Supporting LIFE: Mobile Health Application for Classifying, Treating and Monitoring Disease Outbreaks of Sick Children in Developing Countries Yvonne O' Connor1(), Victoria Hardy2, Ciara Heavin1, Joe Gallagher3, and John O' Donoghue4 1
Health Information Systems Research Centre, University College Cork, Corcaigh, Ireland {y.oconnor,c.heavin}@ucc.ie 2 Department of Family Medicine, University of Washington, Seattle, USA
[email protected] 3 gHealth Research Group, University College Dublin, Dublin, Ireland
[email protected] 4 Global eHealth Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
[email protected]
Abstract. This paper presents the Supporting LIFE (Low cost Intervention For disEase control) project. Supporting LIFE applies a novel combination of Android based smartphone technology, patient vital sign sensors and expert decision support systems to assist Community Health Workers in resource-poor settings in their assessment, classification and treatment of seriously ill children, more specifically children from 2 months to 5 years of age. The application digitises widely accepted WHO/UNICEF paper based guidelines known as Community Case Management. The project also facilitates for disease monitoring and surveillance via a reporting website. Keywords: Mobile Health · Developing Countries · Community Health Workers
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Introduction
In the last decade, the diagnosis and treatment of childhood illness in developing countries has received immense attention (Hazel et al., 2015). The underlying rationale for this increased awareness may stem from the establishment of the eight Millennium Development Goals by the United Nations in 2001, more specifically the fourth goal which focuses on reducing under-five child mortality rates in developing countries. The World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) introduced a community-based initiative to assist Community Health Workers when delivering paediatric healthcare services in rural, remote areas of developing countries. This initiative, known as Community Case Management (CCM), employs clinical guidelines which aim to reduce death, illness and disability while promoting improved growth and development among children under five years of age © Springer International Publishing Switzerland 2015 B. Donnellan et al. (Eds.): DESRIST 2015, LNCS 9073, pp. 366–370, 2015. DOI: 10.1007/978-3-319-18714-3_24
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(WHO, 2013). CCM is an algorithm to guide Community Health Workers through a series of clinical questions and assessment items; capturing socio-demographic and clinical information regarding the presence/absence and duration of symptoms, to classify illness and elicit treatment recommendations for sick children. Numerous countries in low-and-middle income countries employ CCM guidelines (Diaz et al., 2014; Rasanathan et al., 2014). Yet, these guidelines are customised on an individual country basis based on national child health indicators. For example, malaria, infantile diarrhoea and pneumonia are prevalent in Malawi so the CCM guidelines are customised towards theses illnesses. In South Sudan, CCM guidelines have been customised to some extent to focus on malnutrition. Existing research argues that correct implementation of CCM leads to improved child survival (Mugeni et al., 2014). Yet research has emerged showing that the CCM guidelines are often not correctly implemented (Amouzou et al., 2014) thus, potentially endangering the life of a sick child. A lack of knowledge and medical equipment is often reported as the key reasons for incorrectly implementing CCM during sick patient visits (c.f. Kallander et al., 2006; Druetz et al., 2013). To address the challenges faced by Community Health Workers in developing countries an artefact (known as Supporting LIFE) is developed.
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Design of the Artefact
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Overview of Supporting LIFE
The overall goal of Supporting LIFE is to improve standards of care and to establish ways to overcome many of the existing barriers to healthcare delivery in resourcepoor settings using low cost interventions. The Supporting LIFE technological artefact is developed based on widely accepted and validated clinical guidelines known as CCM which comprises 34 questions. It is a smartphone application developed for Andoid 3.0 (Honeycomb) or above which is not only built upon the paper-based system but has also developed a guideline agnostic decision-support rule engine which operates on XML-based definitions of specific guideline instances. Developing the artefact in XML allows the application to be scalable to other countries allowing the rules to be customised on a per-country basis. Based on the assessment data entered into the application, classification(s) of illness(es) and treatment(s) is/are recommended to the Community Health Worker (see Figure 1). As Community Health Workers only receive six days of formal education pertaining to the implementation of CCM the rules-engine developed as part of SL reduces uncertainty surrounding assessing, classifying and treating sick children. Noteworthy, to enhance knowledge of Community Health Workers training material is also available to them. Location awareness is also incorporated within the application, which facilitates geographic tracking and monitoring of CCM patient classifications enhancing automated disease monitoring and notification of disease outbreaks (Figure 2). A website has also been developed; into an infrastructure for the execution of medical-based reports, to facilitate disease surveillance, to identify and monitor disease outbreaks,
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Fig. 1. Sample Screen Shots
and to enable administrative support of medical-based users. This website is cconstructed using Java Server Pages P (JSP), Bootstrap, JQuery, HTML 5.0 and CSS 3.00.
