A novel wide scale well-baby clinic mobile application: an Egyptian pilot study

An interventional study conducted on caregivers of under 5-year-old children living in Egypt, targeting well-educated owners of Android smartphones who agree to participate in the study. Children who have any congenital anomalies or chronic diseases as diabetes, heart or lung diseases were excluded from the study.

A sample size of 500 participants was chosen for this study as a pilot. We used a quota sample of 100 children in each age category. Recruitment of caregivers who comply with inclusion criteria and agree to participate occurred via the in-app online registration.

This study was conducted in four phases:

Before starting the project, a preliminary research about published papers and the existing apps in the childcare field was performed. Market research (mobile app research) is the process of understanding target market, competitors, industry and current market trends. It helps in validating the app’s idea and ensures that it addresses existing market needs. It was done by searching Google play store for pre-existing Arabic apps to address their strength points, weak points, number of downloads, rating and release dates using the following keywords “baby”, “baby health”, “child health”, “child growth”, “child development”, “child teething” and “child nutrition”.

Then, user requirement assessment was done. The objective of this phase was to understand user requirements and assess customers’ needs and expectations in order to maximize the benefits and usage of the mobile app. We used an online google form sheet containing closed and open ended questions to explore participants’ frequency and location of following up their children’s growth and development. We also assessed the needs of services that should be present in the application by asking “What are the services you need most in the application?”. We also assessed previous use of children applications and asked about their feedback about them by asking “If you have ever used a mobile application for tracking children’s health, what do you think of it?”.

The validation phase was divided into 3 phases. The first was the Alpha testing phase which is a testing method used to unveil bugs that might arise due to unexpected errors created by the users and validate the quality state of the app’s software in minimal time. It was done by means of the research team, consisted of systematic and exhaustive procedures executing all the operations permitted by the app in several devices to assess the app performance. These devices are the following: Samsung Galaxy A52 (6.5 inches), Samsung Note 10 Lite (6.7 inches), Samsung Note 20 ultra (6.9 inches), Xiaomi Redmi Note 10 (6.4 inches) and Huawei P30 Pro (6.47 inches).

The second was Beta testing of the app which is performed by the intended audience of the app to get user feedback for the product and check if the product meets the objectives of the app. It was conducted using interviews with a non-random sample of end-users in which they emphasize their feedback and perceptions as they navigate through the services of app. These interviews were conducted to obtain preliminary user feedback, which was used to formalize the final version of the app. Participants were asked to navigate the app and were asked to use different app services and provide feedback [15].

In the third phase, the application was validated using Mobile App Rating Scale (MARS) [16] by public health and pediatrics consultants. It consists of 2 sections: app quality rating and app subjective quality. App quality rating that assesses app quality on four dimensions (engagement, functionality, aesthetics and information). App subjective quality includes the following four questions: Would you recommend this app? How many times do you think you would use this app? Would you pay for this app? What is your overall star rating of the app? MARS is scored by calculating the mean scores of the engagement, functionality, aesthetics, and information quality objective subscales, and an overall mean app quality total score.

Review of available mHealth revealed 13 Arabic apps. None of the apps provided any comprehensive approach to well-baby clinic services. All of them (100%∼13/13) were in the form of written articles that offered no interactive features for parents, and only offered general health education not tailored according to the status of the child. They took the form of nutritional advice, food recipes, parenting advice, static vaccination tables, weight tracking with no interpretation and sleep meter. None of them were developed by a recognized health organization. The most common service available in these apps was “nutrition service” (84.6%∼11/13) but only took the form of narrative articles or recipes. Most of them (92.3%∼12/13) included ads. They were rated from 3.7 – 4.7 stars on Google ratings. Downloads ranged from 1000+ to 500,000+ downloads. Detailed description of apps in the review is illustrated in supplementary file 2.

As for the online survey, two thirds of the mothers were in the age group of 30–39 years. Twenty-eight percent of the mothers had their youngest child range of age from 0 to less than 1 year. More than half (56.5%) of mothers monitor their children’s growth regularly, while two thirds (63.6%) of them monitor their children’s developmental milestones. Approximately sixty percent (60.7%) of mothers reported that working was one of most important factors contributing to not regularly monitoring their children’s growth (Table 2).

Nearly all (97.3%) of mothers reported their need for a new app to monitor their children’s health. Eighty-eight percent of mothers needed nutrition services whereas, 87.4% reported their need for a developmental milestone’s service. Only 57.9% were satisfied by previous use of child monitoring apps (Table 3).

The app consists of the following sections:

Ten public health and pediatrics consultants validated the app using MARS. The mean scores ratings for engagement, functionality, aesthetics and information were 3.5, 3.7, 3.9 and 3.7 respectively. The app quality mean was rated 3.7/5 while the subjective quality score mean was 3.2/5 (Table 4).

The app was launched and made available to the public on Android platform. Four-month period was needed to reach a quota sample of 500 children (100 in each age category. In this period, the app had been downloaded 1445 times, 943 of them registered in the app with an overall response rate of 65.3%. In this period, store listing conversion rate (store listing acquisition divided by store listing visitors) was 59.1%. Figure 4 shows the increase in the downloads throughout this period.

Taking into consideration caregiver’s requirements and app research, we designed the first draft of the app after few brainstorming discussions. In a 4 months period, after several modifications and tailoring, we reached the final design of the app Sehhat Tefly, and it was ready to be developed. The app offers comprehensive services of child’s nutrition, development, safety, teething, growth and immunizations for parent supervision with no financial burden. Elements of this app are available in other child monitoring apps; however, each have three or less services at a time and include subscriptions averaged 57 dollars every year, ranging from 3 to 225 dollars every year, according to a review on English apps [22].

