The feasibility of using mobile-phone based SMS reminders and conditional cash transfers to improve timely immunization in rural Kenya

A review of measles control in Kenya, with focus on recent innovations

Despite the existence of a highly effective measles vaccine and the decrease in worldwide deaths from measles by more than 79% from the 2000 baseline levels, measles today remains one of the leading causes of vaccine-preventable deaths in the world. The African region is a key player in the global fight against measles. Africa has made tremendous progress in its effort to immunize children and to control the disease, increasing its regional measles vaccination coverage from 56% in 2001 to 85% in 2010. The Republic of Kenya has been a strong follower of the World Health Assembly and Measles Elimination 2020 resolutions, which aims to eliminate measles from the country. Since the beginning of the 21st century, Kenya has faced many challenges, but also aid, in the form of new innovations, in their fight against measles. In 2002, Kenya started its first SIA using A-D syringes, and from 2003-2005, GAVI funded injection safety support (INS) to Kenya, as an effort to scale-up safe injection in sub-Saharan Africa. In 2016, the Kenya introduced Measles-Rubella (MR) combined vaccine in its nationwide SIA campaign, after recognizing that rubella is a disease that must be controlled along with measles. In 2009 and 2012 SIAs, Red Cross volunteers conducted H2H visits to promote immunization as well as document information from the community with regards to immunization, including the current coverage, to campaign management levels. Case-based surveillance, using real-time PCR, measles-specific IgM detection and Epi-link were used to confirm and map measles infection during outbreaks. Alternative serosurveys such as Dried Blood Spot and Urine sample surveys were also tested in Kenya. In 2013 and 2016, two studies were also conducted in Kenya on the use of SMS reminder system for routine immunization. These studies, which showed SMS to significantly improve the vaccination coverage, paved way for use of SMS in a larger scale in Kenya.

Mobile phone-delivered reminders and incentives to improve childhood immunisation coverage and timeliness in Kenya (M-SIMU): a cluster randomised controlled trial

BACKGROUND

As mobile phone access continues to expand globally, opportunities exist to leverage these technologies to support demand for immunisation services and improve vaccine coverage. We aimed to assess whether short message service (SMS) reminders and monetary incentives can improve immunisation uptake in Kenya.

METHODS

In this cluster-randomised controlled trial, villages were randomly and evenly allocated to four groups: control, SMS only, SMS plus a 75 Kenya Shilling (KES) incentive, and SMS plus 200 KES (85 KES = USD$1). Caregivers were eligible if they had a child younger than 5 weeks who had not yet received a first dose of pentavalent vaccine. Participants in the intervention groups received SMS reminders before scheduled pentavalent and measles immunisation visits. Participants in incentive groups, additionally, received money if their child was timely immunised (immunisation within 2 weeks of the due date). Caregivers and interviewers were not masked. The proportion of fully immunised children (receiving BCG, three doses of polio vaccine, three doses of pentavalent vaccine, and measles vaccine) by 12 months of age constituted the primary outcome and was analysed with log-binomial regression and General Estimating Equations to account for correlation within clusters. This trial is registered with ClinicalTrials.gov, number NCT01878435.

FINDINGS

Between Oct 14, 2013, and Oct 17, 2014, we enrolled 2018 caregivers and their infants from 152 villages into the following four groups: control (n=489), SMS only (n=476), SMS plus 75 KES (n=562), and SMS plus 200 KES (n=491). Overall, 1375 (86%) of 1600 children who were successfully followed up achieved the primary outcome, full immunisation by 12 months of age (296 [82%] of 360 control participants, 332 [86%] of 388 SMS only participants, 383 [86%] of 446 SMS plus 75 KES participants, and 364 [90%] of 406 SMS plus 200 KES participants). Children in the SMS plus 200 KES group were significantly more likely to achieve full immunisation at 12 months of age (relative risk 1·09, 95% CI 1·02-1·16, p=0·014) than children in the control group.

INTERPRETATION

In a setting with high baseline immunisation coverage levels, SMS reminders coupled with incentives significantly improved immunisation coverage and timeliness. Given that global immunisation coverage levels have stagnated around 85%, the use of incentives might be one option to reach the remaining 15%.

FUNDING

Bill & Melinda Gates Foundation.

Use of m-Health in polio eradication and other immunization activities in developing countries

INTRODUCTION

Reaching the children that are chronically missed by routine immunization services has been a key pillar of success in achieving progress toward polio eradication. The rapid advancement and accessibility of mobile technology ("mHealth") in low and lower middle income countries provides an important opportunity to apply novel, innovative approaches to provide vaccine services. We sought to document the use and effectiveness of mHealth in immunization programs in low and lower middle income countries. We particularly focused on mHealth approaches used in polio eradication efforts by the Global Polio Eradication Initiative (GPEI) to leverage the knowledge and lessons learned that may be relevant for enhancing ongoing immunization services.

METHODS

In June 2016, the electronic database PubMed was searched for peer reviewed studies that focused on efforts to improve immunization programs (both ongoing immunization services and supplemental immunization activities or campaigns) through mobile technology in low and lower middle income countries.

RESULTS

The search yielded 317 papers of which 25 met the inclusion criteria. One additional article was included from the hand searching process. mHealth was used for reminder and recall, monitoring and surveillance, vaccine acceptance, and campaign strategic planning. Mobile phones were the most common mobile device used. Of the 26 studies, 21 of 26 studies (80.8%) reported that mHealth improved immunization efforts.

CONCLUSION

mHealth interventions can effectively enhance immunization services in low and lower middle income countries. With the growing capacity and access to mobile technology, mHealth can be a powerful and sustainable tool for enhancing the reach and impact of vaccine programs.

A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa

BACKGROUND

The prevalence of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa. At the same time, the use of mobile phones is rising, expanding the opportunities for the implementation of mobile phone-based health (mHealth) interventions. This review aims to understand how, why, for whom, and in what circumstances mHealth interventions against NCDs improve treatment and care in sub-Saharan Africa.

METHODS

Four main databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) and references of included articles were searched for studies reporting effects of mHealth interventions on patients with NCDs in sub-Saharan Africa. All studies published up until May 2015 were included in the review. Following a realist review approach, middle-range theories were identified and integrated into a Framework for Understanding the Contribution of mHealth Interventions to Improved Access to Care for patients with NCDs in sub-Saharan Africa. The main indicators of the framework consist of predisposing characteristics, needs, enabling resources, perceived usefulness, and perceived ease of use. Studies were analyzed in depth to populate the framework.

