By Dr Anu Sachdeva & Dr Ashok Deorari
Globally, 2.5 million newborns died in first 28 days in 2017; nearly two-thirds of these deaths were preterm infants (1). In addition, nearly one million newborns survive with developmental delay and cerebral palsy (2). Most of these vulnerable newborns can survive and thrive when they have access to good-quality, evidence-based, safe, organized, accessible, efficient, timely and people-centered health care. The World Health Organization (WHO) & United Nations International Children’s Emergency Fund (UNICEF)’s Survive & Thrive Report-2018 calls upon governments, health professionals, parents and other partners to join in supporting continued investment in health systems that respond to the needs of the most vulnerable (3).
A vital element for improving quality of care is the ongoing education of health care professionals and implementation of evidence-based practices. There is a need to train large numbers of healthcare providers spread over vast geographical areas without taking them away from their workplace for long durations. This requires exploration of cost-effective alternative forms of education and training.
The Every Newborn Action Plan Report has identified the use of digital technology as one of the innovations which can serve as a simple, bedside tool for improving clinical practices, and also as a refresher tool for continuing education of health care professionals (5). In view of the importance accorded to improving care for “small and sick newborns,” who contribute nearly one-third of neonatal mortality, our team at the All India Institute of Medical Sciences, WHO collaborating center (AIIMS WHO CC) decided to create a multimodal training app for optimal preterm care with the “Do No Harm” philosophy.
Based on our previous learning from developing and scaling the usage of apps on standard treatment management of sick newborns (AIIMS WHO CC STPs, more than 10,000 downloads on Google play with average rating of 4.2 and multiple positive reviews), we were convinced that this can be an innovative method to reach more hands quickly in a cost-effective manner.
Why a smart phone app for preterm care?
Traditional websites require a constant, reliable internet connection to be accessed. Users in low- and mid-income countries may not have access to a computer or a reliable Internet connection. A solution to this scenario is a mobile app with a pre-packaged cache of interactive content installed on the device that users can carry with them offline. Digital technology such as smartphone-based solutions are a cost-effective way of providing reliable and technically sound healthcare information and knowledge that can help improve uptake of evidence-based best practices in care of sick preterm babies. The ubiquity of smartphone access now offers a platform that can be leveraged for a variety of interventions, including enhancing knowledge of healthcare providers for best preterm care practices, blended with skills learning at networking institutions.
Unique features
The AIIMS WHO-CC PTC android app (Preterm Care on iTunes) provides a stepwise, modular approach to teaching evidence-based management of preterm neonates. The package uses the latest pedagogy of blended learning. The app is designed to meet the learner’s needs for knowledge acquisition. The user can kick start with any module and then complete the modules in any sequence; however, within a module, each learning objective has to be completed in a systematic sequence. Each module objective is followed by a timed self-assessment multiple choice questionnaire which needs to be attempted with a minimum pass score in order to move to the next objective. The user has three attempts to pass each learning objective.
The app has a myriad of features with the educational content being delivered as 110 videos, 55 webinars, self-reading scripts and self-explanatory posters. The duration of videos and webinars is short, with the median time being five minutes. One unique feature of the educational package is the emphasis on skill learning and practice in a simulated environment.
What is the vision of the AIIMS WHO CC Team?
The smartphone app launched in July-August 2019 is available for free on both Android (download as AIIMS WHOCC PTC from the Google play store) and iOS platforms (download as Preterm Care from the App store). In addition to being user-friendly, the app has the advantage of easy, immediate availability as a point-of-care tool, and gives an opportunity for users to learn and practice skills related to clinical procedures and use of essential equipment at partnering institutions. It is also possible for users to do a self-assessment through multiple-choice questions that are also provided along with a gradebook, and they have to earn a certificate prior to skill and competency-based learning. The skill learning and simulation components are delivered with face to face interaction at networking institutions; after completing the MCQ-based assessment the learner is expected to practice and demonstrate skills in person to a certified trainer. We are sure that this integrated approach will not only improve knowledge and skills, but also actual clinical practice.
What advantage does the app have over textbooks or conventional teaching?
The team involved in the development of this app strongly believe that this new educational methodology involving simulation and hands-on skill learning has a built-in potential for implementation, thus improving the quality of preterm baby care. The revision of a textbook is a rigorous process and takes a long time before a next edition ensues. If mistakes crop in, one must wait for the next edition to make corrections. On the other hand, app updates can be released in quick cycles and deployed very rapidly. Apps are cost effective, paperless, and can reach remote areas, crossing country boundaries in a short time.
Evidence that apps enhance learning
Apps are useful tools for continuing education and as a supplement to pre-service education. The training of physicians working in special newborn care units in district hospitals using the AIIMS-WHO CC STPs led to an improvement in knowledge and skills. Trainees expressed confidence that the app could be used as a job aid to improve clinical practices in managing common newborn conditions (6). The efficacy and acceptability of the app have been evaluated among nursing college students (7). Considering these studies, and increasing usage of mobile devices, this App may serve as a simple, bedside tool for improving clinical practices, and as a refresher tool for continuing education of healthcare professionals.
Future of smartphone apps
With artificial intelligence transforming the way we work and augmented reality making inroads into healthcare education, there is scope for the app to give health workers a real feel of the environment and provide feedback or debriefing to a health care provider during and after actual case management. Additional features that could be introduced include tracking cases, keeping logbook of trainees and healthcare providers, and linking with accountability and remuneration to healthcare providers.
Competing interests
The authors declare that they have no competing interests. The AIIMS WHO CC PTC (Android) & Preterm Care (iOS) was developed by the team at the AIIMS, and Dr. Ashok Deorari is listed as the author of the app. The app is freely downloadable from Google Play and iTune Apple stores.
Acknowledgments
We would like to express our thanks to Queen Elizabeth Diamond Jubilee Trust, UK for supporting a grant for prevention of blindness due to Retinopathy of Prematurity (2014-19) through Public Health Foundation in India.
References
- Levels & trends in child mortality: report 2018. Estimates developed by the UN Inter-agency group for Child Mortality Estimation. New York: United Nations Children’s Fund; 2018
- Lawn JE, Blencowe H, Darmstadt GL, Bhutta ZA. Beyond newborn survival: the world you are born into determines your risk of disability-free survival. Ped Research. 2013;74 (Suppl 1):1–3.
- Survive and thrive: Transforming care for every small and sick newborn .A publication of WHO 2018 .
- WHO, UNICEF. 2017. Reaching the Every Newborn National 2020 Milestones Country progress, plans and moving forward Geneva: World Health Organization
- Free C, Phillips G, Galli L, Watson L, Felix L, Edwards P, Patel V, Haines A. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med. 2013;10(1):e1001362.
- Prakash V, Thukral A, Sankar MJ, Agarwal R, Paul VK, Deorari AK. Efficacy and acceptability of an “App on sick newborn care” in physicians from newborn units. BMC Med Educ. 2016;16:84
- Thukral A, Joshi M, Joshi P, Prakash V, Adkoli BV, Deorari AK. Apps for management of sick newborn: evaluation of impact on health care professionals. J Trop Pediatr. 2014;60:370-6