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

SMS-based interventions for improving child and adolescent vaccine coverage and timeliness: a systematic review

BACKGROUND

The aim of this review was to investigate the impact of short message service (SMS)-based interventions on childhood and adolescent vaccine coverage and timeliness.

METHODS

A pre-defined search strategy was used to identify all relevant publications up until July 2022 from electronic databases. Reports of randomised trials written in English and involving children and adolescents less than 18 years old were included. The review was conducted in accordance with PRISMA guidelines.

RESULTS

Thirty randomised trials were identified. Most trials were conducted in high-income countries. There was marked heterogeneity between studies. SMS-based interventions were associated with small to moderate improvements in vaccine coverage and timeliness compared to no SMS reminder. Reminders with embedded education or which were combined with monetary incentives performed better than simple reminders in some settings.

CONCLUSION

Some SMS-based interventions appear effective for improving child vaccine coverage and timeliness in some settings. Future studies should focus on identifying which features of SMS-based strategies, including the message content and timing, are determinants of effectiveness.

Persistence and heterogeneity of the effects of educating mothers to improve child immunisation uptake: Experimental evidence from Uttar Pradesh in India

Childhood vaccinations are among the most cost-effective health interventions. Yet, in India, where immunisation services are widely available free of charge, a substantial proportion of children remain unvaccinated. We revisit households 30 months after a randomised experiment of a health information intervention designed to educate mothers on the benefits of child vaccination in Uttar Pradesh, India. We find that the large short-term effects on the uptake of diphtheria-pertussis-tetanus and measles vaccination were sustained at 30 months, suggesting the intervention did not simply bring forward vaccinations. We apply causal forests and find that the intervention increased vaccination uptake, but that there was substantial variation in the magnitude of the estimated effects. We conclude that characterising those who benefited most and conversely those who benefited least provides policy-makers with insights on how the intervention worked, and how the targeting of households could be improved.

Utilizing child-centered nursing care approaches for pediatric ENT patients undergoing nasal endoscopy

OBJECTIVE

To investigate whether the child-centered treatment significantly increased satisfaction as revealed by CBCL scores and decreased duration of nasal endoscopy.

METHODS

A total of 206 pediatric patients were selected as study participants. Using a random number table, the participants were divided into the control group and the treatment group, with 103 cases in each group. The control group received routine nursing care, whereas the treatment group received child-centered health education nursing intervention. The differences between the two groups were observed in four aspects: examination compliance, child behavior checklist (CBCL) scores, the satisfaction level of the patient's family with the nurses in the endoscopy room, and the average duration of the nasal endoscopy.

RESULTS

Subsequent to the implementation of the intervention, it was observed that within the treatment group, the level of compliance among pediatric patients undergoing nasal endoscopy exhibited a statistically significant increase when compared to the control group; the CBCL scores of both groups were lower than those before nursing care, and those of the treatment group were statistically significantly lower than those of the control group; the satisfaction rate of the patient's family in two groups was 74 % and 90 %, respectively. The average duration of nasal endoscopy was statistically significantly lower in the treatment group than that in the control group.

CONCLUSIONS

The implementation of a child-centered health education nursing intervention for pediatric patients undergoing nasal endoscopy has been shown to effectively mitigate instances of crying and screaming, enhance patient compliance, reduce examination duration, and elevate the overall satisfaction levels among their respective families.

Impact of mHealth interventions on maternal, newborn, and child health from conception to 24 months postpartum in low- and middle-income countries: a systematic review

BACKGROUND

Mobile health (mHealth) technologies have been harnessed in low- and middle-income countries (LMICs) to address the intricate challenges confronting maternal, newborn, and child health (MNCH). This review aspires to scrutinize the effectiveness of mHealth interventions on MNCH outcomes during the pivotal first 1000 days of life, encompassing the period from conception through pregnancy, childbirth, and post-delivery, up to the age of 2 years.

METHODS

A comprehensive search was systematically conducted in May 2022 across databases, including PubMed, Cochrane Library, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), Web of Science, Scopus, PsycINFO, and Trip Pro, to unearth peer-reviewed articles published between 2000 and 2022. The inclusion criteria consisted of (i) mHealth interventions directed at MNCH; (ii) study designs, including randomized controlled trials (RCTs), RCT variations, quasi-experimental designs, controlled before-and-after studies, or interrupted time series studies); (iii) reports of outcomes pertinent to the first 1000 days concept; and (iv) inclusion of participants from LMICs. Each study was screened for quality in alignment with the Cochrane Handbook for Systematic Reviews of Interventions and the Joanne Briggs Institute Critical Appraisal tools. The included articles were then analyzed and categorized into 12 mHealth functions and outcome domain categories (antenatal, delivery, and postnatal care), followed by forest plot comparisons of effect measures.

RESULTS

From the initial pool of 7119 articles, we included 131 in this review, comprising 56 RCTs, 38 cluster-RCTs, and 37 quasi-experimental studies. Notably, 62% of these articles exhibited a moderate or high risk of bias. Promisingly, mHealth strategies, such as dispatching text message reminders to women and equipping healthcare providers with digital planning and scheduling tools, exhibited the capacity to augment antenatal clinic attendance and enhance the punctuality of child immunization. However, findings regarding facility-based delivery, child immunization attendance, and infant feeding practices were inconclusive.

CONCLUSIONS

This review suggests that mHealth interventions can improve antenatal care attendance and child immunization timeliness in LMICs. However, their impact on facility-based delivery and infant feeding practices varies. Nevertheless, the potential of mHealth to enhance MNCH services in resource-limited settings is promising. More context-specific implementation studies with rigorous evaluations are essential.

"I'll take them another day": A qualitative study exploring the socio-behavioral complexities of childhood vaccination in urban poor settlements

Despite improvement over recent decades, childhood vaccination uptake remains a concern across countries. The World Health Organization observed that over 25 million children missed out on one or more vaccines in 2021, with urban poor and other marginalized groups being the most affected. Given the higher risk of disease transmission and vaccine-preventable diseases (VPD) outbreaks across densely populated urban slums, identifying effective interventions to improve childhood vaccination in this vulnerable population is crucial. This study explored the behavioral and social factors influencing childhood vaccination uptake in urban informal settlements in Nairobi, Kenya. A grounded theory approach was employed to develop a theoretical account of the socio-behavioral determinants of childhood vaccination. Five focus group discussions (FGDs) were conducted with purposively sampled caregivers of children under five years of age residing in informal settlements. The Theory of Planned Behavior guided the structuring of the FGD questions. An iterative process was used to analyze and identify emerging themes. Thirty-nine caregivers (median age 29 years) participated in the FGDs. From the analysis, four main thematic categories were derived. These included attitude factors such as perceived vaccine benefits, cultural beliefs, and emotional factors including parental love. Additionally, subjective norms, like fear of social judgment, and perceived behavioral control factors, such as self-control and gender-based influences, were identified. Furthermore, a number of practical factors, including the cost of vaccines and healthcare providers attitude, also affected the uptake of vaccination. Various social, behavioral, cultural, and contextual factors influence caregiver vaccination decisions in urban poor settings. Community-derived and context-specific approaches that address the complex interaction between socio-behavioral and other contextual factors need to be tested and applied to improve the timely uptake of childhood vaccinations among marginalized populations.

Technologies for strengthening immunization coverage in India: a systematic review

Background

Immunization coverage varies across India in different settings, geographic areas and populations. Technologies for improving immunization access can reduce disparities in coverage. This systematic review, which follows PRISMA guidelines, aims to examine the technologies for strengthening immunization coverage in India.

