CANMI: a system to improve the quality of nutritional care

The objective of the project is to develop an evaluation and monitoring digital system that will allow knowing the quality levels of maternal and child nutritional care at primary care in each health unit and at national and subnational levels in Mexico. This solution can help to identify which regions and states require attendance or reinforcement in one or more of the components of quality of nutritional care. 

In the last three decades, various efforts have been made in Mexico to combat malnutrition problems, and although progress is observed, the numbers are still high especially in stunting (13.9%), childhood overweight and obesity (8.4%) (ENSANUT 2018-2019), anemia during reproductive age (17.5) (ENSANUT, 2018) and low birth weight (7.1%) (Ancira-Moreno, 2020). Added to these problems is the disappearance of the Progresa-Oportunidades-Prospera (POP) program in 2019, which was aimed at the population in conditions of extreme poverty, and sought to influence simultaneously through various components, education, food, and monetary transfer, as well as supplements for pregnant women, breastfeeding women, and children under 5 years of age, and health, which included self-care workshops and mandatory preventive check-ups for the whole family.

In addition to the barriers mentioned to stopping the problems of malnutrition, in Mexico there are significant deficiencies in the quality of care, especially in primary health care. Mexico is one of the worst-rated countries in the continent (Saturno-Hernández PJ, 2015), which is reflected in preventable deaths, including those related to neonatal illnesses. The low quality of care in primary health care includes a lack of leadership -which creates bureaucratic barriers that reduce structural performance, a shortage of equipment, medicines, and supplies, and poor staff training, which leads to dissatisfaction and affectation of the health of users. Especially the lack of staff became more evident with the COVID pandemic because second and tertiary care were prioritized to attend to contingencies and emergencies.

Despite the problems described above, Mexico does not have an evaluation and monitoring system for the quality of maternal and child nutritional care in primary health care, even with the knowledge that all SDGs are related, directly or indirectly, to nutrition status at individual and population level. 

Actions aimed at improving the quality of nutritional care in primary care can have a significant impact on optimizing the nutritional status of the maternal and child population and influence the prevention of intergenerational transmission of pathological conditions and cardiometabolic risks in life course.  Among these actions, access to an efficient, rigorous, and standardized monitoring system that allows knowing the quality levels of nutritional care and the possible disparity between states and regions becomes extremely necessary. 

In the last two years, we have made efforts in collaboration with UNICEF and the Mexican government to validate 16 indicators and an index called quality of maternal and child nutritional care (CANMI for its acronym in Spanish). The study was carried out in 6 states of Mexico (Oaxaca, State of Mexico, Veracruz, Yucatan, Chihuahua, and Chiapas) allowed us to know that the quality of nutritional care in primary care is poor in terms of prevention, diagnosis, and treatment of the various forms of malnutrition during preconception, pregnancy, postpartum, early childhood, and preschool age.

Our solution is to develop a national evaluation and monitoring digital system based on the 16 indicators previously validated that allow the evaluation of the quality of nutritional care during the aforementioned early life stages in the Primary Health Care in Mexico. The information generated through the system will serve as an input for decision-makers to generate effective and focused interventions, for frontline health workers to improve their performance, and also for the civil society to hold leaders accountable to their commitments and call for specific solutions and financing reforms needed to achieve health goals in their communities.

The CANMI evaluation and monitoring system will be available through a mobile application (iOS and Android) and a web application with the following characteristics:

Mobile app (iOS and Android)

• The data collected through the mobile app will serve as input to systematize the indicators.

• It will allow the automatic evaluation of the indicators and will show the traffic lights obtained. Traffic lights is a system for interpreting results as good quality (green light), poor quality (yellow light), and poor quality (red light).

• The app will show the clinical practice recommendations that must be implemented in Primary Health Care by health professionals to improve nutritional care during preconception, pregnancy, postpartum, infancy and preschool age.

• It will not require internet access to collect the data (offline operation).

 • It will not require high-end performance cell phones to be efficient.

• It will have a simple and intuitive interface and an attractive design.

• You will have security and data protection with the latest industry security standards.

• It will have the protection of personal data according to current legislation in Mexico.

• It will have interoperability with the web application.

Web app

• It will allow the systematization and display of visualizations (graphs, georeferencing, trends, etc.) of the results of the indicators, ICANMI, and other data collected with the mobile app related to the quality of care (infrastructure, available material, etc.) in each center health and at state  and national level 

• It will have a simple and intuitive interface and an attractive design.

• You will have security and data protection with the latest industry security standards.

• It will have the protection of personal data according to current legislation in Mexico.

• It will have interoperability with the mobile application.

Our solution involves various actors at different levels:

1. Zonal teams. They will be in charge of collecting the data that will serve as input to evaluate the quality of care and their feedback will be essential in evaluating the performance of our solution. 

