BENCHMARKING OF APPS FOR MOBILE DEVICES TARGETED AT CHILDREN’S HEALTH

Objective: to identify which of the apps available for children include information on monitoring growth and development, in a way similar to the Brazilian Children’s Handbook. Method: this is an exploratory research study to survey apps designed to monitor children’s growth and development. The “Benchmarking” technique was used to assist in the process. The search for apps was carried out in January 2023 in the Google Play and App Store stores. The data were tabulated in Microsoft Excel . After classifying the variables, absolute and relative frequencies were calculated. Results: a total of 624 apps were identified. Of these, 491 were found in Google Play and 133 in the App Store . After analyzing the app descriptions and excluding duplicates


INTRODUCTION
The development of good practices that encourage healthy habits is essential for health care and should begin in childhood, with periodic monitoring of children's growth and development milestones by trained professionals, in order to reduce infant morbidity and mortality.
In this context, despite the reduction in child mortality worldwide, from 12.5 million in the 1990s to 5.3 million in 2018, it is fundamental to promote the prevention of child deaths, mainly given the forecast of 52 million deaths of children before the age of five between 2019 and 2030 1 .
To this end, one of the proven effective actions for health promotion and prevention and reduction of child deaths is childcare, which nationally consists of following-up children by monitoring their development and growth in its entirety.In addition to that, it enables early detection of health problems and promotes better living conditions in early childhood [2][3] .
The Brazilian Ministry of Health (Ministério da Saúde, MS) recommends carrying out at least nine routine consultations for children from zero to two years of age, to monitor their health, as well as to identify and intervene in factors that may cause harms to children's growth and development.These consultations must be carried out in Basic Health Units (BHUs), and the tool for this purpose is the Children's Handbook (Caderneta da Criança, CC) 4 .
The CC is indicated by the National Policy for Comprehensive Children's Health Care (Política Nacional de Atenção Integral à Saúde da Criança, PNAISC) as one of the strategic components for promoting children's health care 2 , and is also a dialogical instrument between health professionals and the family.Distributed by the Ministry of Health and sent to maternity wards and Basic Health Units (BHUs), this tool is organized into two parts: one aimed at the family, with guidelines for health and child care; and the other targeted at professionals, with space for recording information, growth charts and development surveillance instrument 4 .
Although using handbooks to monitor children's health has been established since the 2000s, there is still certain deficit in recording this diverse information.Countless studies were carried out in Brazil to investigate issues related to filling out the CC.Some of them highlighted flaws in Handbook recording, suggesting that the tool has not achieved its objectives [5][6] .Results from a study with 420 handbooks showed that completion of these instruments was not satisfactory (25.5%), reaching 65% of records on head circumference at birth, 21.9% completion of age/head circumference graphs and only 18.1% in the assessment of children's developmental milestones 7 .
In the state of Paraíba, several incorrectly filled-out items were identified in 402 (100%) of the children's handbooks evaluated.Among them is the low percentage of correct filling-out of the "head circumference at birth" chart (13.7%) and the neuropsychomotor development assessment (2%) 8 .This corroborates the results of another study, in which 54.5% of the CCs analyzed did not contain the neurodevelopment surveillance item for children under one year old, and 90% of the CCs for children aged one to three years also did not have the surveillance item 5 .
Furthermore, in 2019 there was discontinuation in the delivery of CCs by the MS, which has not yet been fully normalized, influencing the quantity and quality of children's health information.This situation made it impossible to fill out the information in that instrument.
With the objective of reducing information loss, maternity hospitals and some Brazilian municipalities created a type of card with information about each child, such as name, date and time of birth, name of the maternity hospital, height and weight at birth and space for vaccine registration.Although this was an alternative to reduce children's health monitoring discontinuity, this instrument does not include all the information present in the CC, which may weaken the assistance in monitoring children's growth and development.

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Given this context, it is essential to think of other ways to monitor and record children's health.Therefore, it is necessary to devise strategies to ensure the use of CCs and greater adherence by professionals and users to them, such as a digital app using Information and Communication Technology (ICT) for CCs.
ICTs are strongly present in people's lives, as they contribute to meeting the countless demands for information, as well as serving as interactive tools for the users, which are essential in the learning and decision-making processes 9 .These changes consolidate a new sociocultural and educational era through the rapid spread of information, and several knowledge areas are being modified through technologies, including the health field, incorporating new strategies on information use in the face of epidemiological problems.
The advent and popularization of ICTs have exerted impacts on the health sector through the use of smartphones, software programs and apps that promote several benefits, including use accessibility and portability, in addition to providing more agility in the development of activities 10 .
Apps are technological devices developed for use on mobile devices (tablets or smartphones) and are capable of capturing, storing, receiving and sharing data and information, in addition to enabling customization of the tools according to the clients' needs and preferences 11 .
Given this context and the growing number of new apps in the children's health area, it becomes necessary to identify new products/software programs that are made available to professionals and to the general population.This analysis can be carried out using the "Benchmarking" technique.
Derived from the word "benchmark" meaning "reference", "Benchmarking" is an efficient search technique that evaluates and analyzes products, services and apps available on the market.Through a comparative assessment, it is possible to obtain relevant information with the purpose of promoting innovative ideas and improvements on the study object [10][11] .
In this context, with the aims of expanding discussions for the creation and development of new apps in the children's health area and of contributing to monitoring children's growth and development in a systematic and longitudinal way, the objective was to identify which of the available apps for children include information on monitoring growth and development in a way similar to the Brazilian Children's Handbook.