RESULTS

The search identified 6137 titles for screening, of which 20 were retained for the realist synthesis. The contribution of mHealth interventions to improved treatment and care is that they facilitate (remote) access to previously unavailable (specialized) services. Three contextual factors (predisposing characteristics, needs, and enabling resources) influence if patients and providers believe that mHealth interventions are useful and easy to use. Only if they believe mHealth to be useful and easy to use, will mHealth ultimately contribute to improved access to care. The analysis of included studies showed that the most important predisposing characteristics are a positive attitude and a common language of communication. The most relevant needs are a high burden of disease and a lack of capacity of first-contact providers. Essential enabling resources are the availability of a stable communications network, accessible maintenance services, and regulatory policies.

CONCLUSIONS

Policy makers and program managers should consider predisposing characteristics and needs of patients and providers as well as the necessary enabling resources prior to the introduction of an mHealth intervention. Researchers would benefit from placing greater attention on the context in which mHealth interventions are being implemented instead of focusing (too strongly) on the technical aspects of these interventions.

Assessing Mobile Phone Access and Perceptions for Texting-Based mHealth Interventions Among Expectant Mothers and Child Caregivers in Remote Regions of Northern Kenya: A Survey-Based Descriptive Study

BACKGROUND

With a dramatic increase in mobile phone use in low- and middle-income countries, mobile health (mHealth) has great potential to connect health care services directly to participants enrolled and improve engagement of care. Rural and remote global settings may pose both significant challenges and opportunities.

OBJECTIVE

The objective of our study was to understand the demographics, phone usage and ownership characteristics, and feasibility among patients in rural and remote areas of Kenya of having text messaging (short messaging service, SMS)-based mHealth intervention for improvements in antenatal care attendance and routine immunization among children in Northern Kenya.

METHODS

A survey-based descriptive study was conducted between October 2014 and February 2015 at 8 health facilities in Northern Kenya as part of a program to scale up an mHealth service in rural and remote regions. The study was conducted at 6 government health facilities in Isiolo, Marsabit, and Samburu counties in remote and northern arid lands (NAL). Two less remote health facilities in Laikipia and Meru counties in more populated central highlands were included as comparison sites.

RESULTS

A total of 284 participants were surveyed; 63.4% (180/284) were from NAL clinics, whereas 36.6% (104/284) were from adjacent central highland clinics. In the NAL, almost half (48.8%, 88/180) reported no formal education and 24.4% (44/180) self-identified as nomads. The majority of participants from both regions had access to mobile phone: 99.0% (103/104) of participants from central highlands and 82.1% (147/180) of participants from NAL. Among those who had access to a phone, there were significant differences in network challenges and technology literacy between the 2 regions. However, there was no significant difference in the proportion of participants from NAL and central highlands who indicated that they would like to receive a weekly SMS text message from their health care provider (90.0% vs 95.0%; P=.52). Overall, 92.0% (230/250) of participants who had access to a telephone said that they would like to receive a weekly SMS text message from their health care provider. Most phone users already spent the equivalent of 626 SMS text messages on mobile credit for personal use.

CONCLUSIONS

Despite the remoteness of northern Kenya's NAL, the results indicate that the majority of pregnant women or care givers attending the maternal, newborn, and child health clinics have access to mobile phone and would like to receive text messages from their health care provider. mHealth programs, if designed appropriately for these settings, may be an innovative way for engaging women in care for improved maternal and newborn child health outcomes in order to achieve sustainable development goals.

Educating parents about the vaccination status of their children: A user-centered mobile application

Parents are often uncertain about the vaccination status of their children. In times of vaccine hesitancy, vaccination programs could benefit from active patient participation. The Vaccination App (VAccApp) was developed by the Vienna Vaccine Safety Initiative, enabling parents to learn about the vaccination status of their children, including 25 different routine, special indication and travel vaccines listed in the WHO Immunization Certificate of Vaccination (WHO-ICV). Between 2012 and 2014, the VAccApp was validated in a hospital-based quality management program in Berlin, Germany, in collaboration with the Robert Koch Institute. Parents of 178 children were asked to transfer the immunization data of their children from the WHO-ICV into the VAccApp. The respective WHO-ICV was photocopied for independent, professional data entry (gold standard). Demonstrating the status quo in vaccine information reporting, a Recall Group of 278 parents underwent structured interviews for verbal immunization histories, without the respective WHO-ICV. Only 9% of the Recall Group were able to provide a complete vaccination status; on average 39% of the questions were answered correctly. Using the WHO-ICV with the help of the VAccApp resulted in 62% of parents providing a complete vaccination status; on average 95% of the questions were answered correctly. After using the VAccApp, parents were more likely to remember key aspects of the vaccination history. User-friendly mobile applications empower parents to take a closer look at the vaccination record, thereby taking an active role in providing accurate vaccination histories. Parents may become motivated to ask informed questions and to keep vaccinations up-to-date.

The role of mHealth intervention on maternal and child health service delivery: findings from a randomized controlled field trial in rural Ethiopia

BACKGROUND

The provision of consistent and quality maternal and child health (MCH) services is a challenge for Ethiopia where most of the population lives in the rural setup. Health service delivery is constrained mainly by shortage of health professionals, meager resources, limited awareness among the society and bureaucratic procedures. Low health service utilization of antenatal care (ANC), delivery services, and postnatal care (PNC) are believed to contribute for high maternal and child mortality rates. Innovative approach like mHealth based technological intervention believed to alleviate such challenges in countries like ours. However, currently, there are few evidences that demonstrate the impact of mHealth technology applications on the level of service utilization. Therefore, the objective our study is to assess the role of mobile phone equipped with short message service (SMS) based data-exchange software linking community health workers to Health Centers in rural Ethiopia affect selected MCH outcomes.