Methods

Studies published between January 1, 2011 and July 31, 2021 were searched in Medline (through PubMed), Cochrane Library and Google Scholar. All observational and experimental studies, except qualitative studies, were included. Studies published in the English language and related to technologies for strengthening immunization, conducted on children, pregnant women, adults, elderly, healthcare personnel, caregivers and vulnerable populations across all Indian settings were included. Non-English articles, protocols, commentaries, letters, abstracts, correspondence, opinion articles, modelling, narrative and systematic reviews were excluded. Two reviewers screened studies independently, extracted data in a standardized sheet and appraised the study quality using the Mixed Methods Appraisal Tool. The primary outcome was technologies that improved immunization coverage. The protocol is registered with OSF (https://osf.io/r42gm).

Findings

6592 titles and abstracts were screened, and data extracted from 23 India-specific studies. Quality of 22/23 studies was average or above. Technologies identified included reminder systems, capacity building, community engagement and wearable technologies. Automated incentivised mobile phone reminders, immunization due-list, computerized data tracking, community mobilization and campaigns improved vaccine coverage, although effectiveness of some varied viz., reminder systems, and across states. Newer technologies included the Jyotigram Yojana, Digital Near-field Communication Pendants, "Reaching Every District" Programme and the "My Village My Home" tool.

Interpretation

Technologies for improving immunization systems, capacity building and community engagement were effective. Newer technologies on vaccine delivery, mapping and cold chain logistics were not evaluated in India or were ineffective. There were limited studies in populations other than children and pregnant women. Future work is needed to evaluate the effectiveness of identified technologies across diverse settings.

Funding

No funding was received for preparing this manuscript.

The effect of mHealth on childhood vaccination in Africa: A systematic review and meta-analysis

INTRODUCTION

Vaccine-preventable diseases are the public health problems in Africa, although vaccination is an available, safe, simple, and effective method prevention. Technologies such as mHealth may provide maternal access to health information and support decisions on childhood vaccination. Many studies on the role of mHealth in vaccination decisions have been conducted in Africa, but the evidence needs to provide conclusive information to support mHealth introduction. This study provides essential information to assist planning and policy decisions regarding the use of mHealth for childhood vaccination.

METHODS

We conducted a systematic review and meta-analysis for studies applying mHealth in Africa for vaccination decisions following the Preferred Reporting Items for Systematic and Meta-Analysis [PRISMA] guideline. Databases such as CINAHL, EMBASE, PubMed, PsycINFO, Scopus, Web of Science, Google Scholar, Global Health, HINARI, and Cochrane Library were included. We screened studies in Endnote X20 and performed the analysis using Revman 5.4.1.

RESULTS

The database search yielded 1,365 articles [14 RCTs and 4 quasi-experiments] with 21,070 participants satisfied all eligibility criteria. The meta-analysis showed that mHealth has an OR of 2.15 [95% CI: 1.70-2.72; P<0.001; I2 = 90%] on vaccination rates. The subgroup analysis showed that regional differences cause heterogeneity. Funnel plots and Harbord tests showed the absence of publication bias, while the GRADE scale showed a moderate-quality body of evidence.

CONCLUSION

Although heterogeneous, this systematic review and meta-analysis showed that the application of mHealth could potentially improve childhood vaccination in Africa. It increased childhood vaccination by more than double [2.15 times] among children whose mothers are motivated by mHealth services. MHealth is more effective in less developed regions and when an additional incentive party with the messaging system. However, it can be provided at a comparably low cost based on the development level of regions and can be established as a routine service in Africa.

REGISTRATION

PROSPERO: CRD42023415956.

Factors influencing community-facility linkage for case management of possible serious bacterial infections among young infants in Kenya

Despite evidence showing the feasibility and acceptability of implementing the World Health Organization's guidelines on managing possible serious bacterial infection (PSBI) in Kenya, the initial implementation revealed sub-optimal community-facility referrals and follow-up of PSBI cases. This study explores facilitators and barriers of community-facility linkages in implementing PSBI guidelines in Busia and Migori counties, Kenya. We used an exploratory qualitative study design drawing on endline evaluation data from the 'COVID-19: Mitigating Neonatal Mortality' project collected between June and July 2022. Data include case narratives with caregivers of sick young infants (0-59 days old) (18), focus group discussions with community health volunteers (CHVs) (6), and in-depth interviews with facility-based providers (18). Data were analysed using an inductive thematic analysis framework. Between August 2021 and July 2022, CHVs assessed 10 187 newborns, with 1176 (12%) identified with PSBI danger signs and referred to the nearest facility, of which 820 (70%) accepted referral. Analysis revealed several factors facilitating community-facility linkage for PSBI treatment, including CHVs' relationship with community members and facilities, availability of a CHV desk and tools, use of mobile app, training and supportive supervision. However, challenges such as health system-related factors (inadequate providers, stockout of essential commodities and supplies, and lack of transport/ambulance) and individual-related factors (caregivers' refusal to take referrals) hindered community-facility linkage. Addressing common barriers and fostering positive relationships between community health workers and facilities can enhance acceptance and access to PSBI services at the community level. Combining community health workers' efforts with a mobile digital strategy can improve the efficiency of the identification, referral and tracking of PSBI cases in the community and facilitate linkage with primary healthcare facilities.

Sharpening clinical decision support alert and reminder designs with MINDSPACE: A systematic review

BACKGROUND

Clinical decision support (CDS) alerts and reminders aim to influence clinical decisions, yet they are often designed without considering human decision-making behaviour. While this behaviour is comprehensively described by behavioural economics (BE), the sheer volume of BE literature poses a challenge to designers when identifying behavioural effects with utility to alert and reminder designs. This study tackles this challenge by focusing on the MINDSPACE framework for behaviour change, which collates nine behavioural effects that profoundly influence human decision-making behaviour: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitment, and Ego.

METHOD

A systematic review searching MEDLINE, Embase, PsycINFO, and CINAHL Plus to explore (i) the usage of MINDSPACE effects in alert and reminder designs and (ii) the efficacy of those alerts and reminders in influencing clinical decisions. The search queries comprised ten Boolean searches, with nine focusing on the MINDSPACE effects and one focusing on the term mindspace.

RESULTS

50 studies were selected from 1791 peer-reviewed journal articles in English from 1970 to 2022. Except for ego, eight of nine MINDSPACE effects were utilised to design alerts and reminders, with defaults and norms utilised the most in alerts and reminders, respectively. Overall, alerts and reminders informed by MINDSPACE effects showed an average 71% success rate in influencing clinical decisions (alerts 73%, reminders 69%). Most studies utilised a single effect in their design, with higher efficacy for alerts (64%) than reminders (41%). Others utilised multiple effects, showing higher efficacy for reminders (28%) than alerts (9%).

CONCLUSION

This review presents sufficient evidence demonstrating the MINDSPACE framework's merits for designing CDS alerts and reminders with human decision-making considerations. The framework can adequately address challenges in identifying behavioural effects pertinent to the effective design of CDS alerts and reminders. The review also identified opportunities for future research into other relevant effects (e.g., framing).

Integrating father involvement into early childhood initiatives delivered at scale: key considerations

Early child development (ECD) interventions, usually centered around the mother, exclude fathers from contributing to childcare. Research shows that a father’s involvement in childcare can have a positive impact on the child’s growth. In this light, a trial was conducted in rural India wherein a new program component aimed at enhancing fathers’ engagement in early child was incorporated into an existing childcare intervention. The paper highlights the learnings drawn from the trial to present pathways to change, that is, strategies needed to embed father involvement as a component within the intervention ecosystem.