2. Health professionals who work at the first level of care (physicians, nutritionists, nurses). Through the CANMI app, they will be able to consult the results of the health center where they work and receive recommendations to offer quality nutritional care.

3. Health authorities at different levels (health center, jurisdiction, state, national). They will have access to the results of the quality evaluation, they will receive recommendations for interventions and policies to improve the quality of maternal and child nutritional care considering the context of their health centers. In addition, we will work together with them to implement our solution in more health centers.

4. Maternal and child population (preconception, pregnancy, postpartum, infancy, and preschool age). The central objective of our solution is to improve the health and nutritional status of this population by offering quality nutritional care at the first level of care. The first step to achieving this is to evaluate this quality (what is not measured cannot be improved).

5. Policymakers. The evaluation, monitoring, and public policy recommendations derived from our solution will serve as inputs for the design and implementation of interventions, programs, and policies aimed at improving the quality of maternal and child nutritional care in Primary Health Care.

6. Researchers: A research network will develop and will be assessing the operation of CANMI evaluation and monitoring digital system and analyzing the data generated in this system. 

As a team, we are currently well positioned in influencing public policies related to maternal and child nutrition. Our team is constituted of 10 researchers who work in different institutions such as the Department of Health at the Universidad Iberoamericana, The Research for Development with Equity Institute (EQUIDE), The National Institute of Public Health of Mexico.The  National Institute of Perinatology (Mexico) and The National Institute of Medical Sciences and Nutrition Salvador Zubirán (INCMNSZ). Most of the researchers in our team belong to the national system of researchers in Mexico and have a Ph.D. in areas such as public health and epidemiology. Within the team, we have 3 experts in measuring the quality of care in Primary Care and have directed inter-institutional projects at state and national levels. We also have a team of software developers trained in the development of state-of-the-art applications, data science, and spatial data analysis. 

We have extensive experience working on mixed methods projects in collaboration with the government and different social actors. For the last three years, our team has been working on multi-dimensional/multi-state projects in collaboration with decision-makers, government, and agents involved in formulating, managing, and implementing public policies.  Three years ago, we create the Maternal and Child Observatory (OMI for its acronym in Spanish) to make visible the seriousness of the nutritional and health situation during the preconception stage, pregnancy, lactation, and in children in Mexico (https://omi.ibero.mx/). The OMI´s platform allows the visualization of a set of indicators of maternal and child nutrition.

 For the last two years, we carried out a project whose principal objective was to diagnose the quality of maternal and child nutritional care in 95 health centers belonging to the first level of care in six states of Mexico, is important to mention that two of these states having the highest number of health centers in the entire country. This project was funded by UNICEF and supported by key actors who influence decision-making related to maternal and child nutrition at the first level of health care at state and national levels. 

To develop and implement the solution we propose, we will take advantage of the resources already developed in the aforementioned projects. We will work together with stakeholders with whom we have previously collaborated effectively and successfully in previous research. In addition, another mapping of actors will be carried out to scale the proposal that we are going to develop for more states in Mexico. 

Our project has the potential to scale to the national level and, therefore, improve the quality of maternal and child nutritional care at the first level of health care. Since the first level of care plays an essential role in prevention, diagnosis, and treatment, our solutions would contribute to improving the nutritional status of women of reproductive age, infants, and preschool children. However, we need financial resources to be able to develop the mobile app and scale this solution to assess, monitor, and improve the quality of nutritional care. Unfortunately, financing resources in Mexico are limited, so we seek international financing that allows us to have greater scope and coverage. In addition, obtaining these resources will allow promoting the public agenda with stakeholders.

We have already developed and validated a series of indicators and indices to assess the quality of nutritional care in the early stages of life in the Primary Care System. To our knowledge, there are no indicators to evaluate this outcome in Mexico or worldwide. Our team is interdisciplinary, and our solution uses resources such as implementation science, data science, predictive models in health, and the latest web and mobile technologies: Microservices, Big Data, and Cloud Services.

In addition, the solution considers the context of Internet access in Mexico by offering the possibility of capturing information without the need for Internet access. The query for information is supported by new ways of communicating information from the visualization of interactive data through storytelling and interactive dashboard.

It is expected that by the end of next year, 50% of Primary Health Care centers in the six states in which work has already been done will have access to the CANMI evaluation and monitoring digital system to assess the quality of maternal and child nutritional care. The data obtained will allow feedback on the recommendations addressed to health personnel and evaluators of health centers to improve the quality of nutritional care and thus contribute to the prevention and effective treatment of the various forms of maternal and child malnutrition.