METHOD
This is an exploratory research study to survey apps designed to monitor children's growth and development.To assist in the process, the "Benchmarking" technique was used, which acts as a search instrument, allowing comparisons to be made to support decision-making 10 .The first research phase was searching apps in the Google Play and App Store virtual stores and was guided by the following question: "Which apps present children's health data records (anthropometry, children's growth and development milestones and vaccination records) in a way similar to the Children's Handbook?"The following inclusion criteria were adopted: software program that would enable at least one of the health records proposed by the Children's Handbook, such as anthropometric data or children's development and vaccination milestones.Apps not aimed at monitoring children's health were excluded, such as games and those to help children sleep.
The research took place in January 2023, carried out by a single reviewer in the Google Play store aimed at Android operating system devices and in the Apple App Store, for the iOS operating system.Three devices were used for this purpose, namely: an iOS-compatible iPhone 11; a notebook with Windows operating system; and an Android-compatible Xiomi i9.The reviewer underwent training before starting the research and delved into the literature available to support his investigation.

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The following keywords, in Portuguese, were used separately in each virtual store: "children's health" ("saúde da criança") and "child development" ("desenvolvimento infantil").Apps targeted both at health professionals and at parents/caregivers of children were sought.
After the search, the second research phase was initiated: Cataloging the apps.At this stage, all apps resulting from the search were part of the study population and were organized in an information matrix in Microsoft Excel®.
The following variables were defined: name of the app; developer -author or company responsible-, to identify whether the initiative to produce the app was from a public or private institution; and the app objective -its intended purpose.There was no restriction regarding year of development, free of charge nature and language in which the apps were presented, as the aim was to verify whether the software made it possible to monitor children's anthropometry, as well as developmental milestones and record childhood vaccinations.
After tabulating the apps, the third research phase was initiated: Data processing and analysis.A critical reading of the description/objective of each app was carried out.The software options were classified as "Yes" for apps that had at least one of the characteristics of recording information from the Children's Handbook, and as "No" for those that did not have any type of recording of information on children's health.
The apps selected went through a duplicate removal filter in order to avoid repetitions.With the final sample established, a new analysis was carried out in which the "characteristic of the records" variable was assigned, with the aim of identifying the type of children's health record that the app proposed to offer.
At this moment, in addition to seeing the description of the apps again, their explanatory screens were analyzed, which are made available in online stores.Concerning the final sample, only one app presented in its description and explanatory screens an area intended for monitoring growth (anthropometry) and milestones in child development and vaccination records.The software was downloaded and registered to access the system, in order to learn about its usability.
After classifying the study variables, the absolute and relative frequencies were calculated for subsequent discussion in light of the literature relevant to the topic.As this is a research study which uses information in the public domain in virtual stores, it was not necessary to request the opinion from any Research Ethics Committee or informed consents.

RESULTS
The search data in the app stores compatible for use on mobile devices (smartphone, tablet, etc.), as shown in Figure 1 with Android or IOS systems, resulted in a total of 624 (100%) apps for the terms "saúde da criança" and "desenvolvimento infantil".491 (79%) of them were found in Google Play and 133 (21%) in the App Store.
After analyzing the app titles and reading their characteristics and objectives, 569 (91%) were excluded because they were programs whose purpose was not intended for the proposed objective of the study, such as regulating children's sleep, calculating BMI in adults and children's games.55 software options were pre-selected and subjected to the duplicate identification filter.Then, 07 duplications were identified by the filter and excluded, totaling 48 apps in the final sample (Figure 1).In Chart 1, of the software options selected (n=48), 42% (20) are available in Portuguese and another 58% (28) in other languages such as English, Japanese, Russian and Turkish.The apps were developed in other countries, such as the United States of America, Turkey, Russia and Japan and placed in app stores by companies or individuals independently.