Interventions for improving coverage of childhood immunisation in low- and middle-income countries

BACKGROUND

Immunisation plays a major role in reducing childhood morbidity and mortality. Getting children immunised against potentially fatal and debilitating vaccine-preventable diseases remains a challenge despite the availability of efficacious vaccines, particularly in low- and middle-income countries. With the introduction of new vaccines, this becomes increasingly difficult. There is therefore a current need to synthesise the available evidence on the strategies used to bridge this gap. This is a second update of the Cochrane Review first published in 2011 and updated in 2016, and it focuses on interventions for improving childhood immunisation coverage in low- and middle-income countries.

OBJECTIVES

To evaluate the effectiveness of intervention strategies to boost demand and supply of childhood vaccines, and sustain high childhood immunisation coverage in low- and middle-income countries.

SEARCH METHODS

We searched CENTRAL, MEDLINE, CINAHL, and Global Index Medicus (11 July 2022). We searched Embase, LILACS, and Sociological Abstracts (2 September 2014). We searched WHO ICTRP and ClinicalTrials.gov (11 July 2022). In addition, we screened reference lists of relevant systematic reviews for potentially eligible studies, and carried out a citation search for 14 of the included studies (19 February 2020).

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCTs), non-randomised RCTs (nRCTs), controlled before-after studies, and interrupted time series conducted in low- and middle-income countries involving children that were under five years of age, caregivers, and healthcare providers.

DATA COLLECTION AND ANALYSIS

We independently screened the search output, reviewed full texts of potentially eligible articles, assessed the risk of bias, and extracted data in duplicate, resolving discrepancies by consensus. We conducted random-effects meta-analyses and used GRADE to assess the certainty of the evidence.

MAIN RESULTS

Forty-one studies involving 100,747 participants are included in the review. Twenty studies were cluster-randomised and 15 studies were individually randomised controlled trials. Six studies were quasi-randomised. The studies were conducted in four upper-middle-income countries (China, Georgia, Mexico, Guatemala), 11 lower-middle-income countries (Côte d'Ivoire, Ghana, Honduras, India, Indonesia, Kenya, Nigeria, Nepal, Nicaragua, Pakistan, Zimbabwe), and three lower-income countries (Afghanistan, Mali, Rwanda). The interventions evaluated in the studies were health education (seven studies), patient reminders (13 studies), digital register (two studies), household incentives (three studies), regular immunisation outreach sessions (two studies), home visits (one study), supportive supervision (two studies), integration of immunisation services with intermittent preventive treatment of malaria (one study), payment for performance (two studies), engagement of community leaders (one study), training on interpersonal communication skills (one study), and logistic support to health facilities (one study). We judged nine of the included studies to have low risk of bias; the risk of bias in eight studies was unclear and 24 studies had high risk of bias. We found low-certainty evidence that health education (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.15 to 1.62; 6 studies, 4375 participants) and home-based records (RR 1.36, 95% CI 1.06 to 1.75; 3 studies, 4019 participants) may improve coverage with DTP3/Penta 3 vaccine. Phone calls/short messages may have little or no effect on DTP3/Penta 3 vaccine uptake (RR 1.12, 95% CI 1.00 to 1.25; 6 studies, 3869 participants; low-certainty evidence); wearable reminders probably have little or no effect on DTP3/Penta 3 uptake (RR 1.02, 95% CI 0.97 to 1.07; 2 studies, 1567 participants; moderate-certainty evidence). Use of community leaders in combination with provider intervention probably increases the uptake of DTP3/Penta 3 vaccine (RR 1.37, 95% CI 1.11 to 1.69; 1 study, 2020 participants; moderate-certainty evidence). We are uncertain about the effect of immunisation outreach on DTP3/Penta 3 vaccine uptake in children under two years of age (RR 1.32, 95% CI 1.11 to 1.56; 1 study, 541 participants; very low-certainty evidence). We are also uncertain about the following interventions improving full vaccination of children under two years of age: training of health providers on interpersonal communication skills (RR 5.65, 95% CI 3.62 to 8.83; 1 study, 420 participants; very low-certainty evidence), and home visits (RR 1.29, 95% CI 1.15 to 1.45; 1 study, 419 participants; very low-certainty evidence). The same applies to the effect of training of health providers on interpersonal communication skills on the uptake of DTP3/Penta 3 by one year of age (very low-certainty evidence). The integration of immunisation with other services may, however, improve full vaccination (RR 1.29, 95% CI 1.16 to 1.44; 1 study, 1700 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Health education, home-based records, a combination of involvement of community leaders with health provider intervention, and integration of immunisation services may improve vaccine uptake. The certainty of the evidence for the included interventions ranged from moderate to very low. Low certainty of the evidence implies that the true effect of the interventions might be markedly different from the estimated effect. Further, more rigorous RCTs are, therefore, required to generate high-certainty evidence to inform policy and practice.

Motivating vaccination with financial incentives

Governments and organizations often offer cash payments for vaccination. How effective are such payments? A literature review shows that incentives usually increase vaccination, especially for nonhesitant populations and when using guaranteed payments. Concerns about negative unintended consequences are unsupported. We also discuss open questions and avenues for future research.

Financial incentives for COVID-19 vaccines in a rural low-resource setting: a cluster-randomized trial

We implemented a clustered randomized controlled trial with 6,963 residents in six rural Ghana districts to estimate the causal impact of financial incentives on coronavirus disease 2019 (COVID-19) vaccination uptake. Villages randomly received one of four video treatment arms: a placebo, a standard health message, a high cash incentive (60 Ghana cedis) and a low cash incentive (20 Ghana cedis). For the first co-primary outcome-COVID-19 vaccination intentions-non-vaccinated participants assigned to the cash incentive treatments had an average rate of 81% (1,733 of 2,168) compared to 71% (1,895 of 2,669) for those in the placebo treatment arm. For the other co-primary outcome of self-reported vaccinations 2 months after the initial intervention, the average rate for participants in the cash treatment was 3.5% higher than for participants in the placebo treatment (95% confidence interval (CI): 0.001, 6.9; P = 0.045): 40% (602 of 1,486) versus 36.3% (672 of 1,850). We also verified vaccination status of participants: in the cash treatment arm, 36.6% (355 of 1,058) of verified participants had at least one dose of the COVID-19 vaccine compared to 30.3% (439 of 1,544) for those in the placebo-a difference of 6.3% (95% CI: 2.4, 10.2; P = 0.001). For the intention and the vaccination outcomes, the low cash incentive (20 Ghana cedis) had a larger positive effect on COVID-19 vaccine uptake than the high cash incentive (60 Ghana cedis). Trial identifier: AEARCTR-0008775 .

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Exploring user experiences of a text message-delivered intervention among individuals on opioid use disorder treatment in Kenya: A qualitative study

Opioid use disorder causes significant burden of disease and treatment comprises pharmacotherapy and psychosocial treatment. Cognitive behavioral therapy is an effective psychosocial intervention used in substance use disorders treatment and can be delivered using digital approach. There is limited use of digital treatment among individuals with opioid use disorder in Kenya. This study aimed to describe the experiences and feedback from participants with opioid use disorder enrolled in a text-message intervention in Kenya. Qualitative data was collected from participants in the intervention arm of a feasibility trial testing a text-message intervention based on cognitive behavioral therapy. Data was collected using open-ended questions in a questionnaire and structured in-depth interviews amongst those who received the intervention. Framework method was applied for analysis. Twenty-four participants (83.3% males) were enrolled with a mean age of 32.5 years (SD9.5). Five themes were identified namely: (1) Gain of cognitive behavioral therapy skills which included: identification and change of substance use patterns; drug refusal skills; coping with craving and self-efficacy; (2) Therapeutic alliance which included: development of a bond and agreement on treatment goals; (3) Feedback on intervention components and delivery such as: frequency, and duration of the text message intervention; (4) Challenges experienced during the intervention such as: technical problems with phones; and barriers related to intervention delivery; (5) Recommendations for improvement of intervention in future implementations. The findings demonstrated participants' satisfaction with intervention, gain of skills to change substance use patterns, highlighted challenges experienced and suggestions on improving the intervention among individuals with opioid use disorder. The feedback and recommendations provided by the participants can guide implementation of such interventions to allow acceptability, effectiveness and sustainability. Trial registration: This study was part of a randomized feasibility trial. Clinical trial registration: Pan African Clinical Trial Registry: Registration number: PACTR202201736072847. Date of registration: 10th January 2022.