METHODS

A community-based randomized control trial (RCT) was conducted in three woredas of Guraghe zone (Ezha, partial &Abeshge full intervention, Sodo Control). Mobile phones equipped with FrontlineSMS based, locally developed application was distributed to all health extension workers (HEWs) to both intervention woredas who filled maternal, child and stock related forms and submitted to the central server which in turn sends reminder about the scheduled date of ANC visit, expected date of delivery, PNC, immunization schedule and vaccine and contraceptive stock status. Moreover, in Abeshge, the voluntary health workers (vCHW) and HEW supervisors in both intervention woreda were given a phone to facilitate communication with the HEW. No mobile was offered to the control woreda.Pre [2012] and post [2013] intervention community based survey on mothers who have under 5 and under 1 year old child was done to assess the effect of the mobile intervention on selected MCH process indicators. Structured and pretested questionnaire was used to collect data and SPSS v16 statistical software was used for analysis.

RESULTS

Three thousand two hundred and forty mothers, 1,080 from each, were surveyed in the three woredas. The study revealed that the proportion of mothers receiving more than four ANC visits increased significantly in both intervention woredas. Besides, the rate of ANC delivered by HEWs improved in Ezha woreda (T1) (19.01% to 28.27%), proportions of deliveries attended by skilled health workers increased and home delivery decreased in all woredas; most pronounced increases in referrals from health post to health center by HEWs, reported in Ezha and Abeshge. The intervention also led to a significant reduction in stock-outs of preferred contraceptive products in Ezha (T1) from 16.96% to 8.24% but no change was observed in both contraceptive prevalence and immunization rates in the control and the other intervention woreda.

CONCLUSIONS

The study confirmed the positive contribution of SMS based mobile phone intervention in most of the selected MCH service indicators, like improvement in the percent of recommended number of ANC visit, percentage of delivery attended by health workers and facilitating the work processes of the health workers in rural Ethiopia.

Vaccination adherence: Review and proposed model

BACKGROUND

The prevalence of childhood vaccine-preventable diseases can be significantly reduced through adherence to confirmed vaccination schedules. However, many barriers to vaccination compliance exist, including a lack of awareness regarding the importance of vaccines, missing due dates, and fear of complications from vaccinations. The aim of this study is to review the existing tools and publications regarding vaccination adherence, and to propose a design for a vaccination adherence application (app) for smartphones.

METHODS

Android and iOS apps designed for vaccination reminders have been reviewed to examine six elements: educational factor; customizing features; reminder tools; peer education facilitations; feedback, and the language of apps' interface and content. The literature from PubMed has been reviewed for studies addressing reminder systems or tools including apps.

RESULTS

The study has revealed insufficient (n=6) technology-based interventions for increasing childhood vaccination rates by reminding parents in comparison to the fast growth in technology, out of which are two publications discussed mobile apps. Ten apps have been found in apps stores; only one out of them was designed for the Saudi vaccination schedule in Arabic language with some weaknesses. The study proposed a design for a vaccination reminder app that includes a number of features in order to overcome the limitations discussed in the studied reminders, apps, and systems. The design supports the Arabic language and the Saudi vaccination schedule; parental education including peer education; a variety of reminder methods, and the capability to track vaccinations and refer to the app as a personal health record.

CONCLUSION

The study discussed a design for a vaccination reminder app that satisfies the specific requirements for better compliance to children's immunization schedules based on reviewing the existing apps and publications. The proposed design includes element to educate parents and answer their concerns about vaccines. It involves their peers and can encourage the exchange of experiences and overcome vaccine fears. In addition, it could form a convenient child personal health record.

MHealth to Improve Measles Immunization in Guinea-Bissau: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Recent studies have revealed a low measles vaccination (MV) rate in the Republic of Guinea-Bissau (West Africa) that has not increased in accordance with the increasing coverage of other vaccinations. Measles is the deadliest of all childhood rash/fever illnesses and spreads easily, implying that if the vaccination coverage is declining there is a significant risk of new measles outbreaks [27]. Meanwhile, mobile health (mHealth; the use of mobile phones for health interventions) has generated much enthusiasm, and shown potential in improving health service delivery in other contexts.

OBJECTIVE

The aim of this study is to evaluate the efficiency of mHealth as a tool for improving MV coverage while contributing to the mHealth evidence base.

METHODS

This study will take place at three health centers in different regions of Guinea-Bissau. Participants, defined as mothers of the children receiving the MV, will be enrolled when they arrive with their children at the health center to receive the Bacillus Calmette-Guérin vaccination, usually within one month of the child's birth. Enrolment will continue until a study population of 990 children has been reached. The participants will be randomly assigned to a control arm or one of two intervention arms. Each of the three groups will have 330 participants, distributed equally between health centers. Participants in the first intervention arm will receive a scheduled short message service (SMS) text message reminding them of the MV. Participants in the second intervention arm will receive a voice call in addition to the SMS message, while the control arm will receive no interventions. The MV is scheduled to be administered at 9 months of age. Although the vaccine would still be effective after 12 months, local policy in Guinea-Bissau prevents children aged >12 months from receiving the vaccination, and thus the study will follow-up with participants after the children reach 12 months of age. Children who have not yet received the MV will be offered vaccination by the project group.

RESULTS

The study will analyze the efficiency of the intervention by determining its overall effect on MV coverage and timeliness when children reach 12 months of age. The main analysis will be stratified by intervention group, health center, level of education, ethnic group, and role of the person receiving the text messages (eg, mother, father, other family member). Secondary outcomes include the average number of health center visits (with intention to obtain the MV) required before successful administration.

CONCLUSIONS

Despite the rapid proliferation of mHealth projects, only a small number have been evaluated in terms of direct links to health outcomes. This gap in knowledge requires solid evidence on which policy-makers can base decisions. This study aims to produce significant knowledge about mHealth implementation within a Sub-Saharan context while creating data-supported evidence.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02662595; https://clinicaltrials.gov/ct2/show/NCT02662595 (Archived by WebCite at http://www.webcitation.org/6jH8YiSjY).

The Mobile Solutions for Immunization (M-SIMU) Trial: A Protocol for a Cluster Randomized Controlled Trial That Assesses the Impact of Mobile Phone Delivered Reminders and Travel Subsidies to Improve Childhood Immunization Coverage Rates and Timeliness in Western Kenya

Background

Text message (short message service, SMS) reminders and incentives are two demand-side interventions that have been shown to improve health care–seeking behaviors by targeting participant characteristics such as forgetfulness, lack of knowledge, and transport costs. Applying these interventions to routine pediatric immunizations may improve vaccination coverage and timeliness.