DISCUSSION
Technology is increasingly present in people's daily life.Technological advances and the use of mobile telephony allow various functionalities to be quickly incorporated into modern routines.ICT is a terminology that highlights the role of communication in information technology and corresponds to a group of integrated technological devices that allow the automation and communicability of training processes through software and telecommunications functions 12 .Integration of these technologies with different logics and language articulations supports data storage, development and exchange with agility 13 .
In view of the above, ICTs directly influence the community, contributing new knowledge with sociocultural values at a high speed 14 and changing market trends.Various possibilities and proposals for technological innovation are constantly emerging, and the health area has been strongly impacted by the incorporation of ICTs into general service provision strategies and the development of apps for mobile devices, with the objective of assisting medical and health practices 15 .
Mobile apps can be defined as software or programs developed for mobile devices (cell phones, tablets) that have the most diverse modalities 13,16 .This varied applicability modalities of mobile apps generate innovations that increase dissemination of information and transform the teaching and learning process in modern society 17 .
Mobile apps have gained space in health, and specific software programs have been developed over the years, the use of which allows remote support and patient self-care, assistance in decisionmaking and the creation of public policies for health promotion and control of diseases, as well as in training and qualification of professionals 13,16 .
In this context, health information systems have become indispensable for carrying out surveillance, monitoring health problems and following-up morbidity and mortality indicators 18 .The dissemination of mobile technology in health and the development of apps (mHealth) assist users and professionals in monitoring health remotely (support for diagnosis and decision-making) and in teaching and learning (care self-promotion), as well as in health monitoring 19 .
In the children's health context, the use of apps by health professionals can be effective, as they are considered to induce positive effects and have good receptivity, by automating results and by integrating playful characteristics with specific themes 20 .
However, despite their potential impact on active learning and the perspective of professionals' adherence, there is no identification in the national literature of a free digital app integrated with the SUS as an alternative to CCs, and which can be used by professionals who assist children, including 9/13 monitoring their growth, development and vaccination or other topics inherent to controlling their health, which are scored in the CC.
Similarly to the Brazilian reality, countries such as England, Germany and Australia have implemented health apps that provide tools in some children's health areas, such as recording vaccinations and scheduling medical appointments.
The National Health Service (NHS), the English health system, launched the NHS App, which became the most downloaded free app in the country.It allows children's parents or guardians to register, schedule medical appointments, record allergies and access vaccination records, in addition to having an area for health guidelines 21 .
In Germany, the smartphone app called KleineWeltentdecker App seeks to assist caregivers of children in recording child development milestones such as cognition, language, motor skills and socio-emotional skills.However, the app lacks a general approach to children's health, although it can be considered as a first step in the process of using software to assist in the child care process 22 .
In Australia, procedures were initiated in 2015 to implement the patient's Electronic Medical Record, called My Health Record (MyHR).MyHR is used by approximately 6 million people and incorporated in 13,000 health organizations, including basic health units, laboratories and pharmacies.For greater adherence to MyHR, the country adopted the opt-out approach, that is, all citizens of the country are automatically registered and only those who are not interested in being enrolled should request to be unregistered from the system.When users are under 14 years old, their parents are responsible for accessing and recording all the information [23][24] .
Regarding the MyHR applications, registered users have access to an online summary of key information about their health, such as medical and vaccination records [24][25] .In addition, the patients can include data about their health in MyHR or make personal notes about allergies and adverse reactions after taking medications and vitamins 23 .
With the purpose of knowing the users' perception about the MyHR App, research studies were carried out which showed that the users approved and felt safe with the app, in addition to having added better health care quality, as data were shared between various services and self-management of information by the patients themselves [25][26] .
However, despite the users' positive perception and growing adherence to the app, it is important to highlight that MyHR is not a system exclusively targeted at children and that it does not provide specific tools for monitoring their health.
In this context, it is clear that, although there are initiatives in the development and use of apps in the health area, there is still no identification, both in Brazil and in other countries, of software options that include all the data necessary for children's health care that are similar to the CC items, corroborating the findings of this study.
Furthermore, many challenges need to be overcome to develop an app to monitor children's health.A responsible and equitable approach is necessary to meet the specific demands required by the children's health area 27 .Therefore, creating a digital app, free and integrated with the SUS, to monitor this age group, is a reality that needs to be faced.
In this sense, there is a need to develop software in Brazil for monitoring children's health with the CC methodological scope used in PHC, allowing for the correction of operational weaknesses already mentioned in this study and which will ease using health information in a timely manner, focusing on epidemiological surveillance of child growth and development.
As study limitations, the presence of a single reviewer for sample selection and the predominance of international app are considered, thus hindering the comparison to the CC in a broader sense.

Figure 1 -
Figure 1 -Flowchart corresponding to the search for apps in Google Play and in the App Store.João Pessoa/PB, Brazil, 2023.

Table 1 -
, although not making any reference to availability in the Unified Health System (Sistema Único de Saúde, SUS) services.Proportional distribution of the app attributes, João Pessoa, PB, Brazil, 2023.(n=48)