Fig. 2. Disease Surveillaance Monitoring (left) and Notification of Outbreaks (right)
Aforementioned, a lack of o medical equipment (i.e. stopwatch for measuring breaathing rate) restricts Commun nity Health Workers from performing CCM in accordaance with procedure. To assist in n overcoming this issue Supporting LIFE also includess an electronic breath counter an nd by tapping on the screen in unison with observed inhaalation allows Community Heaalth Workers to measure breathing rate. 2.2
Design Science Con nsiderations
Hevner et al., (2004, p. 82) propose seven guidelines “to assist researchers, review wers, editors, and readers to und derstand the requirements for effective design-science re-
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search.” The application of these guidelines to the Supporting LIFE project are outlined as follows: • Guideline 1: Design as an Artefact - A prototype is nearing end of development which can be utilised and customised in resource-poor settings. • Guideline 2: Problem Relevance - To develop a fully functional technology-based solution to help address the issue of child morbidity and mortality in resource-poor settings. • Guideline 3: Design Evaluation - The prototype is currently on release Version 5.0. An agile methodology approach, with a three monthly release cycle, was employed to facilitate for regular feedback from various stakeholders (e.g. both technical and clinical expertise). It is envisioned that Supporting LIFE will be evaluated initially vis-à-vis a feasibility study prior to a Randomised Control Trial in Malawi, Africa. The study will focus on functionality (i.e. mobile application), completeness (e.g. syncing of records to the cloud), consistency with existing approach, accuracy in terms of classifications and treatment of sick children, performance (e.g. speed), reliability (e.g. battery, solar panel chargers), usability (e.g. ease of use) and fit. • Guideline 4: Research Contribution - Supporting LIFE is an open-source project which encourages other people outside of the consortium to become involved in the initiative. Our knowledge repository provides clear guidelines on how to build and contribute to the Supporting LIFE codebase. The source code is stored and shared through a GitHub repository. • Guideline 5: Research Rigor - The prototype to date is predominantly developed based on widely validated paper-based CCM guidelines, with inputs from both clinical and technical personnel both on and off the ground of Malawi, Africa. Furthermore, when designing Supporting LIFE the contextual (e.g. requirements, constraints, technical, organisational and cultural) factors were considered. • Guideline 6: Design as a Search Process - Preliminary testing to date in Malawi reveals that Supporting LIFE does indeed operate on the ground. Further testing is required to see what are the existing problems faced by people in Malawi and how Supporting LIFE can continuously attempt to solve these issues. • Guideline 7: Communication of Research - The plan is to hold workshops before, during and/or after any Supporting LIFE testing in Malawi to inform community members about the motivation of the project, the need for and outcomes of the project. The findings will be disseminated to the Malawian Ministry of Health and in both clinical and technological academic outlets.
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Forthcoming Evaluation of the Artefact
Malawi is ranked as one of the ten poorest countries in the world with a high rate of child mortality and morbidity (Callaghan-Koru et al., 2013). As a result, our research attentions and any forthcoming evaluations of Supporting LIFE will be conducted in Malawi, Africa.
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Acknowledgement. The Supporting LIFE project (305292) is funded by the Seventh Framework Programme for Research and Technological Development of the European Commission www.supportinglife.eu.
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