Study protocol for a cluster-randomised controlled trial of hybrid parents and health workers adaptive intervention for optimal routine childhood immunisation coverage in the communities of Ebonyi state, Nigeria: the AGINTOPIC trial protocol

INTRODUCTION

Vaccine-preventable infectious diseases (VPDs) are major causes of morbidity/mortality among children under 5 years of age worldwide and in Nigeria/Ebonyi state. Routine childhood immunisation is an invaluable prevention strategy for many VPDs. Due to suboptimal coverage and untimely receipt/delay in receipt of vaccinations, outbreaks of VPDs such as measles, yellow fever, diphtheria and others continue to reoccur around the world and in Nigeria/Ebonyi state. This study aims to evaluate the effectiveness of hybrid parents and health workers adaptive intervention in increasing the optimal/timely (cumulative age-appropriate) routine childhood immunisation coverage in the communities in Ebonyi state, Nigeria.

METHODS AND ANALYSES

A two-arm, parallel, open label, covariate-constrained cluster-randomised controlled trial with 1:1 allocation of 16 geographical clusters (the nearest catchment areas for at least one public primary healthcare (PHC) facility with at least 500 households or a population size of 3000) will be used to evaluate the effects of hybrid/combined parents and PHC workers adaptive engagement compared with control. The primary outcomes are the optimal/timely (cumulative age-appropriate) receipt of the recommended vaccines in the routine childhood immunisation schedule by children aged 5-9 completed months and 10-11 completed months and the age-appropriate vaccines receipt score for the recommended vaccines. The outcomes will be measured through a population-based household survey of at least 15 children aged 5-9 and 10-11 months per cluster at baseline and at the end of the study using a structured interviewer-administered questionnaire in KoBoCollect installed in android devices. All analyses will be done using a cluster-level method on as-randomised basis.

ETHICS AND DISSEMINATION

Ethical approval for the trial was obtained from the Ebonyi State Health Research and Ethics Committee (EBSHREC/01/06/2022-31/05/2023) and verbal consent will be obtained from participants. Study findings will be reported at local/national and international levels as appropriate.

TRIAL REGISTRATION NUMBER

ISRCTN59811905.

Improving the timeliness and completeness of childhood vaccination through color-coded bracelets: a pilot study among Fulani tribe populations in Nigeria

Background

Childhood immunization remains one of the most cost-effective public health interventions. Globally, millions of children are not being reached with safe and effective vaccines and Nigeria has the highest number of unprotected children.

Objective

The effects of locally adapted interventions on vaccination timeliness and completeness were studied amongst Fulani populations across 6 health facilities in 2 districts of Bauchi State, Nigeria.

Methods

The intervention group consisted of newborns who received 5-color-coded bracelets representing different immunization contacts, while the control group had no bracelets. Vaccination rates across contacts were followed for 11 months. In addition, mothers of children in the intervention group were voluntarily recruited as peer-to-peer mobilizers (PPM).

Results

In this study, 435 children were studied. Vaccination completeness was higher in the intervention group compared to the control group at all contacts during follow-up. The difference was most noticeable at the fifth contact, with 158/256 (62%) children in the intervention group completing, compared to 73/179 (41%) in the control group (P<0.0001). Vaccination timeliness was better in the intervention group compared to the control one, which reached statistical significance at the second and third vaccination contacts (P<0.05). 68% of women volunteered as PPM and recruited 82 additional children for vaccination.

Conclusion

This study demonstrated the feasibility of a composite intervention (bracelets and PPM) to increase the completeness and timeliness of childhood immunization and provided preliminary evidence for its efficacy among Fulani populations in Nigeria. Findings from this pilot study should be confirmed through a larger cluster randomized controlled trial.

An economic incentive package to support the wellbeing of caregivers of adolescents living with HIV during the COVID-19 pandemic in South Africa: a feasibility study protocol for a pilot randomised trial

BACKGROUND

The mental and financial strain linked to unpaid caregiving has been amplified during the COVID-19 pandemic. In sub-Saharan Africa, carers of adolescents living with HIV (ALHIV) are critical for maintenance of optimum HIV treatment outcomes. However, the ability of caregivers to provide quality care to ALHIV is undermined by their ability to maintain their own wellbeing due to multiple factors (viz. poverty, stigma, lack of access to social support services) which have been exacerbated by the COVID-19 pandemic. Economic incentives, such as cash incentives combined with SMS reminders, have been shown to improve wellbeing. However, there is a lack of preliminary evidence on the potential of economic incentives to promote caregiver wellbeing in this setting, particularly in the context of a pandemic. This protocol outlines the design of a parallel-group pilot randomised trial comparing the feasibility and preliminary effectiveness of an economic incentive package versus a control for improving caregiver wellbeing.

METHODS

Caregivers of ALHIV will be recruited from public-sector HIV clinics in the south of the eThekwini municipality, KwaZulu-Natal, South Africa. Participants will be randomly assigned to one of the following groups: (i) the intervention group (n = 50) will receive three cash payments (of ZAR 350, approximately 23 USD), coupled with a positive wellbeing message over a 3-month period; (ii) the control group (n = 50) will receive a standard message encouraging linkage to health services. Participants will be interviewed at baseline and at endline (12 weeks) to collect socio-demographic, food insecurity, health status, mental health (stigma, depressive symptoms) and wellbeing data. The primary outcome measure, caregiver wellbeing, will be measured using the CarerQoL instrument. A qualitative study will be conducted alongside the main trial to understand participant views on participation in the trial and their feedback on study activities.

DISCUSSION

This study will provide scientific direction for the design of a larger randomised controlled trial exploring the effects of an economic incentive for improving caregiver wellbeing. The feasibility of conducting study activities and delivering the intervention remotely in the context of a pandemic will also be provided.

TRIAL REGISTRATION

PACTR202203585402090. Registry name: Pan African Clinical Trials Registry (PACTR); URL: https://pactr.samrc.ac.za/ ; Registration. date: 24 March 2022 (retrospectively registered); Date first participant enrolled: 03 November 2021.

Effects of Loss and Gain Incentives on Adherence in Pediatric Weight Management: Preliminary Studies and Economic Evaluation of a Theoretical Trial

Pediatric weight management is often hampered by poor engagement and adherence. Incentives based on loss have been shown to be more effective than gain-based incentives in improving outcomes among children with health conditions other than obesity. In preparation for a clinical trial comparing loss-framed to gain-framed incentives, a survey of youth and caregiver attitudes on weight management incentives, reasons for program attendance, and an economic evaluation of a theoretical trial were conducted. Ninety of 835 (11%) surveys were completed by caregiver and child. The economic evaluation showed that loss-framed incentives had a preferable incremental cost-effectiveness ratio (a lower value is considered preferable) than gain-based incentives. Most youth and caregivers felt a gain incentive would be superior, agreed that the full incentive should go to the youth (vs. the caregiver), and identified "improving health" as a top reason for pursuing weight management.

