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The NeoTree application: developing an integrated mHealth solution to improve quality of newborn care and survival in a district hospital in Malawi
  1. Caroline Crehan1,
  2. Erin Kesler1,
  3. Bejoy Nambiar2,
  4. Queen Dube3,
  5. Norman Lufesi4,5,
  6. Matteo Giaccone6,
  7. Charles Normand7,
  8. Kishwar Azad8,9,
  9. Michelle Heys1
  1. 1 Great Ormond Street Hospital Institute of Child Health, University College London, London, UK
  2. 2 Institute for Global Child Health, University College London, London, UK
  3. 3 Paediatric Department, College of Medicine, University of Malawi, Blantyre, Malawi
  4. 4 Ministry of Health Acute Respiratory Illness Unit, Government of Malawi, Lilongwe, Malawi
  5. 5 Paediatrics and Child Health Association (PACHA), Blantyre, Malawi
  6. 6 Ubiqueworks, London, UK
  7. 7 Spinspire Consulting, London, UK
  8. 8 Ibrahim Medical College, Dhaka, Bangladesh
  9. 9 Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders at Shahbag, Dhaka, Bangladesh
  1. Correspondence to Dr Caroline Crehan; c.crehan{at}


More than two-thirds of newborn lives could be saved worldwide if evidence-based interventions were successfully implemented. We developed the NeoTree application to improve quality of newborn care in resource-poor countries. The NeoTree is a fully integrated digital health intervention that combines immediate data capture, entered by healthcare workers (HCW) on admission, while simultaneously providing them with evidence-based clinical decision support and newborn care education. We conducted a mixed-methods intervention development study, codeveloping and testing the NeoTree prototype with HCWs in a district hospital in Malawi. Focus groups explored the acceptability and feasibility of digital health solutions before and after implementation of the NeoTree in the clinical setting. One-to-one theoretical usability workshops and a 1-month clinical usability study informed iterative changes, gathered process and clinical data, System Usability Scale (SUS) and perceived improvements in quality of care. HCWs perceived the NeoTree to be acceptable and feasible. Mean SUS before and after the clinical usability study were high at 80.4 and 86.1, respectively (above average is >68). HCWs reported high-perceived improvements in quality of newborn care after using the NeoTree on the ward. They described improved confidence in clinical decision-making, clinical skills, critical thinking and standardisation of care. Identified factors for successful implementation included a technical support worker. Coproduction, mixed-methods approaches and user-focused iterative development were key to the development of the NeoTree prototype, which was shown to be an agile, acceptable, feasible and highly usable tool with the potential to improve the quality of newborn care in resource-poor settings.

  • mHealth
  • data collection
  • infant mortality
  • health facilities
  • quality of healthcare
  • user-computer interface

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  • Handling editor Soumitra Bhuyan

  • Contributors MH, CC and EK conceptualised the NeoTree. CC configured the app, carried out the study, conducted the analysis, collected the data and wrote the manuscript. EK contributed to app configuration, collected data in the field and edited the manuscript. BN provided in-country supervision for CC during the study, advised on and reviewed and edited the manuscript. QD reviewed the NeoTree-Alpha and was the Malawi principle investigator for the project, contributing to fieldwork and reviewing the manuscript. NL advised from the Ministry of Health Malawi on fieldwork logistics, and reviewed the manuscript. MG was the main developer on the project and provided android coding and software development of the editor platform and the app and contributed to technical aspects of the manuscript. CN was the project manager and provided considerable advice on logistics, app development and writing technical aspects of the manuscript. KA reviewed the early prototypes of the app in Bangladesh and reviewed the manuscript. MH was the UK principle investigator overseeing the project, advising on all aspects, conceptualising both the application and the research study, collaborating with partners, writing and reviewing the manuscripts and supervising CC (first author).

  • Funding The systematic review and formative phase 1 work was funded by UCL Grand Challenges grant. Phase 3 work was funded by RCPCH Global Health Development Fund and the Naughton/Clift-Matthews Global Health Fund. MH was funded by the National Institute for Health Research, UK, during this project.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Malawi College of Medicine Research Ethics Committee (COMREC; reference number: 17PP12).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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