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In Thailand, children born in government hospitals receive a maternal and child health handbook (MCHH). However, when a new MCHH edition is released, those with the previous editions do not have access to the updated information. A mobile app is an appealing platform to fill this gap. We developed a mobile app called “KhunLook” as an interactive electronic MCHH intended to assist parents in child health supervision.
This study describes the user requirements and development of the KhunLook mobile app, validity of parents’ growth assessments, and parents’ evaluation of feasibility and acceptability of the app.
Phase 1 was a qualitative study using individual interviews. The interview data were used to revise the prototype. In phase 2, parents were randomly assigned to assess their children’s growth with the app or the MCHH. The outcomes were compared to those of the physician’s assessment, and congruence was determined. In phase 3, parents evaluated the feasibility and acceptability of the app in comparison to the MCHH through a web-based survey.
Four health care providers and 8 parents participated in phase 1. Two themes were identified: (1) the mobile app potentially counters parents’ infrequent use of the MCHH with accuracy, attractiveness, convenience, and simplicity, and (2) health supervision needs to be standard, up-to-date, and understandable. KhunLook was publicly launched with a family page and 7 key features: growth and nutrition, development, immunizations, oral health, reminders for the next appointment, memories, and health advice. In phase 2, 56 parents participated in the growth parameter assessments; 34 were in the App group and 22 in the MCHH group. The outcomes of the growth parameter assessments between parents and physicians in both the App and MCHH groups were not significantly different. The congruence proportions were higher in the App group for weight and head circumference, but the differences were not statistically significant. In phase 3, 356 parents from all over Thailand participated in a web-based survey. Parents rated the app feasibility as “very easy to easy” to use at higher proportions than the MCHH in all health assessment domains (growth, development, and immunizations) and ease-of-use domains with statistical significance (
KhunLook, a Thai mobile app for child health supervision, was developed, validated for growth assessments, and was well accepted for ease-of-use by parents. Further studies should be conducted with a large scale of users, and the impact of this app on health behaviors and health outcomes must be evaluated.
Child health supervision is critical to the development of the child, family, community, and the future of populations. Periodic well-child visits foster strong relationships between the health care provider and the child and family, enabling provisioning of preventive measures such as appropriate surveillance, screening, anticipatory guidance, counseling, and immunizations [
The MCHH was developed and provided to pregnant women at antenatal visits and for children who were born in government hospitals since 1985 [
While the MCHH is widely used and well-accepted, several studies have identified its shortcomings. The MCHH is revised intermittently to include up-to-date growth curve standards, relevant information, and changes in the country’s expanded immunization program [
mHealth technology is defined as “medical and public health practice supported by mobile devices,” which includes delivering health care services and useful information to patients, family members, and health care providers through the use of mobile devices and communication [
A mobile app is an appealing platform for the development of an interactive electronic MCHH because it addresses many of the printed book’s disadvantages [
In this study, we developed and evaluated an interactive electronic MCHH mobile app called “KhunLook,” which translates to “my dear child” to assist Thai parents and health care providers with child health supervision. The validity of the growth assessments and user acceptability were also examined.
This study was approved by the Khon Kaen University Ethics Committee for Human Research. This study consisted of 3 phases: (1) phase 1, understanding user requirements and development of the KhunLook mobile app, conducted during 2013-2015, (2) phase 2, validation of the growth assessment study, conducted in 2015, and (3) phase 3, parent evaluation of the feasibility and acceptability of the KhunLook app, conducted during 2017 (
An overview of the methodology of the study. MCHH: maternal and child health handbook.
Posters were used to publicize the study. Participation in the study was voluntary. Confidentiality was assured and written or electronic consent was obtained.
A mobile app wireframe prototype was developed based on the major requirements from a brainstorm meeting with pediatricians, dentists, and app developers (n=12). The app prototype had sections pertinent to child health supervision, including a family page, birth history, growth, development, immunizations, oral care, reminders for the next visit appointment, memories, and health advice. A panel of experts in pediatric subspecialties related to each content domain selected evidence-based and culturally appropriate content that is in accordance with the latest standards and written in a brief and comprehensible manner. The content was cross-checked for content appropriateness and understandability by 2 other subspecialists who were nationally recognized in their field, and adjustments were made until consensus was reached. The content was then incorporated into the app.