In addition, the data obtained in the app will be uploaded and systematized on a platform to which all those interested in this topic will have access. In this way, the quality of care will be monitored, and the data can be viewed in different ways (maps, graphs, tables).

It is expected to work together with the health authorities so that in the next five years this digital system will be incorporated in more states of the country. We hope that at the end of the next 5 years at least 50% of the health centers will use the CANMI evaluation and monitoring digital system. This will allow decision-makers to have a diagnosis that serves as a basis for implementing strategies to improve the quality of maternal and child nutritional care. 

The indicators that will allow us to measure the progress of our solution are:

• Number and proportion of states in which the quality-of-care evaluation and monitoring system is implemented at different levels (jurisdiction, state, national). 
• Data generated in the platform (spatial data, graphics).
• The number of visits and downloads of the platform. 
• Percentage of annual improvement in the indicators that evaluate the quality of care at different levels (jurisdiction, state, national).

The attached image describes the process of the proposed solution based on the theory of change.

In addition, Implementation science and PIP were used to develop the inputs for the CANMI evaluation and monitoring system. Therefore, these frameworks are essential components of our project.

Program Impact Pathway (PIP).

To implement the CANMI evaluation and monitoring system we will use the PIP. This model will allow the identification of possible facilitators or barriers during the implementation of this system in order to recognize early the factors related to its success or failure. The steps proposed in the literature will be followed:

a) Description of the logical model of the intervention: in this,

identify its objectives, the target population, and the environment, as well as the inputs, activities, products, and evaluation indicators. The description must be based on what is actually being done, that is, what is actually being implemented.

b) Development of the PIP diagram: it implies the development of the roadmap that is expected to be followed so that the inputs and activities actually lead to the expected results.

 c) Summary of the PIP: indicating whether the objectives of the program can be achieved based on the activities proposed in the program, whether the investment in time and money is sufficient, the evaluation of program processes, and the evaluation of impact indicators.

Implementation science

Chambers and Glasgow's dynamic sustainability model starts from the basic principle that implementing interventions, which can often require substantial resources, is meaningless without successful use and long-term benefits of the intervention components. This model will be used as a theoretical input for the methodological development of the CANMI evaluation and monitoring system and its implementation since it will allow the identification of those items, components, and actors that should be considered in the design, implementation, and evaluation of this system to evaluate and monitor the quality of maternal and nutritional care at Primary Health care.

Our solution will be a combination of different modern and scalable development technologies. The mobile application will be built with Flutter, which is an open source framework developed by Google to build offline and online cross-platform applications (iOS and Android). The web application will be built on the Django framework, which makes use of the Python programming language to build robust and scalable web applications. The data will be stored in postgreSQL, which will also allow us to store geographic information. The web application and the mobile application will be interoperable through APIs.

In the Mexican health system, those in charge of supervising that the health personnel complies with the norms and procedure manuals are the zonal teams ("equipos zonales") at Primary Health Care. The members of these teams will be in charge of evaluating the quality of maternal and child nutritional care in health centers through the CANMI app.  Researchers and research assistants will train health professionals and supervisors on the use of the app.

The growing evidence supports that high-quality Primary Health Care reduces health inequities. For this reason, semi-structured interviews were applied during the development and validation process of the quality indicators to identify barriers and facilitators that health professionals face on a day-to-day basis to offer high nutritional care based on diversity, inclusivity, intercultural, and equity approach. This technique was also applied to users who receive nutritional care during preconception, pregnancy, postpartum, or who are caregivers of infants and preschool children. Consequently, CANMI evaluation and monitoring system will allow us to know the proportion of people receiving the nutritional care they need in the health units at primary care levels, regardless of where they live, their gender, whether or not they speak any indigenous language, how much money they have, or how much education they have received.

We are currently part of a research network that emerged with the development of the Maternal and Child Observatory (https://omi.ibero.mx/) in which public and private institutions and researchers participate. Our solution is supported by this research network and we are constantly applying for funding from various agencies to keep research projects active. An important part of our solution is working together with health personnel (professionals who work in health centers and zonal teams), health authorities at different levels, and decision-makers. In this way, we hope that the CANMI evaluation and monitoring digital system will be financially sustainable in the long term.

An example is the Maternal and Child Observatory (OMI by its acronym in Spanish), which is a platform that aims to systematize data obtained from open databases regarding the six nutritional indicators that are considered as the global targets for improving maternal, infant and young child nutrition for 2025 by WHO. 

The OMI started in 2020 and we have kept this platform active thanks to the work of the researchers who are part of the aforementioned network and the funding we have obtained from various agencies. 

We intend that the CANMI evaluation and monitoring digital system be used systematically at the national level to assess the quality of maternal and child nutritional care at Primary Health Care with support of the researchers, public and private institutions, non-governmental organizations and government.