completed and completed faster than pCNCP assessments (100% vs 23.8%, p < 0.001; 17.5 vs 23.6 min; p < 0.001). mCNCP facilitated calculations of respiratory rate, temperature, and gestational age. CHWs using mCNCP were more likely to identify small newborns (Odds Ratio (OR): 20.8, Confidence Interval (CI): (7.1, 60.8), p < 0.001), and to correctly classify 7 out of 16 newborn conditions evaluated, including severe weight loss (OR: 13.1, CI: (4.6, 37.5), p < 0.001), poor movement (OR: 6.6, CI: (2.3, 19.3), p = 0.001), hypothermia (OR: 14.9, CI: (2.7, 82.2), p = 0.002), and feeding intolerance (OR: 2.1, CI: (1.3, 3.3), p = 0.003). CHWs with mCNCP were more likely to provide counseling as needed on 4 out of 7 case management recommendations evaluated, including kangaroo mother care.

Conclusions: CHWs in rural Bangladesh with limited experience using tablets successfully used a mobile application for neonatal assessment after a two-day training. mCNCP may aid frontline health workers in Bangladesh to improve completion of neonatal assessment, classification of illnesses, and adherence to neonatal management guidelines.

Keywords: Bangladesh clinical guidelines; Community health worker; Comprehensive Newborn Care Package; Integrated Management of Childhood Illnesses; Newborn assessment; Newborn care; Newborn case management; Newborn danger signs; User-centered design; m-Health; mCNCP.

Fig. 1

mCNCP Mobile Application Interface (English Translation). Screenshots of the mCNCP mobile application interface (with English-translated instructions), using an Android tablet or phone. Interface images demonstrate prompts for health workers to measure vital signs, assess for conditions and danger signs, and manage conditions. a Prompt for health worker to provide date and time of birth using a calendar and drop-down time feature, and a table to translate month names from English to Bangla; b Prompt for health worker to measure and record infant’s temperature; c Prompt for health worker to assess infant for severe chest indrawing; d Prompt for health worker to assess infant’s movement and tone; e Generated summary of feeding assessment and feeding advice based on health workers’ responses; f Generated summary of infant’s danger signs, conditions, and referral management advice. At the time of the study, mCNCP pages were displayed in the Bangla language. Most images in the mCNCP version used in the study were taken from Bangladesh’s Comprehensive Newborn Care Package (CNCP) guidelines for newborn assessment, that were developed in collaboration with the American Academy of Pediatrics using open source images from Essential Care for Small Babies (ECSB; Provider Guide), Essential Care for Every Baby (ECEB; Parent Guide), and Helping Babies Breathe (HBB; Provider Guide)

Fig. 2

Summary of CHW Focus Group Findings on mCNCP User-Satisfaction and Preferences. Key findings across post-user-testing focus groups with community health workers (CHWs). Topics include positive feedback, identified areas for improvement, and perceptions on the feasibility of mCNCP scale-up