mHealth tools to combat childhood pneumonia

Setting the quality management global benchmark for tackling childhood pneumonia in India

About

The two-year project VISHWAAS is a collaboration between Philips Foundation, Save the Children India, the social enterprise ZMQ Development and Philips India CSR to develop and prove low-cost innovative approaches for prevention, diagnosis and management of Childhood Pneumonia. The project is built around digital mHealth applications, targeting four audiences: community members, frontline health workers (ASHAs, ANMs), and medical officers/staff nurses. The intervention also uses the ChARM (Children’s Automated Respiration Monitor) device to aid pneumonia identification through automated respiratory rate measurement.

Partners

How

The VISHWAAS project’s integrated approach to combating childhood pneumonia uses a systemic change model that addresses prevention, protection, diagnosis and treatment of pneumonia. The key interventions focused on social behavior change communication (SBCC) and case management. These were supported with technology interventions, as well as strengthened capacity building, immunization and medication.

Key interventions included:

SBCC tool aimed at increased community awareness of pneumonia and improved care seeking behavior.
Case management tool for improved reporting and monitoring at community and hospitals.
The tools are complemented with app and web-based dashboards for improved collaboration and management.
The ChARM point of care diagnostic tool for early diagnosis (respiratory rate counting based) used by frontline health workers for improved case detection and referral.
Improved prevention and protection through promotion of exclusive breastfeeding, nutrition, hygiene and immunization.
Provision of pre-referral dose of amoxicillin by frontline health workers and strengthening supply chain for availability.
Capacity building of frontline health workers, ASHAs and ANMs through training, supervision and skill enhancement initiatives.

A solid monitoring and evaluation framework was pursued to measure the outcomes of increased community awareness and care-seeking behavior, as well as improved case detection and management. In addition, data and information systems were strengthened to allow systematic tracking of pneumonia care outcomes.

The project was implemented across 45 urban wards in Rajasthan and two rural blocks in Uttar Pradesh and delivered high-quality pneumonia care to approximately 110,000 children under five years old.

Results

After almost two years of project implementation, strong improvement in outcome indicators can be observed across the board for community awareness and care seeking, as well as for improved case management. Key achievements include:

The percentage of children with symptoms of Acute Respiratory Infection decreased from 18.3% to 6.7% over the course of the project.
Increased community awareness of pneumonia and improved care seeking behavior. E.g., the percentage of households with knowledge of signs of childhood pneumonia increased from 34% at baseline to 75% at endline. Preventive behavior, such as immunization and exclusive breastfeeding, improved as well.
Improved detection and management of pneumonia cases. E.g., treatment coverage and provision of antibiotics to children with suspected pneumonia increased from 29% to almost 70%, while 62% of ASHAs are now equipped with pre-referral doses of amoxidllin vs. 0% at baseline.

Learnings and next steps

The Android-based mHealth Pneumonia Tools designed to drive behavior change and support frontline health workers with standard protocols to identify, classify, manage, refer and treat childhood pneumonia – developed by ZMQ – were successfully used by 144 ASHAs and 26 ANMs.

Some observations about the use of the tools made by Dr. Op Singh, Head Program Implementation Health & Nutrition at Save the Children India, during a webinar organized by Philips Foundation:

The digital tools not only empower frontline health workers in doing their job, but also gives them a new face and role in their communities. The tools boost health workers’ confidence and make them more trusted in counseling towards families and community groups.
The standard protocols provided by the tool's eases consistent registration, classification, assessment and case referral and will lead to improved perceived quality of care and demand for services.
Health workers are able to use the digital tools to influence decision making at the household level. Adoption of the tool's spreads by word of mouth.

Observations related to digital tool design (from Ayushi Singh, program manager ZMQ, shared during the same webcast):

It is important to apply inclusive design principles to ensure that digital tools meet the skills and requirements of the targeted care givers and audience. However, context and culture aware deployment strategies are as important for successful implementation.
Solution design needs to start with participatory interaction on the ground, using methods like story labs, stage plays and group sessions to deeply understand social-cultural backgrounds.

The open-source tools are available free of charge from Google Play Store. Please find the direct download links in the resource section below.

The ChARM point of care device for respiratory rate measurement received good acceptance among health workers. Most of them found the device useful for their work. They indicated the assessment with ChARM is less time-consuming and the red light that displays increased breathing makes classification easier and is helpful in convincing parents to take the child to a health facility for follow up assessment.

Save the Children India has formulated a comprehensive set of recommendations to convert the learnings from the VISHWAAS project to deliver a more sustained and scalable impact.