The objective was to understand user requirements in order to maximize the benefits and usage of the mobile app. The phase 1 study design was as follows. We used a qualitative design to explore participants’ perspectives by asking the question, “What are your perspectives of using a mobile app in lieu of the hard copy of MCHH?” The participants were then provided with the prototype on a tablet. They were encouraged to use and explore the prototype by themselves and then provide comments. The interviews were conducted by a trained research assistant who was not involved in the development of the app. An investigator (KS) and 2 trained research assistants who were the mobile app developers observed the process, took field notes, and assisted the participants as requested. The participants were then asked the next question, “What are your comments and additional requirements for the app?”
We used purposive sampling—a nonprobability selection of participants—based on our criteria of interest for richness of data. We targeted health care professionals who worked with children and parents with children under the age of 6 years, who use smartphones and an MCHH, to obtain a wide range of perspectives [
We used individual in-depth interviews and field notes to collect data. Interviews were audio-recorded and transcribed verbatim, except for personal identifiers, which were removed [
Data collection and analysis occurred concurrently. Researchers RA and KS read the initial 3 transcripts to develop the codes and coding categories. Codes and coding categories were discussed, compared, and clarified for the development of the initial coding schemes. After reaching consensus on the coding scheme, further transcripts were analyzed individually, followed by team discussions and consensus. Data collection continued until further themes failed to emerge. The last interview did not introduce new concepts, suggesting that theoretical saturation was achieved. After the transcripts were coded, related codes were grouped into categories and used to generate key themes. Themes and their relationships were discussed and linked to construct an understanding and address the research questions. An updated version of the KhunLook mobile app based on phase 1 input was publicly launched and made available for users to download without charge in January 2015.
The objectives of the phase 2 of the study were as follows: (1) to evaluate the congruence of the child growth assessments between parents and physicians and (2) to compare the proportion of congruence of parent and physician child growth assessments between the App group and the MCHH group.
Although KhunLook has many health assessment domains as shown in
Demonstrative screenshots of the KhunLook app.
We used a questionnaire to collect the baseline characteristics and outcomes of growth assessment by parents and physicians. Growth parameters that were assessed included weight for age, height for age, and head circumference.
Growth parameters were categorized into 3 categories: below normal, normal, and above normal. Growth parameters were considered normal when they were between the 3rd and 97th percentile for age and sex, which was the reference provided in the app and MCHH [
The phase 3 objective was to assess parents’ evaluations of the KhunLook app in terms of feasibility and acceptability.
For a wider range of user evaluations, a web-based survey was used to collect the parents’ evaluations of the KhunLook app and the MCHH in comparable sections in terms of feasibility and acceptability. The survey was launched in July 2017. The inclusion criteria of the parents of children under the age of 6 years were as follows: (1) own an MCHH and (2) used the KhunLook app within the past month.
We used a web-based questionnaire to collect information on the baseline characteristics, feasibility, and acceptability of the app and MCHH. For feasibility, parents rated the ease of using the app compared to the MCHH on 5 health assessment domains and 6 ease-of-use domains on a 4-rank rating scale (very easy, easy, difficult, and very difficult). For acceptability, parents were asked to provide an overall score from 0 to 10 (0=least acceptable, 10=most acceptable) for the app and MCHH; they were asked to choose the preferred method, if they would continue to use the app, and if they would advise others to use the app.
For feasibility, the first 2 ratings were grouped as “very easy to easy” and the last 2 were grouped as “difficult to very difficult,” and then, the proportions were calculated. We used McNemar test for change to compare the feasibility ratings between the mobile app and MCHH. For acceptability, a paired two-sided
Four health care providers and 8 parents participated in this phase. Half of the health care providers were women with a mean (SD) age of 49 (19) years (range, 36-76 years) and 50% (2/4) had practice experiences of more than 15 years. Three providers were pediatricians and one was a dentist. All of the parents were mothers with mean (SD) age of 32 (2.7) years (range, 30-36 years), and regarding their levels of education, 75% (6/8) had a doctorate degree and 25% (2/8) had a bachelor’s degree; 88% (7/8) of the mothers had a monthly income of more than 15,000 Baht per month. Five mothers had 2 children, while 3 had 1 child. The mean (SD) age of their children was 3.6 (2.3) years (range 0.9-6 years). Five mothers used iPhones and 3 used Android smartphones. One mother had previously used mobile apps to track her child’s health. From the qualitative data analysis, we identified 2 major themes that were raised by the participants and relevant to our research questions. These themes are discussed in greater detail along with the representative quotes below (
Themes and the illustrative quotes.