Implementing SMS reminders for routine immunization in Northern Nigeria: a qualitative evaluation using the RE-AIM framework

BACKGROUND

Short Message Service (SMS) reminders have improved vaccine uptake in low- and middle-income countries (LMICs). However, the limited use of SMS reminders in LMICs requires evaluating the intervention's internal and external validity to improve adoption and sustainability. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we qualitatively assessed the impact of a SMS reminder intervention implemented in Kebbi State, Northwest Nigeria between May 20, 2019 and May 31, 2020. This will guide and inform future SMS reminder interventions to improve childhood immunization uptake in LMICs.

METHODS

In June 2020, we conducted 14 focus group discussions, 13 in-depth interviews, and 20 key informant interviews among 144 purposively selected participants from five local government areas of Kebbi State. For analysis, we used a deductive approach to develop preliminary codes based on the RE-AIM framework and the inductive approach to generate themes that emerged from the interviews.

RESULTS

The perceived importance and impact of the SMS reminder in improving demand and uptake for vaccinations were the consistent contributing factors that encouraged participants' participation. Other facilitators included the involvement of health workers in supporting SMS reminder registration and community gatekeepers using existing structures to convey messages on scheduled immunization services. Policymakers adopted the intervention because it aligns with the state's priority to improve immunization coverage. Similarly, the SMS reminder appealed to health workers and program managers because it reduced their workload and served as a performance monitoring tool to track immunization and intervention defaulters. Despite these, low mobile phone ownership and the inability to read text messages due to the low literacy level were the main barriers during implementation. Finally, data availability on cost-effectiveness and the intervention's impact on improving coverage was critical for scalability.

CONCLUSIONS

Our study demonstrated that SMS reminders in local languages could improve vaccination demand and uptake in resource-constrained settings due to their perceived importance and impact. Addressing the cited implementation barriers and promoting the facilitators is critical to its adoption and sustainability. Costing and impact data are needed to collaborate findings on the effectiveness of the SMS reminder to improve childhood vaccination uptake.

Use of community engagement interventions to improve child immunisation in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To support evidence informed decision-making, we systematically examine the effectiveness and cost-effectiveness of community engagement interventions on routine childhood immunisation outcomes in low-income and middle-income countries (LMICs) and identify contextual, design and implementation features associated with effectiveness.

DESIGN

Mixed-methods systematic review and meta-analysis.

DATA SOURCES

21 databases of academic and grey literature and 12 additional websites were searched in May 2019 and May 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included experimental and quasi-experimental impact evaluations of community engagement interventions considering outcomes related to routine child immunisation in LMICs. No language, publication type, or date restrictions were imposed.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers extracted summary data from published reports and appraised quantitative risk of bias using adapted Cochrane tools. Random effects meta-analysis was used to examine effects on the primary outcome, full immunisation coverage.

RESULTS

Our search identified over 43 000 studies and 61 were eligible for analysis. The average pooled effect of community engagement interventions on full immunisation coverage was standardised mean difference 0.14 (95% CI 0.06 to 0.23, I2=94.46). The most common source of risk to the quality of evidence (risk of bias) was outcome reporting bias: most studies used caregiver-reported measures of vaccinations received by a child in the absence or incompleteness of immunisation cards. Reasons consistently cited for intervention success include appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints. The median intervention cost per treated child per vaccine dose (excluding the cost of vaccines) to increase absolute immunisation coverage by one percent was US$3.68.

CONCLUSION

Community engagement interventions are successful in improving outcomes related to routine child immunisation. The findings are robust to exclusion of studies assessed as high risk of bias.

Parental Reminder Strategies and the Cost Implication for Improved Immunisation Outcomes: A Systematic Review and Meta-Analysis

Getting children vaccinated amidst prevailing barriers to immunisation has been challenging in both developed and developing countries. To address these problems, studies on parental reminder strategies were conducted to improve immunisation outcomes in children. These led to the development of different parental reminder interventions. This review systematically reviews different parental interventions and their cost implication for improved immunisations. Five online databases; Medline Complete, the Cumulative Index for Nursing and Allied Health Literature [CINAHL], Academic search premier, SPORTDiscus, and Health Source Nursing/Academic were searched using search terms. A total of 24 articles that met the inclusion criteria were included in this review. Studies that provided sufficient information were included for meta-analysis using Comprehensive Meta-Analysis version three, while narrative synthesis was used for the other studies. Results indicate that a heterogeneous and low-quality certainty of evidence on parental voice calls (OR 4.752, 95% CI 1.846-12.231, p = 0.001) exists in improving immunisation coverage. Regarding immunisation timeliness, a high-quality certainty of evidence on Short Message Services (SMS)-delivered health education messages (OR 2.711 95% CI 1.387-5.299, p = 0.004) had more effect on timely immunisation uptake. The average cost of SMS-delivered parental reminder interventions for improved immunisation outcomes was USD 0.50. The study concludes that mobile technology is a promising, cost-effective strategy for improved immunisation outcomes.

Overcoming Vaccine Hesitancy for Future COVID-19 and HIV Vaccines: Lessons from Measles and HPV Vaccines

BACKGROUND

The discovery of vaccines significantly reduced morbidity and mortality of infectious diseases and led to the elimination and eradication of some. Development of safe and effective vaccines is a critical step to the control of infectious diseases; however, there is the need to address vaccine hesitancy because of its potential impact on vaccine uptake.

METHODS

We conducted a narrative review of studies on interventions to address measles and human papillomavirus vaccine hesitancy. We discussed how lessons learned from these studies could be applied towards COVID-19 and future human immunodeficiency virus vaccines.

RESULTS

We found that there are several successful approaches to improving vaccine acceptance. Interventions should be context specific and build on the challenges highlighted in various settings.

CONCLUSION

Strategies could be used alone or in combination with others. The most successful interventions directly targeted the population for vaccination. Use of financial incentives could be a potential tool to improve vaccine uptake.

Use of community engagement interventions to improve child immunisation in low- and middle-income countries: A systematic review and meta-analysis

Immunisation is one of the most cost-effective interventions to prevent and control life-threatening infectious diseases. Nonetheless, rates of routine vaccination of children in low- and middle-income countries (LMICs) are strikingly low or stagnant. In 2019, an estimated 19.7 million infants did not receive routine immunisations. Community engagement interventions are increasingly being emphasised in international and national policy frameworks as a means to improve immunisation coverage and reach marginalised communities. This systematic review examines the effectiveness and cost-effectiveness of community engagement interventions on outcomes related to childhood immunisation in LMICs and identifies contextual, design and implementation features that may be associated with effectiveness. We identified 61 quantitative and mixed methods impact evaluations and 47 associated qualitative studies related to community engagement interventions for inclusion in the reteview. For cost-effectiveness analysis 14 of the 61 studies had the needed combination of cost and effectiveness data. The 61 included impact evaluations were concentrated in South Asia and Sub-Saharan Africa and spread across 19 LMICs. The review found that community engagement interventions had a small but significant, positive effect on all primary immunisation outcomes related to coverage and their timeliness. The findings are robust to exclusion of studies assessed as high risk of bias. Qualitative evidence indicates appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints and practicalities on the ground are consistently cited as reasons for intervention success. Among the studies for which we were able to calculate cost-effectiveness, we find that the median non-vaccine cost per dose of intervention to increase immunisation coverage by 1% was US $3.68. Given the broad scope of the review in terms of interventions and outcomes, there is significant variation in findings. Among the various types of community engagement interventions, those that involve creation of community buy-in or development of new cadres of community-based structures were found to have consistent positive effect on more primary vaccination coverage outcomes than if the engagement is limited to the design or delivery of an intervention or is a combination of the various types. The evidence base for sub-group analysis for female children was sparse (only two studies) and the effect on coverage of both full immunisation and third dose of diphtheria pertussis tetanus for this group was insignificant.

mHealth interventions to reduce maternal and child mortality in Sub-Saharan Africa and Southern Asia: A systematic literature review

Background

Reducing maternal mortality, neonatal mortality and under 5-year mortality are important targets addressed by the United Nations' Sustainable Development Goals. Despite studies reported an improvement in maternal and child health indicators, the progress achieved is not uniform across regions. Due to the increasing availability of mobile phones in low and middle-income countries, mHealth could impact considerably on reducing maternal and child mortality and maximizing women's access to quality care, from the antenatal stage to the post-natal period.

