2. mHealth for Acute Malnutrition
Presentation outline
The problem and context
Key features of mHealth application
Lessons learned from 5 country experiences
Future priorities
Good afternoon,
I am pleased to have this opportunity today to share with your our experience in using mhealth in acute malnutrition programming. This presentation is going to cover the following: the problem and context, key feature of the mhealth application, lessons learned from the piloting of this app in 5 countries, and future priorities.

3. Background 50 million children suffer from wasting/acute malnutrition
Severe wasting causes up to 2 million preventable deaths/year
Community-based management of acute malnutrition (CMAM) is the global approach used to treat wasting
CMAM treatment uses ready-to-use foods, provided at home, with weekly visits to the health centre
To start off with some context. The WHO/UNICEF/World Bank estimate that 50 million children suffer from wasting, of that 17 million – severe wasting.
Severe wasting, also known as severe acute malnutrition. A child with severe wasting is 9 times more likely to die than a child who is not malnourished, and overall severe wasting causes up to 2 million preventable deaths annually.
Thankfully, there is an effective treatment approach for wasting, known as CMAM (community-based management of acute malnutrition). CMAM is a globally endorsed approach. In 2014, over 3.2 million children were treated across 73 countries using the approach (UNICEF, 2014). World Vision has supported CMAM programmes since 2005 in 21 countries, in both Africa and Asia.

4. CMAM mHealth application features
Challenge in CMAM programming
Complex treatment protocol and low protocol adherence
Low literacy, numeracy of health workers and language barrier with local population
Difficulties in tracking an individual during treatment and between different treatment programmes
Application feature
Response-triggered decision tree algorithms
Text, voice, and pictures prompt HWs along the treatment protocol
Automated referral initiation and tracking
Automatic reminders for follow-up
Referral notifications
Over the last decade of CMAM programming – specific challenges to achieving an effective program have been identified, and based upon our experience in using mhealth in other nutrition and health programs, World Vision believed that a technology solution, could help to address some of these challenges. I am going to take some time now to touch on some of the specific challenges and the design features of the mhealth solution to address these challenges.
Complex treatment protocol/Poor adherence - CMAM has a complex clinical protocol and skipping steps (i.e. not adhering to the protocol is common). Why is this the case? CMAM protocols are time consuming to implement. Skipping steps saves the health worker time, and allows them to get on with other tasks in their busy schedule. Another major challenge with protocol adherence relates to staff training - both from the perspective of insufficient training/experience in CMAM programming, or frequent turn-over of trained staff. A feature of the application to address this, is response triggered decision tree algorithms.
Another challenge was low literacy, numeracy and a language barrier with the local population. To address this, the app includes text, voice and picture to prompt the HWs through the treatment protocol. It also allows for recording of key messages in the local language that can be played for the caregiver during the consultation.
A third challenge relates to the tracking system – to follow individual children through treatment, and to follow-up for children requiring referrals and home visits. The applications automates this process through built-in reminder for follow-up and referral notifications.

5. CMAM mHealth application features
Challenge in CMAM programming
Infrequent, inconsistent counselling on improved nutrition, health and hygiene practices
Paper-based system slow, unresponsive and poor quality—not available for decision makers
Unresponsive stock management system: Frequent stock outs of therapeutic and / or supplementary food at health facilities
Application feature
Integrated multimedia for targeted counselling
Real-time monitoring through automatic generation of reports
Reminders and alerts to supervisors and supply chain
Additional challenges are:
The quality of counselling provided during the weekly consultation. The application addresses this by including integrated multimedia
A further challenge relates to the record keeping - the monitoring and reporting tools paper-based systems, incomplete records, mean that data that is available is not routinely used to inform programmes, or to improve the quality of service provided. In addition, CMAM programmes are sometime implemented as part of emergency responses, in remote or insecure contexts. In such environments, the opportunities for on-site supervision are limited. The application includes real-time monitoring through automatic generation of reports.
And finally paper-based stock management system mean time-lags in getting essential supplies to needed areas. To address this, the application includes reminders and alerts to supervisors on the supply chain.

6. Paper Registers

7. Let’s have a look Managing patient data Registration
Individual child record
Digital individual child record is created.

8. Improving worker performance
Prompts and decision support
Screen shot on far left guides the health worker on how to assess the severity of vomiting.
Middle screen shot – includes photos on how to assessing bilateral pitting oedema
Right – assessing the severity of diarrhea

9. Respiratory Rate Counter
Automatic Calculation of fast breathing according to standards for child’s age
Respiratory Rate Counter
The application also includes a built-in counter for respiration rate. This is helpful as we know, this step is often done incorrect, or skipped completely. The app automatically calculates ‘fast breathing’ according to the standards for the child’s age.

