mHealth for Mother and Child Health Nutrition - IEEE Xplore

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mHealth for Mother and Child Health Nutrition –

A Review and Proposed Design for Indonesia Focus on Early Life Nutrition in Indonesia

Lily Indriani Octovia, Nurul Ratna Mutu Manikam, Fiastuti Witjaksono, Krisadelfa Sutanto

Nutrition Department Faculty of Medicine Universitas Indonesia-Dr. Cipto Mangunkusumo

National Hospital (FMUI-RSCM) Jakarta, Indonesia

Allya P. Koesoema, Soegijardjo Soegijoko

IEEE Special Interest Group on Humanitarian Technologies

Indonesian Section Bandung, Indonesia [email protected]

Yoke S. Irawan

Biomedical Engineering Department, School of Electrical Engineering and

Informatics Institut Teknologi Bandung

Bandung, Indonesia

Abstract— Information and communication technologies (ICTs), such as computer, mobile phone, and internet, are emerged as an accelerator in the health sector development. They can play a critical role in pursuing outcome for most vulnerable groups, such as pregnant woman and children in developing countries. In this paper, we review the use of m-Health to improve mother and child health. We use the result of this review to propose a design for a set of m-Health applications focused on the improvement of mother and child nutrition in Indonesia. Our analysis of existing applications includes both a literature review and an empirical search of publicly available mobile apps from Google Search, Google Play, and Apple Store. From the review, we found that there exist several mobile and or e-Health systems focusing in improving early life nutrition delivery, both state and privately made. In Indonesia specifically, the Minister of Health has launched a mobile app for early life to work in conjunction an established monitoring book of mother and child health “Buku Kesehatan Ibu dan Anak”. However, the download rate of this app remains low. This result produced important information that can be further learned, so we could set and deliver a successful humanitarian technology implementation in improving early life nutrition care in Indonesia.

Keywords—maternal health; child nutrition; mHealth

I. INTRODUCTION

The early life is a period of rapid growth and development.

All organs and tissues are being formed and developed. This important period is called “1000 days of life” that starts from the first day of pregnancy until two years of life. It is a critical period to form long-term health.

Nutrition plays an important role in this period, as we now face double burden of malnutrition. Both under- and over- nutrition, can have negative effects on the growth and development of the child. Many researches had shown strong associations between malnutrition and non-communicable diseases in later life, such as obesity, diabetes, cancer, heart disease, and etc.

During the first 1000 days of life, it is vital that pregnant and breastfeeding women, infants and young children receive appropriate, specific nutrition input. At this stage, nutrition has key impact on physical growth as well as development of cognitive, digestive, and immune system. Proper nutrition in early life can also play a pivotal role on the development of healthy eating habits for infant.

Indonesia has an established program to enhance mother and child outcome during this period, which includes mobile application in improving quality of mother and child care (Balita Sehat mobile app). However, national data showed that the prevalence of low birth weight and maternal deaths were still high in 2013. This gap brings a challenge to set and deliver a good quality of early life care. In this paper, we will review existing m-Health applications in improving early life nutrition services, both in Indonesia and internationally. From this review, we propose a design for an integrated system of m- Health applications aimed to improve early life nutrition in Indonesia

II. REVIEW OF EXISTING APPLICATIONS AND IMPACT To review existing solutions and evidence as a base for design, a literature review and an empirical search of publicly available mobile apps was conducted.

A. mHealth and Early Life Nutrition

With the exponential growth of its adoption in the developing world, the use of mobile technologies has a vast potential to contribute in improving healthcare results for resource constrained settings. However, the measurement of their impact, the sustainability of applications and replication of best practices still need to be improved. Several studies have highlighted key best practices for impact, as well as the key challenges that still have to be surmounted.

Agarwal et al (2015) in a systematic literature review highlighted that frontline health workers were able to use m- Health to improve different facets of their work, including

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data collection and reporting, training and decision support, emergency referrals, work planning through alerts and reminders, and improved supervision of and communication between healthcare workers. m-Health based data collection increases data timeliness and completeness as well as reduce errors. There is also empirical evidence supporting the impact of mobile based health information delivery to compliance to treatments.

Specific to early life nutrition, Viljoen and Sowah (2015) identified best practices and challenges in five specific m- Health strategies using both feature and smartphone applications. The five m-Health strategies include client education and behavioural change communication, data collection and reporting, supply chain management, electronic decision support, and financial transaction and incentives.