Methods

A systematic literature review of mHealth interventions aimed at reducing maternal and child mortality in Sub-Saharan Africa and Southern Asia. Primary outcomes were maternal mortality, neonatal mortality, and under-five mortality. Secondary outcomes were skilled birth attendance, antenatal care (ANC) and post-natal care (PNC) attendance, and vaccination/immunization coverage. We searched for articles published from January 2010 to December 2020 in Embase, Medline and Web of Science. Quantitative comparative studies were included. The protocol was developed according to the PRISMA Checklist and published in PROSPERO [CRD42019109434]. The Quality Assessment Tool for Quantitative Studies was used to assess the quality of the eligible studies.

Results

23 studies were included in the review, 16 undertaken in Sub-Saharan Africa and 7 in Southern Asia. Most studies used SMS or voice message reminders for education purposes. Only two studies reported outcomes on neonatal mortality, with positive results. None of the studies reported results on maternal mortality or under-five mortality. Outcomes on skilled birth attendance, ANC attendance, PNC attendance, and vaccination coverage were reported in six, six, five, and eleven studies, respectively. Most of these studies showed a positive impact of mHealth interventions on the secondary outcomes.

Conclusion

Simple mHealth educational interventions based on SMS and voice message reminders are effective at supporting behavior change of pregnant women and training of health workers, thus improving ANC and PNC attendance, vaccination coverage and skilled birth attendance. Higher quality studies addressing the role of mHealth in reducing maternal and child mortality in resource-limited settings are needed, especially in Southern Asia.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019109434, identifier CRD42019109434.

Small mobile conditional cash transfers (mCCTs) of different amounts, schedules and design to improve routine childhood immunization coverage and timeliness of children aged 0-23 months in Pakistan: An open label multi-arm randomized controlled trial

BACKGROUND

Cost-effective demand-side interventions are needed to increase childhood immunization. Multiple studies find tying income support programs (≥USD 50 per year) to immunization raises coverage. Research on maximizing impact from small mobile-based conditional cash transfers (mCCTs) (≤USD 15 per fully immunized child) delivered in lower-income settings remains sparse.

METHODS

Participants in Karachi, Pakistan, were individually randomized into a seven arm, factorial open label study with five mCCT arms, one reminder (SMS) only arm, and one control arm. The mCCT arms varied by amount (high ∼USD 15 per fully immunized child versus low ∼USD 5 per fully immunized child), schedule (flat versus rising payments over the schedule), design (certain versus lottery payments), and payment method (airtime or mobile money). Children were enrolled at BCG, pentavalent-1 (penta-1) or pentavalent-2 (penta-2) vaccination and followed until at least 18 months of age. A serosurvey in 15% sub-sample validated reported study coverage. The full immunization coverage (FIC) at 12 months (primary outcome) was analyzed using logit regression. ClinicalTrials.gov (NCT03355989), 3ie registry (58f6ee7725fc1), and AEA RCT Registry (AEARCTR-0001953).

FINDINGS

Between November 6, 2017, and October 10, 2018, a total of 11,197 caregiver-child pairs were enrolled, with 1598-1600 caregiver-child pairs per arm. FIC at 12 months was statistically significantly higher for any mCCT versus SMS (OR:1.18, 95% CI: 1.05-1.33; p = 0.005). Within the mCCT arms, FIC was statistically significantly higher for high versus low amount (OR: 1.16, 95% CI: 1.04-1.29; p = 0.007), certain versus lottery payment (OR: 1.30, 95% CI: 1.17-1.45; p < 0.001) and airtime versus mobile money (OR: 1.17, 95% CI:1.01-1.36; p = 0.043). There was no statistically significant difference between a flat and increasing schedule (OR: 1.03, 95% CI: 0.93-1.15; p = 0.550). SMS had a marginally statistically significant impact on FIC versus control (OR: 1.16, 95% CI: 1.00-1.35; p = 0.046). Findings were similar for up-to-date coverage of penta-3, measles-1 and measles-2 at 18 months.

INTERPRETATION

Small mCCTs (USD 0.8-2.4 per immunization visit) can increase FIC at 12 months and up-to-date coverage at 18 months at USD 23 per additional fully immunized child, in resource-constrained settings like Pakistan. Design details (certainty, schedule and delivery method of mCCTs) matter as much as the size of payments.

FUNDING

Global Innovation Fund, GiveWell.

Timeliness of routine childhood vaccination in 103 low-and middle-income countries, 1978-2021: A scoping review to map measurement and methodological gaps

Empiric studies exploring the timeliness of routine vaccination in low-and middle-income countries (LMICs) have gained momentum in the last decade. Nevertheless, there is emerging evidence suggesting that these studies have key measurement and methodological gaps that limit their comparability and utility. Hence, there is a need to identify, and document these gaps which could inform the design, conduct, and reporting of future research on the timeliness of vaccination. We synthesised the literature to determine the methodological and measurement gaps in the assessment of vaccination timeliness in LMICs. We searched five electronic databases for peer-reviewed articles in English and French that evaluated vaccination timeliness in LMICs, and were published between 01 January 1978, and 01 July 2021. Two reviewers independently screened titles and abstracts and reviewed full texts of relevant articles, following the guidance framework for scoping reviews by the Joanna Briggs Institute. From the 4263 titles identified, we included 224 articles from 103 countries. China (40), India (27), and Kenya (23) had the highest number of publications respectively. Of the three domains of timeliness, the most studied domain was 'delayed vaccination' [99.5% (223/224)], followed by 'early vaccination' [21.9% (49/224)], and 'untimely interval vaccination' [9% (20/224)]. Definitions for early (seven different definitions), untimely interval (four different definitions), and delayed vaccination (19 different definitions) varied across the studies. Most studies [72.3% (166/224)] operationalised vaccination timeliness as a categorical variable, compared to only 9.8% (22/224) of studies that operationalised timeliness as continuous variables. A large proportion of studies [47.8% (107/224)] excluded the data of children with no written vaccination records irrespective of caregivers' recall of their vaccination status. Our findings show that studies on vaccination timeliness in LMICs has measurement and methodological gaps. We recommend the development and implement of guidelines for measuring and reporting vaccination timeliness to bridge these gaps.