Objective

The Mobile Solutions for Immunization (M-SIMU) trial aims to determine if text message reminders, either with or without mobile phone–based incentives, sent to infant’s parents can improve immunization coverage and timeliness of routine pediatric vaccines in rural western Kenya.

Methods

This is a four-arm, cluster, randomized controlled trial. Villages are randomized to one of four study arms prior to enrollment of participants. The study arms are: (1) no intervention (a general health-related text message will be texted to this group at the time of enrollment), (2) text message reminders only, (3) text message reminders and a 75 Kenyan Shilling (KES) incentive, or (4) text message reminders and a KES200 incentive. Participants assigned to study arms 2-4 will receive two text message reminders; sent 3 days before and one day before the scheduled immunization visit at 6, 10, and 14 weeks for polio and pentavalent (containing diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenza type b antigens) type b antigens) vaccines, and at 9 months for measles vaccine. Participants in incentive arms will, in addition to text message reminders as above, receive mobile phone–based incentives after each timely vaccination, where timely is defined as vaccination within 2 weeks of the scheduled date for each of the four routine expanded program immunization (EPI) vaccination visits. Mother-infant pairs will be followed to 12 months of age where the primary outcome, a fully immunized child, will be ascertained. A fully immunized child is defined as a child receiving vaccines for bacille Calmette-Guerin, three doses of pentavalent and polio, and measles by 12 months of age. General estimating equation (GEE) models that account for clustering will be employed for primary outcome analyses.

Results

Enrollment was completed in October 2014. Twelve month follow-up visits to ascertain immunization status from the maternal and child health booklet were completed in February 2016.

Conclusions

This is one of the first studies to examine the effect of text message reminders on immunization coverage and timeliness in a lower income country and is the first study to assess the effect of mobile money-based incentives to improve immunization coverage.

Trial Registration

Clinicaltrials.gov NCT01878435; https://clinicaltrials.gov/ct2/show/NCT01878435 (Archived by WebCite at http://www.webcitation.org/6hQlwGYJR)

Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review

Introduction

Maternal and neonatal mortality remains high in many low- and middle-income countries (LMIC). Availability and use of mobile phones is increasing rapidly with 90% of persons in developing countries having a mobile-cellular subscription. Mobile health (mHealth) interventions have been proposed as effective solutions to improve maternal and neonatal health. This systematic review assessed the effect of mHealth interventions that support pregnant women during the antenatal, birth and postnatal period in LMIC.

Methods

The review was registered with Prospero (CRD42014010292). Six databases were searched from June 2014–April 2015, accompanied by grey literature search using pre-defined search terms linked to pregnant women in LMIC and mHealth. Quality of articles was assessed with an adapted Cochrane Risk of Bias Tool. Because of heterogeneity in outcomes, settings and study designs a narrative synthesis of quantitative results of intervention studies on maternal outcomes, neonatal outcomes, service utilization, and healthy pregnancy education was conducted. Qualitative and quantitative results were synthesized with a strengths, weaknesses, opportunities, and threats analysis.

Results

In total, 3777 articles were found, of which 27 studies were included: twelve intervention studies and fifteen descriptive studies. mHealth interventions targeted at pregnant women increased maternal and neonatal service utilization shown through increased antenatal care attendance, facility-service utilization, skilled attendance at birth, and vaccination rates. Few articles assessed the effect on maternal or neonatal health outcomes, with inconsistent results.

Conclusion

mHealth interventions may be effective solutions to improve maternal and neonatal service utilization. Further studies assessing mHealth’s impact on maternal and neonatal outcomes are recommended. The emerging trend of strong experimental research designs with randomized controlled trials, combined with feasibility research, government involvement and integration of mHealth interventions into the healthcare system is encouraging and can pave the way to improved decision making on best practice implementation of mHealth interventions.

Do Maternal Knowledge and Attitudes towards Childhood Immunizations in Rural Uganda Correlate with Complete Childhood Vaccination?

Improving childhood vaccination coverage and timeliness is a key health policy objective in many developing countries such as Uganda. Of the many factors known to influence uptake of childhood immunizations in under resourced settings, parents' understanding and perception of childhood immunizations has largely been overlooked. The aims of this study were to survey mothers' knowledge and attitudes towards childhood immunizations and then determine if these variables correlate with the timely vaccination coverage of their children. From September to December 2013, we conducted a cross-sectional survey of 1,000 parous women in rural Sheema district in southwest Uganda. The survey collected socio-demographic data and knowledge and attitudes towards childhood immunizations. For the women with at least one child between the age of one month and five years who also had a vaccination card available for the child (N = 302), the vaccination status of this child was assessed. 88% of these children received age-appropriate, on-time immunizations. 93.5% of the women were able to state that childhood immunizations protect children from diseases. The women not able to point this out were significantly more likely to have an under-vaccinated child (PR 1.354: 95% CI 1.018-1.802). When asked why vaccination rates may be low in their community, the two most common responses were "fearful of side effects" and "ignorance/disinterest/laziness" (44% each). The factors influencing caregivers' demand for childhood immunizations vary widely between, and also within, developing countries. Research that elucidates local knowledge and attitudes, like this study, allows for decisions and policy pertaining to vaccination programs to be more effective at improving child vaccination rates.

Reducing routine vaccination dropout rates: evaluating two interventions in three Kenyan districts, 2014

Background

Globally, vaccine preventable diseases are responsible for nearly 20 % of deaths annually among children <5 years old. Worldwide, many children dropout from the vaccination program, are vaccinated late, or incompletely vaccinated. We evaluated the impact of text messaging and sticker reminders to reduce dropouts from the vaccination program.

Methods

The evaluation was conducted in three selected districts in Kenya: Machakos, Langata and Njoro. Three health facilities were selected in each district, and randomly allocated to send text messages or provide stickers reminding parents to bring their children for second and third dose of pentavalent vaccine, or to the control group (routine reminder) with next appointment date indicated on the well-child booklet. Children aged <12 months presenting for their first dose of pentavalent vaccine were enrolled. A dropout was defined as not returning for vaccination ≥2 weeks after scheduled date for third dose of pentavalent vaccine. We calculated dropout rate as a percentage of the difference between first and third pentavalent dose.