Sehhat Tefly app was developed by academic health care providers in the field of public health and computer science app developers. The app provides evidence-based content and respects privacy of users’ data. Privacy and protection of data were ensured by applying authentication. Thus, only the research team were granted access to this data. App users had their own usernames and passwords to access their profile in the app. The app’s data were not shared with other parties or service settings. An Australian study reported that only 40% of the apps involved health care professionals and provided evidence-based content, and only 30% implemented user privacy security measures [23]. Health care providers should be equipped with strategies to guide parents safe use of technology and to support parents in their search for evidence based apps. They can encourage parents to look for the privacy policy of apps to ensure that their personal information is not shared with third parties and to verify the quality of health information [24]. Since caregivers generally rely on the content present in the app store to make informed decisions about which apps to download according to their needs [25], we included all the app details in the Google play store download page of the app mentioning all referencing agencies as WHO and CDC.

The app offers tailored feedbacks and interactive features that have more persuasion than standalone apps (with no interactivity) [26]. Non-feedback apps constituted about 63.7% of the apps included in review by DeWitt et al. [22]. The repot section of the app also gathers all health data of the child in one place, this single place storage would make it easy for parents to share their children’s health data with their health care providers.

Well babies’ health services have been introduced in previous apps. Some assessed child’s risk of obesity as “Memphis FitKids” app that used collected information to create a report with tailored recommendations on how to make healthy changes in weight and lifestyle of children [27]. Two other studies have shown that apps can help improve caregiver’s understanding of growth charts [28] and detection of abnormal child growth early in life [29]. Other studies addressed dental caries and oral health, the apps improved the oral health knowledge and practice of caregivers while oral hygiene as a result of plaque control was superior in children of mothers using apps containing games [30, 31].

Another study included developmental screening tool, but unlike our app, text messages were used. The app was considered usable and acceptable in low-income setting [32]. Other mhealth tool sent reminders of immunization schedule to parents in the form of SMS and reported that it was a feasible tool for increasing routine immunization coverage in Pakistan [33].

Since app quality is one of the most influencing factors in the success of mHealth apps, validation of this app was conducted by public health and pediatrics experts in the field of child health using MARS questionnaire [16]. The app quality mean was rated 3.7/5 while the subjective quality score was 3.2/5. The consultants thought the app was comprehensive, relevant and useful to parents for keeping track of their baby’s health in Arabic language using explanatory videos and photos. They recommended adding some features as gamified health education messages, adding the additional recommended vaccines next to the compulsory vaccination schedule and adding illustrative photos to each of the developmental milestones and vaccine side effects.

Mobile apps can support parents to identify and document patterns in their child’s health that would otherwise go undetected and encourage caregivers to seek medical attention. At the same time, these apps can risk pathologizing health behaviors, raising unfounded fears, performing self-management, and adding stress to families [22]. There had been numerous tracking apps for children’s health as “Child Growth Tracker” app (rated 4.5/5 by MARS) which was simple and easy to use because it offers multiple evidence-based scales for tracking a child's growth, but it was solely designed for recording infants’ growth such as height, weight, head circumference, and BMI ignoring other important options as information, immunization, developmental milestones or reminders [24].

Other successful story in the field of child health apps is “KhunLook” app which included seven key features: growth and nutrition, development, immunizations, oral health, reminders for the next appointment, memories and health advice [34]. Other apps showed success in monitoring vaccination schedule, nutritional health, developmental milestones and injury prevention of children [8, 35‐37].

Sehhat Tefly app is categorized as being an “academic app”. In contrast, “MyMedela Breastfeeding Companion” app (rated 4.3/5 by MARS), a commercial app, was designed for breastfeeding mothers to promote Medela products; however, users are not required to buy any Medela products in order to use the app. It provides basic activity tracking and some information but offers no immunization service or scheduled child visits. Caution is advised while using the app given that the information provided might be influenced by financial gains [24]. Commercial apps, which are more popular among parents than academic ones [38], may jeopardize privacy and security of users’ information by leaking or selling personal data to third parties. Commercial parenting apps may not be developed and validated with the same rigor as apps developed based on research [22]. Unfortunately, Google Play store and Apple store do not have extensive guidelines or regulatory supervision over parenting apps aside from legal restrictions on claims of specific health outcomes [39].

The primary objective of the app is for child health supervision by caregivers, but it can also be used as a database for epidemiologic surveillance. The app’s developed database can measure important growth indicators as stunting, overweight, obesity & underweight [7] and nutritional indicators as ever breastfeeding, exclusive breastfeeding first 6 months and weaning. Digital data collection has been shown to have fewer errors when compared to manual data reporting [40] and considered as a faster tool of surveillance of nutritional problems [41]. Previous app called “Information for Action” succeeded in repackaging routinely collected child growth and development assessment data into useful decision support for caregivers and program planners [42].

The potential of this mHealth app has not been fully established yet. Further studies should be implemented to assess accessibility and usability of the app to explore difficulties and barriers faced by users in different services using of focus group discussions (FGDs). Comparative studies should be conducted involving a large number of users to assess its effect on behavioral change and health outcomes. Further, validation studies should be designed to evaluate the congruence of the assessment between the app and the traditional medical services.