What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years

Progress has been made globally in improving the coverage of key maternal, newborn, and early childhood interventions in low-income and middle-income countries, which has contributed to a decrease in child mortality and morbidity. However, inequities remain, and many children and adolescents are still not covered by life-saving and nurturing care interventions, despite their relatively low costs and high cost-effectiveness. This Series paper builds on a large body of work from the past two decades on evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach the most vulnerable. We review the current evidence base on the effectiveness of a variety of essential and emerging interventions that can be delivered from before conception until age 20 years to help children and adolescents not only survive into adulthood, but also to grow and develop optimally, support their wellbeing, and help them reach their full developmental potential. Although scaling up evidence-based interventions in children younger than 5 years might have the greatest effect on reducing child mortality rates, we highlight interventions and evidence gaps for school-age children (5-9 years) and the transition from childhood to adolescence (10-19 years), including interventions to support mental health and positive development, and address unintentional injuries, neglected tropical diseases, and non-communicable diseases.

Effect of mobile phone text message and call reminders in the completeness of pentavalent vaccines in Kano state, Nigeria

PURPOSE

This study assessed the effect of mobile phone text message and call reminders in the completeness of the pentavalent vaccine administered against diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenza.

DESIGN AND METHODS

The population for this quasi-experimental study were recent mothers of children not more than three weeks old selected from six local government areas of Kano State, Northern Nigeria. Three local government areas were each allocated to the intervention (reminder) and control groups of the study. Mobile phone reminders (SMS and follow-up calls) were sent to mothers in the reminder group three days to and on the due date of their child's schedule for the 1st, 2nd and 3rd doses of the pentavalent vaccine. All statistical data were entered into the Statistical Package for Social Sciences (SPSS) version 23.0 and analysed using descriptive and inferential statistics.

RESULTS

A total of 541 mothers (271 in the intervention group and 270 in the control group) participated in the study. Completion rates for the three doses of the pentavalent vaccine were observed to be higher for children in the reminder group (n = 161, 59.4%) compared to those in the control group (n = 92, 34.1%).

CONCLUSION

Mobile phone reminders were effective and improved the rate of completeness of the pentavalent vaccine in the studied population. In line with the findings of the study, it is recommended that future studies should focus on identifying the best approach to remind parents either through SMS, phone calls, or voice messages or a combination of any of the approaches.

PRACTICE IMPLICATION

Nurses and other health care providers will have empirical evidence on the use of mobile phone technology to improve the health and wellbeing of children by protecting them from vaccine-preventable diseases.

Timeliness of routine childhood vaccinations in Indonesian infants in the first year of life

BACKGROUND

Vaccines have proven to be one of the most effective strategies to control infectious diseases and contributed to childhood survival. While high vaccine coverages provide individual's and herd immunity, age-appropriate vaccination or vaccine timeliness is important for maximum vaccine's protection, but often not evaluated. We aimed to describe the timeliness of childhood vaccination for Indonesian infants and identify risk factors associated with delayed vaccination.

METHODS

This study was a sub-study of the Indonesian Pneumonia and Vitamin D status (IPAD) study, a community-based cohort study to investigate pneumonia incidence in two districts in Yogyakarta province, Indonesia. Socio-demographic data were obtained from structured interviews and vaccine status was obtained from maternal and child health records. Timely vaccination was defined if the vaccine was received between four days or less before and within 28 days after the recommended age of vaccination.

RESULTS

359 (85%) out of 422 IPAD participants and their immunisation records were included. Between December 2015 and December 2017, vaccination coverage was high and ranged from 96.1% (Measles) to 100% (DTP-HepB-Hib 1). However, two thirds (67%, 242/359) of all participants had received either early or late vaccines, with dose 2 IPV (40%, 143/356), dose 3 IPV (56%, 196/349) and dose 3 DTP-HepB-Hib (29%, 103/354) most delayed, and only 1% received early doses. The main risk factors for untimely vaccination were if the infant was born in a private practice versus in a public health facility (AOR 1.90; 95% CI: 1.18-3.07) and rural residence (AOR 1.84; 95% CI: 1.15-2.94).

CONCLUSIONS

Despite high vaccine coverage for Indonesian infants (>95%), two thirds (67%) of infants had untimely vaccinations, with dose 3 IPV (56%) the most delayed. Future strategies should focus on coordination between government, health care providers, and carers to ensure timely access and vaccination of infants to ensure adherence to vaccination schedules.

Tracking Demographic Movements and Immunization Status to Improve Children's Access to Immunization: Field-Based Randomized Controlled Trial

Background

Countries’ Expanded Program on Immunization (EPI) contribute to the reduction of mortality and morbidity, but access to these vaccines remains limited in most low-income countries.

Objective

We aim to assess whether involving community volunteers (CVs) to track children’s vaccination status and demographic movements and using recorded data to plan catch-up immunization sessions can improve children’s vaccination timeliness, completeness, and coverage.

Methods

This was a field-based randomized controlled trial and communities of the Foumban health district in West Cameroon were allocated to intervention or control groups. In the intervention group, a CV per community was trained to visit households monthly for a year to assess and record in a register, details of EPI-targeted children, their demographic movements and immunization status. The scanned recorded pages were sent to the health center immunization team through WhatsApp and used to organize monthly community catch-up immunization sessions. In the control group, EPI vaccination sessions were routinely conducted. Surveys were conducted at 6 and 12 months from the beginning of the intervention in both study groups to assess and compare immunization timeliness, coverage, and completeness.

Results

Overall, 30 buildings per cluster were surveyed at midline and endline. Of the 633 and 729 visited households in the intervention group at midline and endline, 630 (99.5%) and 718 (98.4%), respectively, consented to participate. In the control group, 507 and 651 households were visited and 505 (99.6%) and 636 (97.7%), respectively, consented to participate. At 12 months intervention, the month one timeliness of bacille Calmette–Guerin (BCG) vaccine did not increase in the intervention group compared with the control group for the age groups 0-11 months (adjusted odds ratio [aOR] 1.1, 95% CI 0.7-1.8) and 0-59 months (aOR 1.1, 95% CI 0.9-1.4), and significantly increased for the first-year BCG vaccine administration for the age group 0-23 months (aOR 1.5, 95% CI 1.1-2.2). The coverage of diphtheria-pertussis-tetanus and hepatitis B+Hemophilus influenzae type B (DPT-Hi +Hb) dose 3 (aOR 2.0, 95% CI 1.5-2.7) and of DPT-Hi+Hb dose 1 (aOR 1.8, 95% CI 1.4-2.4) vaccines increased significantly in the intervention group compared with the control group in the age groups 12-59 months and 12-23 months, respectively. Specific (DPT-Hi+Hb dose 1 to DPT-Hi+Hb dose 3: aOR 1.9, 95% CI 1.4-2.6) and general (BCG to measles: aOR 1.5, 95% CI 1.1-2.1) vaccine completeness increased significantly in the intervention group compared with the control group.

Conclusions

Findings support that involving CVs to track children’s vaccination status and demographic movements and using recorded data to plan catch-up immunization sessions improve children’s vaccination timeliness, completeness, and coverage. This strategy should be adopted to improve access to vaccination for EPI target populations and the consistency verified in other contexts.