Results

We enrolled 1,116 children; 372 in each intervention and 372 controls between February and October 2014. Median age was 45 days old (range: 31–99 days), and 574 (51 %) were male. There were 136 (12 %) dropouts. Thirteen (4 %) children dropped out among those who received text messages, 60 (16 %) among who received sticker reminders, and 63 (17 %) among the controls. Having a caregiver with below secondary education [Odds Ratio (OR) 1.8, 95 % Confidence Interval (CI) 1.1–3.2], and residing >5 km from health facility (OR 1.6, CI 1.0–2.7) were associated with higher odds of dropping out. Those who received text messages were less likely to drop out compared to controls (OR 0.2, CI 0.04–0.8). There was no statistical difference between those who received stickers and controls (OR 0.9, CI 0.5–1.6).

Conclusion

Text message reminders can reduce vaccination dropout rates in Kenya. We recommend the extended implementation of text message reminders in routine vaccination services.

Exploring the ambivalent evidence base of mobile health (mHealth): A systematic literature review on the use of mobile phones for the improvement of community health in Africa

BACKGROUND

Africa is labelled the world's fastest-growing 'mobile region'. Considering such growth and the fragility of the continent's healthcare, mHealth has flourished. This review explores mHealth for community health in Africa in order to assess its still ambivalent evidence base.

METHODS

Using PubMed, Web of Science, OvidSP and Google Scholar, a systematic review was conducted of one decade (2005-2015) of peer-reviewed literature on mHealth in Africa. Data analysis focused on qualifications of success and failure. Impact evaluations of project assessments (n = 65) were complemented with general analyses/overviews of mHealth's effectiveness (n = 35).

RESULTS

Review of these texts reveals ambivalence in the appraisal of mHealth; essentially, the critical stance in general analyses/overviews is absent from project assessments. Especially weak evidence concerning sustainability and scalability is stressed in overviews. Project assessments are more optimistic. Their analysis suggests a causal connection between simplicity and success. Effective interventions are thus characterized by straightforward design and modest objectives. Greatest impediments of impact are general technology-related issues and intervention inappropriateness due to insufficient understanding of beneficiaries and specific context of use (circumstantial complications).

CONCLUSION

Distinguishing between these two categories of complications helps to break the deadlock that marks the mHealth debate and add nuance to claims that mHealth's evidence base is weak. Constructive realism - rather than unfounded optimism or pessimism without nuance - should guide the design of interventions. Besides anticipative of technology-related complications, such realism must lead to either basic interventions or to smart mHealth shaped by deep understanding of the context of implementation.

Did you get your shots? Experimental evidence on the role of reminders

Many families fail to vaccinate their children despite the supply of these services at no cost. This study tests whether personal reminders can increase demand for vaccination. A field experiment was conducted in rural Guatemala in which timely reminders were provided to families whose children were due for a vaccine. The six-month intervention increased the probability of vaccination completion by 2.2 percentage points among all children in treatment communities. Moreover, for children in treatment communities who were due to receive a vaccine, and whose parents were expected to be reminded about that due date, the probability of vaccination completion increased by 4.6 percentage points. The cost of an additional child with complete vaccination due to the intervention is estimated at about $7.50.

Using mHealth to Improve Usage of Antenatal Care, Postnatal Care, and Immunization: A Systematic Review of the Literature

Mobile health (mHealth) technologies have been implemented in many low- and middle-income countries to address challenges in maternal and child health. Many of these technologies attempt to influence patients', caretakers', or health workers' behavior. The purpose of this study was to conduct a systematic review of the literature to determine what evidence exists for the effectiveness of mHealth tools to increase the coverage and use of antenatal care (ANC), postnatal care (PNC), and childhood immunizations through behavior change in low- and middle-income countries. The full text of 53 articles was reviewed and 10 articles were identified that met all inclusion criteria. The majority of studies used text or voice message reminders to influence patient behavior change (80%, n = 8) and most were conducted in African countries (80%, n = 8). All studies showed at least some evidence of effectiveness at changing behavior to improve antenatal care attendance, postnatal care attendance, or childhood immunization rates. However, many of the studies were observational and further rigorous evaluation of mHealth programs is needed in a broader variety of settings.

A systematic literature review of missed opportunities for immunization in low- and middle-income countries

BACKGROUND

Missed opportunities for immunization (MOIs) may contribute to low coverage in diverse settings, including developing countries.

METHODS

We conducted a systematic literature review on MOIs among children and women of childbearing age from 1991 to the present in low- and middle-income countries. We searched multiple databases and the references of retrieved articles. Meta-analysis provided a pooled prevalence estimate and both univariate and multivariate meta-regression analysis was done to explore heterogeneity of results across studies.

RESULTS

We found 61 data points from 45 studies involving 41,310 participants. Of the 45 studies, 41 involved children and 10 involved women. The pooled MOI prevalence was 32.2% (95% CI: 26.8-37.7) among children - with no change during the study period - and 46.9% (95% CI: 29.7-64.0%) among women of child-bearing age. The prevalence varied by region and study methodology but these two variables together accounted for only 12% of study heterogeneity. Among 352 identified reasons for MOIs, the most common categories were health care practices, false contraindications, logistic issues related to vaccines, and organizational limitations, which did not vary by time or geographic region.

CONCLUSIONS

MOI prevalence was high in low- and middle-income settings but the large number of identified reasons precludes standardized solutions.

Assessing the impact of mHealth interventions in low- and middle-income countries--what has been shown to work?

BACKGROUND

Low-cost mobile devices, such as mobile phones, tablets, and personal digital assistants, which can access voice and data services, have revolutionised access to information and communication technology worldwide. These devices have a major impact on many aspects of people's lives, from business and education to health. This paper reviews the current evidence on the specific impacts of mobile technologies on tangible health outcomes (mHealth) in low- and middle-income countries (LMICs), from the perspectives of various stakeholders.

DESIGN

Comprehensive literature searches were undertaken using key medical subject heading search terms on PubMed, Google Scholar, and grey literature sources. Analysis of 676 publications retrieved from the search was undertaken based on key inclusion criteria, resulting in a set of 76 papers for detailed review. The impacts of mHealth interventions reported in these papers were categorised into common mHealth applications.