Within these strategies they identified several best practices, i.e. robust multisectoral partnerships, comprehensive quality control, high quality data on user adoption and impact, sustainable business models for all relevant stakeholders, user- centric and data-driven design, multiple recruitment/communication channels, and the inclusion of key activities supporting the m-Health application. Notably, the success stories range from applications using simple feature phones for broadcasting information to comparatively more sophisticated applications in smartphones, such as supply chain management apps. In addition, they identified the lack of interoperability and integration between m-Health applications, as well as the dearth of high quality evidence on safety, health system impact and cost as key challenges yet to be overcome.

B. A short empirical review of publically available smart- phone based mHealth applications in Improving Early Life and Nutrition

To empirically review existing solutions, we searched major app databases and browsers, including Google Play and Apple Store, as well as conduct a general Google Search to retrieve mobile apps and or e-Health systems in early life nutrition. The major keywords used are “humanitarian technology in early life nutrition”, “nutrition in early life”,

“nutrition in early life mobile app”, “maternal health apps”,

“e-Health system in early life nutrition”, “mom health”, “mom and child health”, “healthy pregnancy”, “child nutrition”,

“baby health”. We performed a brief assessment of feature of existing mobile apps and or e-Health system in early life nutrition in Indonesia.

We found many humanitarian mobile applications in early life that are aimed to reduce the number of maternal and infant deaths. A large portion is targeted for sub-Saharan Africa, where the maternal mortality ratios are the highest. In that place, we found several mobile apps, including Abiye Safe Motherhood Initiative (Nigeria), Gifted Mom (Cameroon), Mom Connect (South Africa), Safe Delivery App (Ethiopia), Safe Pregnancy and Birth (Ethiopia), Mobile Midwife (Ghana), Zero Mother Die (Ghana, Gabon, Mali, Nigeria, and Zambia).

For applications with a wider audience, we discovered one app, i.e. MAMA (Mobile Alliance for Maternal Action) which

delivers free health messages to new and expectant mother in South Asia (Bangladesh, India) and sub-Saharan Africa (Nigeria, South Africa). In Asia, we found several apps that have been developed to reduce maternal and infant deaths.

Maymay is a free app for couples expecting a baby. The app aims to reduce maternal and infant mortality in Myanmar.

Meanwhile, Soyujana is a similar app specific to India as its area of implementation.

In Indonesia, Minister of Health has developed and delivered a mobile app in early life to complete a monitoring book of mother and baby care. Balita Sehat is set to deliver growth and development monitoring of babies under five. This app is limited to android basis that was launched in 2011 and last updated in 2016. Unfortunately, download rate is still low and the feature still needs further development.

With regards to applications specializing in early life nutrition, while there are numerous applications which focus on nutrition for pregnant mothers, babies or children, they are generally informal with features such as recipes and general information. Almost none of the applications were aimed to adhere to formal healthcare guidelines or are targeted for certain nutrition issues such as under-nutrition or nutrition for special needs. An example of one of these apps was developed by Danone-Nutricia, Netherland and Hongkong. The app run in android and iOS basis and was last updated in 2016 and 2015, respectively. Total downloads are 10.000-50.000 and 1000- 5000, respectively.

Based on this review, we found that most apps for early life has a broad focus or are aimed for casual users. Most app features focus on the growth and monitoring of infant as well in an alert system to reduce major pregnancy complication. M- Health applications that focus on early life nutrition and, especially ones that focus on how to administer, monitor, and improve adequate nutrition delivery during this period remains limited.

Given the information, in this paper we propose the design of an m-Health system for early life nutrition that integrates the different elements of the healthcare system and is aimed for application in Indonesia.

III. P^ROPOSEDD^ESIGN

Our proposed m-Health system aims to provide an integrated set of modular, interoperable services that encompasses the different actors and activities within the integrated health system for early life nutrition. This approach is chosen because of several factors. First, most existing m- Health applications are only focused on one segment of the health system, such as broadcasting information to clients, or helping community health workers to be more efficient. This leads to the second factor, in which interoperability is still a key challenge in m-Health. Finally, the disconnected nature of different m-Health services also makes health system impact and cost analysis more difficult, especially taking into account the interconnected nature of the healthcare system.

By having an integrated system of modular, but interoperable services that covers the different actors in the

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system, an analysis of potential strategies, cost and impact of m-Health on a systemic level will be more feasible. To achieve this system, the design includes specialized portals for each type of healthcare actors that are integrated in a central server. The integration is aimed to facilitate efficient, timely and coordinated information dissemination, analysis, and care.