Theme | Illustrative quote |
The mobile app potentially counters parents’ infrequent use of the MCHHa with accuracy, attractiveness, convenience, and simplicity. | … |
Health supervision needs to be standard, up-to-date, and understandable. | … |
aMCHH: maternal and child health handbook.
Theme 1: Health care providers and parents expressed that mobile apps are potentially useful by countering the infrequent usage of the MCHH and by helping caregivers to understand their child’s health. The downside would be the need for internet connectivity.
Theme 2: Health care providers and parents expressed the need for standard and up-to-date information that is in Thai language.
The updated version of the KhunLook mobile app based on phase 1 input contains a family page and 7 key features: growth and nutrition, development, immunizations, oral health, reminders for the next visit appointment, memories, and health advice. Demonstrative screenshots are shown in
Demonstrative screenshots of the KhunLook app.
Growth standards were based on the Thai national growth reference [
Of the 56 parents who participated, 34 were in the App group and 22 were in the MCHH group. The baseline characteristics of the parents are shown in
Baseline characteristics of the parents and the children by group.
Demographics | App group, n=34 | MCHHa group, n=22 | |||||
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Sex, female, n (%) | 27 (79) | 17 (77) | .85 | |||
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.81 | |||||
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Mean (SD) | 33.7 (5.4) | 34.0 (5.8) |
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Range | 20-45 | 21-44 |
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.11 | |||||
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Less than bachelor’s degree | 3 (9) | 5 (23) |
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Bachelor’s degree | 12 (35) | 11 (50) |
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Master’s or doctoral degree | 19 (56) | 6 (27) |
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Monthly income <15000 Baht/monthb, n (%) | 3 (9) | 3 (14) | .65 | |||
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.12 | |||
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iPhone | 24 (71) | 11 (50) |
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Android | 10 (29) | 11 (50) |
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Parents who used other apps to assess child’s health in the past, n (%) | 8 (24) | 7 (3) | .49 | |||
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Sex, female, n (%) | 11 (32) | 13 (59) | .048c | |||
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.002c | |||||
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Mean (SD) | 2.6 (1.3) | 3.8 (1.6) |
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Range | 0.3-4.9 | 0.1-6 |
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.82 | ||||
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Below normal | 1 (3) | 1 (5) |
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Normal | 31 (91) | 19 (86) |
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Above normal | 2 (6) | 2 (9) |
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.90 | ||||
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Below normal | 1 (3) | 1 (5) |
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Normal | 32 (94) | 20 (90) |
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Above normal | 1 (3) | 1 (5) |
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.75 | ||||
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Below normal | 0 (0) | 0 (0) |
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Normal | 33 (97) | 21 (95) |
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Above normal | 1 (3) | 1 (5) |
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Year (range) | 2005-2014 | 2007-2013 |
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aMCHH: maternal and child health handbook.
b1 USD=35.3 Baht.
cDifferences were statistically significant at
Congruence of child growth assessments between parents and physicians by group.
Group, growth parameter assessment | Parent, normal |
Physician, normal assessment, n (%) | Congruence of |
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Weight | 29 (85) | 31 (91) | 31 (91) | .16 | ||||
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Length/height | 29 (85) | 32 (94) | 31 (91) | .22 | ||||
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Head circumference | 32 (94) | 33 (97) | 33 (97) | .32 | ||||
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Weight | 17 (77) | 19 (86) | 20 (91) | .37 | ||||
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Length/height | 20 (91) | 20 (91) | 21 (95) | .61 | ||||
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Head circumference | 18 (82) | 21 (95) | 19 (86) | .08 |
aMCHH: maternal and child health handbook.
In this study, 356 parents from all regions of Thailand participated in the web-based survey. The baseline characteristics are shown in
Baseline characteristics of the parents and children in the web-based survey (n=356).