10. Treatment calculation and stock monitoring Diagnosis and action
The app provides a summary of the clinical assessment and a diagnosis.
Advice on medications to provide to child

11. 5 country experience
Contextualized and piloted the app in Chad, Niger, Mali, Kenya and Afghanistan
Partners: Ministries of Health, Dimagi, International Medical Corps in Chad, Save the Children in Kenya, Mobile Network Operators
Reached 104 health facilities, 191 health workers
Implementation (2014–2016), final evaluations 2016
Application development started in 2013, during which specifications for the app were developed based upon the national CMAM protocols for Chad. This was then used as the basis for contextualization of the application of other countries
Implementation was done in a staggered approach over 2014 – 2016
Final evaluation used a common set of tools for quantitative and qualitative data collection. An observation checklist was used to observe clinical case management in sites with and without the mhealth application. Records were reviewed and compared between mhealth sites and non-mhealth sites. Key informant interviews were conducted with health workers, as well as caregivers.

12. Key Learning
With training and support, good health worker acceptability
High level of beneficiary acceptance
Data completeness, protocol adherence and beneficiary tracing were improved across the 5 countries
Technology barriers: battery life, screen size, network coverage
Country contextualization and testing was much more complex and time consuming than anticipated
Initially some health were resistant to try the technology; however, with training and support, there was a good level of acceptance of the application among health care workers.
Similarly, the beneficiaries reported a high level of acceptance – in fact it was reported that use of the application improved health worker – beneficiary relations in some circumstances. The beneficiaries tended to ‘trust’ the advice coming from the device, and didn’t argue or question the health worker.
The pilot project found significant improvements in CMAM programming as a result of the mHealth app, such as improved data completeness and protocol adherence: completed child registration information-100% (project sites) versus 17% (comparison sites); HWs correctly measured and recorded height, weight and MUAC -100% (project sites) versus 67% incorrect MUAC measurement (comparison sites); completion of physical exam steps -100% (project sites) versus skipped steps in one third of the observed cases in comparison sites; correct z-score calculations, oedema and appetite test – 100% (project sites) versus 67% (comparison sites).
Some common challenges across the 5 countries were also identified. With respect to the technology – battery life was a problem, screen size (the Kenya program, opted to use tablets instead of mobile phones, which was determined to be much more appropriate for this application. In some cases poor network coverage met that health workers had to travel to upload the data.
And finally, the development of this app was based on the premise that once the app was developed to match the global CMAM specifications, then the level of contextualization at the country level would be relatively minor. However, this turned out to be an incorrect assumption – for example the Kenya national protocols for CMAM are quite different from that in Mali, Chad and Niger. And there were notable difference between the West Africa countries.
Location: Refine and test application with a few users, and in an easy to access location before deployment to remote location
Gov’t engagement: Plan and budget for Government engagement from the onset

13. Future Priorities
Review and understand what is feasible for health workers in low resource settings with high patient caseloads. Simplify protocols?
Building and field testing integrated app: iCCM + acute malnutrition
Interoperability with national HMIS systems
Capacity building to support app uptake and use of application (performance reports, supervision functions)
The learnings from these 5 countries raised some issues for future consideration:
The first is related to the CMAM protocols themselves. By using the app, the HW would adhere to the protocol – which required them to spend longer on each consultation. For a HW providing these services in a busy center with a high patient caseload – this sometimes was not perceived as a positive thing. From this, the question is raised – are the current CMAM protocols feasible for HWs in low resource settings with high patient caseloads?
Secondly – CMAM services are most often provided within a health centre, along side other interventions such as IMCI, or through outreach programs using community case management of childhood illness. A future priority will be to develop an integrated application
Linking the application to the national health data system is a crucial priority for country scale-up – Mali, Kenya and Afghanistan have expressed interest in this
And in addition – more can and should be done with regard to capacity building to support use and uptake of the app – particularly around the use of performance reports and supervision functions.

14. Acknowledgements
Implementing Partners: Save the Children, International Medical Corps
Funders: USAID/OFDA, Government of Canada
Field Exchange Publication:
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15. CARLA LEGROS, PROJECT MANAGER, DIMAGI WEST AFRICA
“This project had probably the highest impact potential
of any project I have worked on. If you go to these project
sites, you immediately see why the intervention is needed… When you
observe the nurses, you see the mistakes they make using
paper forms, and the off-the-fly decisions they make that
have serious impact on the child’s health. So you could
see, from the beginning, how the app would really add
structure and eliminate a lot of mistakes. And we have
been able to see real value on the ground, real value added
to such an important programme.”
CARLA LEGROS, PROJECT MANAGER, DIMAGI WEST AFRICA

16. Senior Emergency Nutrition Advisor World Vision International
Colleen Emary
Senior Emergency Nutrition Advisor
World Vision International
Skype: colleen.emary