A block diagram of the proposed m-Health system components is depicted on Figure 1.

Figure 1. System Block Diagram A. Mother Portal

The Mother Portal is aimed to help mothers to keep track and manage nutrition and development for herself and her children. This portal should consist of several modules. The first basic module should contain nutrition educational information, which can be implemented as time sensitive broadcast messages based on stages of pregnancies/chid development, or as part of a smartphone based mobile application.

Additional features of the module would be implemented as a smartphone based application, to allow for more complex functionalities.

A key module is a meal planning and tracking, which includes recipes, meal planning and nutritional calculator, as well as target based nutritional tracking with customized feedback based on health guidelines and the nutrition/health outcomes history generated from the use of the application.

A healthcare module is included for access and reminder for nutrition relevant health services such as Fe supplements for pregnant mothers, as well as Posyandu (Integrated Service Centers) days, which include nutrition education and supplement for infants and children. Additional sub-modules are included in this healthcare module and meal planning/tracking module according to certain health needs, such as chronic malnutrition or over-nutrition.

Finally, the communication module allows mothers to privately communicate with their peers and relevant nutritional consultants/community healthcare providers.

B. Family and Community Education Portal

The Family and Community Education module consists of two main modules. The first is a general education module, giving general information on nutrition in early life.

Meanwhile, the communication module allows family or community members to express their questions and concerns to appropriate healthcare providers. This module can be implemented both as a web and mobile application, with potential for simple SMS communication functionality for feature phones users.

C. Healthcare Provider Portal

This portal helps healthcare providers deliver efficient and timely care. The patient management module includes patient medical and nutritional record management function, scheduling and administration functions, nutritional supplement supply management and reporting, as well as a clinical referral function that connects providers with the health referral system as needed.

The Education module provides continuing education for healthcare workers, including updates in the clinical science and procedures.

Finally, a communication module will allow healthcare providers to communicate in a timely manner with their patients. The portal can be implemented both as a web and mobile application, with web based functionalities including aggregation and analysis of patient data for healthcare Healthcare Facility

Health Decision Maker Portal

Healthcare

Provider Portal Supply Chain Management

Module

Mother/Patient Portal Family

and Community

Education Portal

Education Module Nutrition Planning and Tracking

Healthcare Module General

Nutritional Health

Context Specific Treatment

Communication Module

Community Education Module

Communication Module Nutrition & Health

Data Aggregation &

Analysis

Supply Chain Monitoring &

Decision System Module

Health Referral Module

Communication Module

• Data Reporting

• Referral

• Coordination

Primary care Information Queries &

Reminders

Information Broadcast Information Broadcast

Information, Queries, Reminders Patient management

module Education module

Communication module

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providers.

D. Health Decision Maker/Referral Portal

The health referral portal is aimed to aid healthcare decision makers to obtain more timely and accurate information from the field, as well as provide timely clinical referral to healthcare providers and parents. The data analysis module aggregates data from the healthcare worker and mothers. This in turn allows decision makers to have real time epidemiological data of its coverage area, facilitating timely and data driven decision making.

The decision maker portal also contains the clinical referral module, which facilitates timely medical referrals and their follow up from healthcare providers. Similarly, a connection to the supply chain monitoring module recapitulates data on micronutrient and other nutrition related supplies availability in its coverage area.

Finally, a communications module facilitates the broadcast and other communication with other actors within the system, such as the delivery of urgent health instructions to healthcare workers or general guidelines to the public.

E. Supply Chain Management Portal

The Supply Chain portal in each relevant health/provider facility provides healthcare facilities managers with tools to monitor delivery, supply and payment of nutrition supporting products across their coverage area. This is aimed to match demand and supply, prevent both stockouts and expiring products, thus enabling suppliers to provide more cost effective and timely service.

IV. D^ISCUSSION

This review produced information in this area and shaped our point of view in developing m-Health applications to improve nutrition delivery and monitoring in early life.

Identification of each obstacles in the development and implementation of humanitarian m-Health system in this area is one of the most important work should be performed.

In addition to technical and healthcare features, relationship building and training are core parts of successful m-Health system as it is a crucial part of m-Health system or any humanitarian technology implementation.

To close, the development and implementation humanitarian technology in any sector needs a long-term work, strong leadership and collaboration, as well as continuous funding.

V. REFERENCES

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