RESULTS

There is a growing evidence base for the efficacy of mHealth interventions in LMICs, particularly in improving treatment adherence, appointment compliance, data gathering, and developing support networks for health workers. However, the quantity and quality of the evidence is still limited in many respects.

CONCLUSIONS

Over all application areas, there remains a need to take small pilot studies to full scale, enabling more rigorous experimental and quasi-experimental studies to be undertaken in order to strengthen the evidence base.

Use of mobile phone text message reminders in health care services: a narrative literature review

BACKGROUND

Mobile text messages are a widely recognized communication method in societies, as the global penetration of the technology approaches 100% worldwide. Systematic knowledge is still lacking on how the mobile telephone text messaging (short message service, SMS) has been used in health care services.

OBJECTIVE

This study aims to review the literature on the use of mobile phone text message reminders in health care.

METHODS

We conducted a systematic literature review of studies on mobile telephone text message reminders. The data sources used were PubMed (MEDLINE), CINAHL, Proquest Databases/ PsycINFO, EMBASE, Cochrane Library, Scopus, and hand searching since 2003. Studies reporting the use of SMS intended to remind patients in health services were included. Given the heterogeneity in the studies, descriptive characteristics, purpose of the study, response rates, description of the intervention, dose and timing, instruments, outcome measures, and outcome data from the studies were synthesized using a narrative approach.

RESULTS

From 911 initial citations, 60 studies were included in the review. The studies reported a variety of use for SMS. Mobile telephone text message reminders were used as the only intervention in 73% (44/60) of the studies, and in 27% (16/60) of the remaining studies, SMS was connected to another comprehensive health intervention system. SMS reminders were sent to different patient groups: patients with HIV/AIDS (15%, 9/60) and diabetes (13%, 8/60) being the most common groups. The response rates of the studies varied from 22-100%. Typically, the text message reminders were sent daily. The time before the specific intervention to be rendered varied from 10 minutes (eg, medication taken) to 2 weeks (eg, scheduled appointment). A wide range of different evaluation methods and outcomes were used to assess the impact of SMS varying from existing databases (eg, attendance rate based on medical records), questionnaires, and physiological measures. About three quarters of the studies (77%, 46/60) reported improved outcomes: adherence to medication or to treatment reportedly improved in 40% (24/60) of the studies, appointment attendance in 18% (11/60) of the studies, and non-attendance rates decreased in 18% (11/60) of the studies. Other positive impacts were decreased amount of missed medication doses, more positive attitudes towards medication, and reductions in treatment interruptions.

CONCLUSIONS

We can conclude that although SMS reminders are used with different patient groups in health care, SMS is less systematically studied with randomized controlled trial study design. Although the amount of evidence for SMS application recommendations is still limited, having 77% (46/60) of the studies showing improved outcomes may indicate its use in health care settings. However, more well-conducted SMS studies are still needed.

Infectious causes of childhood disability: results from a pilot study in rural Bangladesh

PURPOSE

To identify the contribution of infectious aetiologies to major childhood disabilities in Bangladesh.

METHODS

Active community-based survey was conducted for severe childhood disability using the Key Informants Method between September 2011 and March 2012 in a rural sub-district of Bangladesh.

RESULTS

We screened 1069 children and identified 859 with severe disabilities. The mean age of the disabled children was 8.5 year and 42.9% were girls. The major forms of impairments/conditions were cerebral palsy (n = 324, 37.7%), hearing impairment (n = 201, 23.4%), physical impairment (n = 147, 17.1%), visual impairment (n = 49, 5.7%), cerebral palsy with epilepsy (n = 39, 4.5%) and epilepsy (n = 41, 4.7%). Congenital rubella syndrome was identified in 1.1% (n = 9). 7.1% disabilities resulted from clinically confirmed infections, and another 10.8% originated from probable infections; thus a total of 17.9% disabilities were related to an infectious origin.

CONCLUSIONS

Infectious diseases appear to be one of the major causes of severe childhood disability in rural Bangladesh.

The government of Kenya cash transfer for orphaned and vulnerable children: cross-sectional comparison of household and individual characteristics of those with and without

Background

The ‘Cash Transfer to Orphans and Vulnerable Children’ (CT-OVC) in Kenya is a government-supported program intended to provide regular and predictable cash transfers (CT) to poor households taking care of OVC. CT programs can be an effective means of alleviating poverty and facilitating the attainment of an adequate standard of living for people’s health and well-being and other international human rights. The objective of this analysis was to compare the household socioeconomic status, school enrolment, nutritional status, and future outlook of orphaned and separated children receiving the CT compared to those not receiving a CT.

Methods

This project analyzes baseline data from a cohort of orphaned and separated children aged <19 years and non-orphaned children living in 300 randomly selected households (HH) in 8 Locations of Uasin Gishu County, Kenya. Baseline data were analyzed using multivariable logistic and Poisson regression comparing children in CT-HH vs. non-CT HH. Odds ratios are adjusted (AOR) with 95% confidence intervals (CI) for guardian age and sex, child age and sex, and intra-HH correlation.

Results

Included in this analysis were data from 1481 children and adolescents in 300 HH (503 participants in CT, 978 in non-CT households). Overall there were 922 (62.3%) single orphans, 324 (21.9%) double orphans, and 210 (14.2%) participants had both parents alive and were living with them. Participants in CT-HH were less likely to have ≥2 pairs of clothes compared to non-CT HH (AOR: 0.32, 95% CI: 0.16-0.63). Those in CT HH were less likely to have missed any days of school in the preceding month (AOR: 0.62, 95% CI: 0.42-0.94) and those aged <1-18 years in CT-HH were less likely to have height stunting for their age (AOR: 0.65, 95% CI: 0.47-0.89). Participants aged at least 10 years in CT-HH were more likely to have a positive future outlook (AOR: 1.72, 95% CI: 1.12-2.65).

Conclusions

Children and adolescents in households receiving the CT-OVC appear to have better nutritional status, school attendance, and optimism about the future, compared to those in households not receiving the CT, in spite of some evidence of continued material deprivation. Consideration should be given to expanding the program further.

