mHealth for pneumonia prevention

Pneumonia continues to be one of the leading killers of children under-five with 90,000 children dying annually in Pakistan attributed to delayed care-seeking for pneumonia secondary to impaired illness perception of caregivers of children under-five. WHO and UNICEF have emphasized the implementation of effective strategies for improving child health. One such approach is through community health workers (CHWs), referred to as, Lady Health Workers (LHWs) in Pakistan as they act as a bridge between the community and healthcare system. With the rise in telecommunication in Pakistan to 83% of the total population, mobile health (mHealth) could prove to be beneficial for bringing healthcare services and education closer to the community. I, therefore, tested the feasibility of using an mHealth based intervention package implemented through LHWs to educate caregivers about under-five pneumonia in a rural community in Pakistan. The intervention design was finalized upon conduction of a systematic review and formative research. I appraised the available literature on mHealth approaches to improve management of childhood illnesses by CHWs through a systematic review. I found twenty-three articles involving around 300,000 individuals with eight types of study designs with twenty studies conducted in Africa, two in Asia, and one in Latin America primarily focused on pneumonia or respiratory tract infections followed by malaria and diarrhoea in children. The review showed that the most common mHealth approaches were use of mobile applications for decision support for illness management, text message reminders for timely follow ups with healthcare providers and adherence to treatment and use of electronic health record in the form of collecting medical data in mobile phones from the field. I also found that the focus of these studies was more on health care service delivery and education about recognizing or managing illness with less emphasis on prevention. Additionally, the majority of these studies were not able to demonstrate behaviour change clearly. To explore caregivers’ care seeking practices, their perception of under-five pneumonia and to obtain their views on an mHealth intervention package, I conducted 12 in depth interviews with mothers and 2 focus group discussions with fathers and grandmothers of children under-five. These interviews showed that the majority of caregivers were not aware of the danger signs of pneumonia and the fact that pneumonia was caused by pathogens. They considered predisposing factors such as exposure to cold as one of the major causes of pneumonia. I also found that the majority of the caregivers waited and watched the child when he/she developed minor-moderate symptoms of pneumonia. Based on these interviews I modified an existing mHealth intervention which used an audio-visual mobile application used by LHWs to educate caregivers on under-five pneumonia supported by follow-up educational text and voice messages directed to caregivers. This intervention, was implemented over 6-months across 1771 households in a rural community, Tarlai, in Islamabad (the federal capital). This study also included a pre- and post-intervention survey conducted across a randomly selected sample of 50 mothers. This showed that statistically significant changes were seen in the perception of pneumonia being a cold (45.8% vs 16.7% ) and breathlessness being a danger sign (31.2% to 62.5%) between the pre and post intervention phase. Similarly, for care seeking 75% mothers in the post-intervention phase as compared to 54.2% in the pre-intervention phase stated to take the child to a doctor on time for management. For those cases where pneumonia did develop in children under-five, 43.8% of caregivers took the child timely to a healthcare provider as compared to 31% in the pre-intervention phase. Regarding the feedback of the mothers on the intervention, 58.3% of them were overall satisfied with it, with the video clips being the most beneficial aspect of the application, in their opinion. 47.9% of the mothers stated that they learnt something new about pneumonia especially on addressing risk factors such as protecting the child from the cold during winters, keeping the rooms ventilated to avoid the spread, and consulting a doctor in time. They suggested to continue this intervention for longer and include more educational videos for future. A feedback session with the LHWs was also conducted which revealed that they liked the use of the application overall as it enhanced their capacity to provide uniform information about pneumonia especially with the use of the video clips. The least liked/popular feature with the LHWs was the uploading of forms which was challenging due to network issues. Most LHWs stated that the intervention could be scaled up provided the government cooperates. Thus, mHealth has the potential to improve access to health information on under-five pneumonia and this work has also shown that this intervention is likely to be acceptable by the community