Demographics | Values | |||
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Sex, female, n (%) | 331 (93.0) | ||
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Mean (SD) | 28.1 (6.1) | |
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Range (years) | 18-45 | |
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North | 50 (14.0) | |
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Northeast | 57 (16.0) | |
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East | 54 (15.2) | |
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Central | 147 (41.3) | |
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South | 25 (7.0) | |
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West | 23 (6.5) | |
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Less than bachelor’s degree | 31 (8.7) | |
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Bachelor’s degree | 217 (61.0) | |
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Master’s or doctoral degree | 108 (30.3) | |
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Monthly income < 15,000 Baht/montha, n (%) | 25 (7.0) | ||
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1 | 281 (78.9) | |
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2 | 59 (16.6) | |
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>3 | 16 (4.5) | |
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iPhone | 229 (64.3) | |
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Android | 127 (35.7) | |
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Parents who used other apps to assess child’s health in the past, n (%) | 24 (6.7) | ||
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Age (years), mean (SD) | 2.92 (2.9) | ||
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Sex, female, n (%) | 131 (36.7) |
a1 USD=33 Baht.
Parents’ ratings of feasibility: health assessment and convenience of use of mobile app versus maternal and child health handbook (n=356).
Feasibility | App | MCHHa | ||
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Weight | 352 (98.9) | 268 (75.3) | <.001 |
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Length/height | 350 (98.3) | 268 (75.3) | <.001 |
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Head circumference | 350 (98.3) | 271 (76.1) | <.001 |
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Development | 353 (99.2) | 279 (78.4) | <.001 |
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Immunization | 333 (93.5) | 284 (79.8) | <.001 |
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Data input | 352 (98.9) | 287 (80.6) | <.001 |
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Access to desired segment | 340 (95.5) | 248 (69.7) | <.001 |
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Understandability of content | 342 (96.1) | 290 (81.7) | <.001 |
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Applicability of content | 346 (97.2) | 282 (79.2) | <.001 |
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Usefulness | 354 (99.4) | 261 (73.3) | <.001 |
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Overall convenience | 354 (99.4) | 252 (70.8) | <.001 |
aMCHH: maternal and child health handbook.
For acceptability, on a scale of 10, the KhunLook app received a mean (SD) score of 8.59 (1.1) (range 3-10), which was significantly higher than that of the MCHH (7.6 [1.8], range 0-10;
This is the first study to describe the development and evaluation of a mobile app for child health supervision by comparing the congruence of parent-physician growth assessments and parental evaluation in Thailand. Our participants in phase 1 offered insight into the requirements of an ideal app. Participants suggested that the app could counter parents’ infrequent use of the MCHH book. They also emphasized the importance of standard, up-to-date, understandable content, and offline functionality. Parents who used the app or the MCHH could comparably assess their child’s growth status to that of a physician’s assessment. Parents who used the app had higher proportions of congruence to the physician’s assessment for weight and head circumference than parents who used the MCHH, but the differences were not statistically significant. For acceptability, parents rated the app significantly more feasible and acceptable in relation to the MCHH (
mHealth technology interventions in maternal and child health are increasing worldwide [
Mobile apps are used to support interventions for maternal and child health care [
Successful benefits of mHealth services require acceptability and engagement from the user [
We developed the KhunLook app based on the belief that parental involvement would increase early detection and adequate childcare. Initially, the goal was to develop the app to compliment the MCHH. During the process, it has become eminent that the maintenance of content update, feature development, and user service is crucial. However, for the app to reach its potential, implementation at a wide scale is imperative. We started with a small team of health care providers, app developers, and users. Later on, we involved stakeholders on a wider scale. While drafting this paper (August 2020), the KhunLook app has been downloaded more than 320,000 times. It is endorsed by the Ministry of Public Health, and a link to download the app is currently provided in the MCHH.
The results of this study are interpretations from a certain time and do not reflect the current app. The development of “KhunLook” in phase 1 and 2 involved a convenient sample of parents at a university hospital. Most of the parents were well educated and were willing to try new technology but the number of participants was too small to draw generalized conclusions.
In this study, KhunLook, a Thai mobile app for child health supervision, was developed, validated for growth assessments, and was found to be well accepted for ease-of-use by parents. The full potential of this mHealth app is yet to be defined. Further studies on parental and clinical use should be conducted such as a randomized study involving a wider scale of users or studies to evaluate its impact on health behaviors and health outcomes.
maternal and child health handbook
mobile health
This study was funded by the Health Systems Research Institute, Ministry of Public Health, and the National Research Council of Thailand.
None declared.