Preparing for human papillomavirus vaccine introduction in Kenya: implications from focus-group and interview discussions with caregivers and opinion leaders in Western Kenya

BACKGROUND

Cervical cancer claims the lives of 275,000 women each year; most of these deaths occur in low-or middle-income countries. In Kenya, cervical cancer is the leading cause of cancer-related mortality among women of reproductive age. Kenya's Ministry of Public Health and Sanitation has developed a comprehensive strategy to prevent cervical cancer, which includes plans for vaccinating preteen girls against human papillomavirus (HPV) by 2015. To identify HPV vaccine communication and mobilization needs, this research sought to understand HPV vaccine-related perceptions and concerns of male and female caregivers and community leaders in four rural communities of western Kenya.

METHODS

We conducted five focus groups with caregivers (n = 56) and 12 key-informant interviews with opinion leaders to explore cervical cancer-related knowledge, attitudes and beliefs, as well as acceptability of HPV vaccination for 9-12 year-old girls. Four researchers independently reviewed the data and developed codes based on questions in interview guides and topics that emerged organically, before comparing and reconciling results through a group consensus process.

RESULTS

Cervical cancer was not commonly recognized, though it was understood generally in terms of its symptoms. By association with cancer and genital/reproductive organs, cervical cancer was feared and stigmatized. Overall acceptability of a vaccine that prevents cervical cancer was high, so long as it was endorsed by trusted agencies and communities were sensitized first. Some concerns emerged related to vaccine safety (e.g., impact on fertility), program intent, and health equity.

CONCLUSION

For successful vaccine introduction in Kenya, there is a need for communication and mobilization efforts to raise cervical cancer awareness; prompt demand for vaccination; address health equity concerns and stigma; and minimize potential resistance. Visible endorsement by government leaders and community influencers can provide reassurance of the vaccine's safety, efficacy and benefits for girls and communities. Involvement of community leadership, parents and champions may also be critical for combatting stigma and making cervical cancer relevant to Kenyan communities. These findings underscore the need for adequate planning and resources for information, education and communication prior to vaccine introduction. Specific recommendations for communication and social-marketing strategies are made.

Engaging Patients through Mobile Phones: Demonstrator Services, Success Factors, and Future Opportunities in Low and Middle-income Countries

OBJECTIVES

Evolving technology and infrastructure can benefit patients even in the poorest countries through mobile health (mHealth). Yet, what makes mobile-phone-based services succeed in low and middle-income countries (LMIC) and what opportunities does the future hold that still need to be studied. We showcase demonstrator services that leverage mobile phones in the hands of patients to promote health and facilitate health care.

METHODS

We surveyed the recent biomedical literature for demonstrator services that illustrate well-considered examples of mobile phone interventions for consumer health. We draw upon those examples to discuss enabling factors, scalability, reach, and potential of mHealth as well as obstacles in LMIC.

RESULTS

Among the 227 articles returned by a PubMed search, we identified 55 articles that describe services targeting health consumers equipped with mobile phones. From those articles, we showcase 19 as demonstrator services across clinical care, prevention, infectious diseases, and population health. Services range from education, reminders, reporting, and peer support, to epidemiologic reporting, and care management with phone communication and messages. Key achievements include timely adherence to treatment and appointments, clinical effectiveness of treatment reminders, increased vaccination coverage and uptake of screening, and capacity for efficient disease surveillance. We discuss methodologies of delivery and evaluation of mobile-phone-based mHealth in LMIC, including service design, social context, and environmental factors to success.

CONCLUSION

Demonstrated promises using mobile phones in the poorest countries encourage a future in which IMIA takes a lead role in leveraging mHealth for citizen empowerment through Consumer Health Informatics.

Coverage, timeliness, and determinants of immunization completion in Pakistan: evidence from the Demographic and Health Survey (2006-07)

BACKGROUND

 Immunization coverage data and determinants for completion are not well described for Pakistan. This study determines immunization coverage rates and timeliness based on the 2006-07 Pakistan Demographic and Health Survey (DHS) and identifies determinants for completion of immunizations.

METHODS

 DHS data from 9177 randomly selected households from across Pakistan were analyzed to assess immunization coverage and timeliness for children aged 0-5 years, and to investigate determinants of immunization completion through logistic regressions.

RESULTS

 The proportion of children immunized for a third dose of the oral poliovirus vaccine (OPV3) was 80.3%, and combination diphtheria, tetanus, and pertussis vaccines (DTP3) was 55.9%. Measles coverage was 62.5%. Late immunizations were most likely to occur for third doses of the OPV (65.5%) and DTP series (65.5%). Early doses were most likely to be administered for measles (21.9%). The proportion of children not immunized for any vaccine was 6.2%. Receiving a dose of maternal tetanus was a major determinant for immunization completion for OPV3 (OR 1.35, 95% CI: 1.14-1.60), DTP3 (OR 2.54, 95% CI: 2.13-3.02), and measles (OR 2.78, 95% CI: 2.27-3.40). Other independent variables associated with improved immunization completion included higher household wealth and maternal education.

CONCLUSION

 Poor routine immunization coverage and timeliness were identified through the DHS in Pakistan. Encouraging maternal tetanus uptake among women of child-bearing age and greater integration of immunization services with antenatal care may help improve childhood immunization completion.

Systematic review on what works, what does not work and why of implementation of mobile health (mHealth) projects in Africa

BACKGROUND

Access to mobile phone technology has rapidly expanded in developing countries. In Africa, mHealth is a relatively new concept and questions arise regarding reliability of the technology used for health outcomes. This review documents strengths, weaknesses, opportunities, and threats (SWOT) of mHealth projects in Africa.

METHODS

A systematic review of peer-reviewed literature on mHealth projects in Africa, between 2003 and 2013, was carried out using PubMed and OvidSP. Data was synthesized using a SWOT analysis methodology. Results were grouped to assess specific aspects of project implementation in terms of sustainability and mid/long-term results, integration to the health system, management process, scale-up and replication, and legal issues, regulations and standards.

RESULTS

Forty-four studies on mHealth projects in Africa were included and classified as: "patient follow-up and medication adherence" (n = 19), "staff training, support and motivation" (n = 2), "staff evaluation, monitoring and guidelines compliance" (n = 4), "drug supply-chain and stock management" (n = 2), "patient education and awareness" (n = 1), "disease surveillance and intervention monitoring" (n = 4), "data collection/transfer and reporting" (n = 10) and "overview of mHealth projects" (n = 2). In general, mHealth projects demonstrate positive health-related outcomes and their success is based on the accessibility, acceptance and low-cost of the technology, effective adaptation to local contexts, strong stakeholder collaboration, and government involvement. Threats such as dependency on funding, unclear healthcare system responsibilities, unreliable infrastructure and lack of evidence on cost-effectiveness challenge their implementation. mHealth projects can potentially be scaled-up to help tackle problems faced by healthcare systems like poor management of drug stocks, weak surveillance and reporting systems or lack of resources.

CONCLUSIONS

mHealth in Africa is an innovative approach to delivering health services. In this fast-growing technological field, research opportunities include assessing implications of scaling-up mHealth projects, evaluating cost-effectiveness and impacts on the overall health system.

The feasibility, patterns of use and acceptability of using mobile phone text-messaging to improve treatment adherence and post-treatment review of children with uncomplicated malaria in western Kenya

BACKGROUND

Trials evaluating the impact of mobile phone text-messaging to support management of acute diseases, such as malaria, are urgently needed in Africa. There has been however a concern about the feasibility of interventions that rely on access to mobile phones among caregivers in rural areas. To assess the feasibility and inform development of an intervention to improve adherence to malaria medications and post-treatment review, mobile phone network, access, ownership and use among caregivers in western Kenya was assessed.

METHODS

A cross-sectional survey based on outpatient exit interviews was undertaken among caregivers of children with malaria at four trial facilities. The main outcomes were proportions of caregivers that have mobile signal at home; have access to mobile phones; are able to read; and use text-messaging. Willingness to receive text-message reminders was also explored. Descriptive analyses were performed.

RESULTS

Of 400 interviewed caregivers, the majority were female (93.5%), mothers of the sick children (87.8%) and able to read (97.3%). Only 1.7% of caregivers were without any education. Nearly all (99.8%) reported access to a mobile signal at home. 93.0% (site range: 89-98%) had access to a mobile phone within their household while 73.8% (site range: 66-78%) possessed a personal phone. Among caregivers with mobile phone access, 93.6% (site range: 85-99%) used the phone to receive text-messages. Despite only 19% having electricity at home nearly all (99.7%) caregivers reported that they would be able to have permanent phone access to receive text-messages in the next 28 days. Willingness to receive text-message reminders was nearly universal (99.7%) with 41.7% of caregivers preferring texts in English, 32.3% in Kiswahili and 26.1% in Dholuo.

CONCLUSIONS

Despite concerns that the feasibility of text-messaging interventions targeting caregivers may be compromised in rural high malaria risk areas in Kenya, very favourable conditions were found with respect to mobile network, access and ownership of phones, use of text-messaging and minimum literacy levels required for successful intervention delivery. Moreover, there was a high willingness of caregivers to receive text-message reminders. Impact evaluations of carefully tailored text-messaging interventions targeting caregivers of children with malaria are timely and justified.

Teenagers and texting: use of a youth ecological momentary assessment system in trajectory health research with latina adolescents

Background

Adolescent females send and receive more text messages than any others, with an average of 4050 texts a month. Despite this technological inroad among adolescents, few researchers are utilizing text messaging technology to collect real time, contextualized data. Temporal variables (ie, mood) collected regularly over a period of time could yield useful insights, particularly for evaluating health intervention outcomes. Use of text messaging technology has multiple benefits, including capacity of researchers to immediately act in response to texted information.

Objective

The objective of our study was to custom build a short messaging service (SMS) or text messaging assessment delivery system for use with adolescents. The Youth Ecological Momentary Assessment System (YEMAS) was developed to collect automated texted reports of daily activities, behaviors, and attitudes among adolescents, and to examine the feasibility of YEMAS. This system was created to collect and transfer real time data about individual- and social-level factors that influence physical, mental, emotional, and social well-being.

Methods

YEMAS is a custom designed system that interfaces with a cloud-based communication system to automate scheduled delivery of survey questions via text messaging; we designed this university-based system to meet data security and management standards. This was a two-phase study that included development of YEMAS and a feasibility pilot with Latino adolescent females. Relative homogeneity of participants was desired for the feasibility pilot study; adolescent Latina youth were sought because they represent the largest and fastest growing ethnic minority group in the United States. Females were targeted because they demonstrate the highest rate of text messaging and were expected to be interested in participating. Phase I involved development of YEMAS and Phase II involved piloting of the system with Latina adolescents. Girls were eligible to participate if they were attending one of the participating high schools and self-identified as Latina. We contacted 96 adolescents; of these, 24 returned written parental consent forms, completed assent processes, and enrolled in the study.

Results

YEMAS was collaboratively developed and implemented. Feasibility was established with Latina adolescents (N=24), who responded to four surveys daily for two two-week periods (four weeks total). Each survey had between 12 and 17 questions, with responses including yes/no, Likert scale, and open-ended options. Retention and compliance rates were high, with nearly 18,000 texts provided by the girls over the course of the pilot period.

Conclusions

Pilot results support the feasibility and value of YEMAS, an automated SMS-based text messaging data collection system positioned within a secure university environment. This approach capitalizes on immediate data transfer protocols and enables the documentation of participants’ thoughts, feelings, and behaviors in real time. Data are collected using mobile devices that are familiar to participants and nearly ubiquitous in developed countries.

Determinants and coverage of vaccination in children in western Kenya from a 2003 cross-sectional survey

This study assesses full and timely vaccination coverage and factors associated with full vaccination in children ages 12-23 months in Gem, Nyanza Province, Kenya in 2003. A simple random sample of 1,769 households was selected, and guardians were invited to bring children under 5 years of age to participate in a survey. Full vaccination coverage was 31.1% among 244 children. Only 2.2% received all vaccinations in the target month for each vaccination. In multivariate logistic regression, children of mothers of higher parity (odds ratio [OR] = 0.27, 95% confidence interval [95% CI] = 0.13-0.65, P ≤ 0.01), children of mothers with lower maternal education (OR = 0.35, 95% CI = 0.13-0.97, P ≤ 0.05), or children in households with the spouse absent versus present (OR = 0.40, 95% CI = 0.17-0.91, P ≤ 0.05) were less likely to be fully vaccinated. These data serve as a baseline from which changes in vaccination coverage will be measured as interventions to improve vaccination timeliness are introduced.