Trial Registration

Pan African Clinical Trials Registry PACTR201808527428720; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=3548

Measles

Measles is a highly contagious, potentially fatal, but vaccine-preventable disease caused by measles virus. Symptoms include fever, maculopapular rash, and at least one of cough, coryza, or conjunctivitis, although vaccinated individuals can have milder or even no symptoms. Laboratory diagnosis relies largely on the detection of specific IgM antibodies in serum, dried blood spots, or oral fluid, or the detection of viral RNA in throat or nasopharyngeal swabs, urine, or oral fluid. Complications can affect many organs and often include otitis media, laryngotracheobronchitis, pneumonia, stomatitis, and diarrhoea. Neurological complications are uncommon but serious, and can occur during or soon after the acute disease (eg, acute disseminated encephalomyelitis) or months or even years later (eg, measles inclusion body encephalitis and subacute sclerosing panencephalitis). Patient management mainly involves supportive therapy, such as vitamin A supplementation, monitoring for and treatment of secondary bacterial infections with antibiotics, and rehydration in the case of severe diarrhoea. There is no specific antiviral therapy for the treatment of measles, and disease control largely depends on prevention. However, despite the availability of a safe and effective vaccine, measles is still endemic in many countries and causes considerable morbidity and mortality, especially among children in resource-poor settings. The low case numbers reported in 2020, after a worldwide resurgence of measles between 2017 and 2019, have to be interpreted cautiously, owing to the effect of the COVID-19 pandemic on disease surveillance. Disrupted vaccination activities during the pandemic increase the potential for another resurgence of measles in the near future, and effective, timely catch-up vaccination campaigns, strong commitment and leadership, and sufficient resources will be required to mitigate this threat.

Biliary Atresia Screening in India-Strategies and Challenges in Implementation

OBJECTIVE

To assess the utilization of SCC implemented in southern India and the effect on SCC utilization of face-to-face verbal education versus video-based content delivery.

METHODS

The study included newborns with postnatal age of less than 2 wk at discharge. Mothers were administered SCCs and provided standardized verbal or video health education based on the time-period of enrollment. Home based monitoring of stool color and return of SCC on postnatal day 21 was advised. Telephone surveys were conducted to identify SCC use among families that did not return the SCC by post.

RESULTS

Of the 2254 newborns enrolled, 1130 were in the verbal-counseling group and 1124 in the video-counseling group. No newborns with pale stools and biliary atresia were identified. SCC return rates were 3.8% and 2.8%. Comparing the verbal and video-counseling groups, there were no differences in the conservative (81.8% vs. 81.5%) and optimistic estimates (97.1% vs. 97.3%) of SCC utilization rates. Mothers with better educational status had higher optimistic estimates of SCC utilization.

CONCLUSIONS

The use of a validated SCC in Tamil with standardized information delivery leads to good utilization rates in southern India, with video content delivery being as effective as face-to-face verbal content delivery. SCC return by post is not a feasible mode of identification of card use.

TRIAL REGISTRATION

The study is registered under Clinical Trials Registry - India (CTRI/2018/01/011285).

Socio-Demographic Characteristics of COVID-19 Vaccine Recipients in Kwara State, North Central Nigeria

Understanding key socio-demographic variables of 2019 coronavirus disease (COVID-19) vaccine recipients is crucial to improving its acceptance and Nigeria's COVID-19 control strategy. The survey was conducted as a non-probability cross-sectional survey of 2,936 COVID-19 vaccine recipients in Kwara State. Our findings revealed that 74% (n = 2,161) of the vaccine recipients were older than 40 years. Forty percent (n = 1,180) of the vaccine recipients earned a monthly income >100,000 Naira (equivalent to US $200). Most of the vaccine recipients (64%, n = 1,880) had tertiary education, while 15% (n = 440) of them had no formal education. Almost half of the recipients (47%, n = 1,262) were government employees and 28.8% (n = 846) of them had health-related backgrounds. Only 17% (n = 499) of the vaccine recipients have been screened for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of which 21% (n = 105/499) of them were tested positive. Only 47% (n = 1,378) had been fully immunized. The prevalence of confirmed COVID-19 cases among COVID-19 vaccine recipients in Kwara State was 3.6% (n = 105/2,936). The most recurrent adverse events following immunization (AEFIs) among vaccine recipients were fever (14%, n = 411), pain at injection site (47%, n = 1,409), headache (19%, n = 558), and body weakness (9%, n = 264). The need to protect themselves from the deadly virus was the main reason that prompted people to voluntarily accept the COVID-19 vaccine. There is a high level of COVID-19 vaccine acceptance among respondents across all social classes including those with no formal education, those with very low monthly income (< US $2 per day), and in untested population. Hence, vaccine donors should prioritize equitable distribution to Low-and-Middle-income Countries (LMICs) such as Nigeria, and health authorities should improve vaccine advocacy to focus on vaccine safety and efficacy.

Vaccination dropout rates among children aged 12-23 months in Democratic Republic of the Congo: a cross-sectional study

Background

Overall, 1.8 million children fail to receive the 3-dose series for diphtheria, tetanus and pertussis each year in the Democratic Republic of the Congo (DRC). Currently, an emergency plan targeting 9 provinces including Kinshasa, the capital of the DRC, is launched to reinforce routine immunization. Mont Ngafula II was the only health district that experienced high vaccination dropout rates for nearly five consecutive years. This study aimed to identify factors predicting high immunization dropout rates among children aged 12-23 months in the Mont Ngafula II health district.

Methods

A cross-sectional household survey was conducted among 418 children in June-July 2019 using a two-stage sampling design. Socio-demographic and perception data were collected through a structured interviewer-administered questionnaire. The distribution of 2017-2018 immunization coverage and dropout rate was extracted from the local health district authority and mapped. Logistic random effects regression models were used to identify predictors of high vaccination dropout rates.

Results

Of the 14 health areas in the Mont Ngafula II health district, four reported high vaccine coverage, only one recorded low vaccine coverage, and three reported both low vaccine coverage and high dropout rate. In the final multivariate logistic random effects regression model, the predictors of immunization dropout among children aged 12-23 months were: living in rural areas, unavailability of seats, non-compliance with the order of arrival during vaccination in health facilities, and lack of a reminder system on days before the scheduled vaccination.

Conclusions

Our results advocate for prioritizing targeted interventions and programs to strengthen interpersonal communication between immunization service providers and users during vaccination in health facilities and to implement an SMS reminder system on days before the scheduled vaccination.

Compliance Indicators of COVID-19 Prevention and Vaccines Hesitancy in Kenya: A Random-Effects Endogenous Probit Model

Vaccine hesitancy remains a major public health concern in the effort towards addressing the COVID-19 pandemic. This study analyzed the effects of indicators of compliance with preventive practices on the willingness to take COVID-19 vaccines in Kenya. The data were from the COVID-19 Rapid Response Phone Surveys conducted between January and June 2021 during the fourth and fifth waves. The data were analyzed with the random-effects endogenous Probit regression model, with estimated parameters tested for robustness and stability. The results showed that willingness to take vaccines increased between the fourth and fifth waves. Compliance with many of the preventive practices also improved, although the utilizations of immune system-promoting practices were very low. The panel Probit regression results showed that compliance indicators were truly endogenous and there was existence of random effects. Immune system-boosting and contact-prevention indicators significantly increased and decreased the willingness to take vaccines, respectively (p < 0.01). The experience of mental health disorders in the form of nervousness and hopelessness also significantly influenced vaccine hesitancy (p < 0.10). Willingness to take vaccines also significantly increased among older people and those with a formal education (p < 0.01). Different forms of association exist between vaccine hesitancy and the prevention compliance indicators. There is a need to properly sensitize the people to the need to complement compliance with COVID-19 contact-prevention indicators with vaccination. Addressing mental health disorders in the form of loneliness, nervousness, depression, hopelessness and anxiety should also become the focus of public health, while efforts to reduce vaccine hesitancy should focus on individuals without formal education, males and youths.

Messages that increase COVID-19 vaccine acceptance: Evidence from online experiments in six Latin American countries

As safe and effective vaccines become widely available, attaining herd immunity and limiting the spread of COVID-19 will depend on individuals choosing to vaccinate—and doing so quickly enough to outpace mutations. Using online surveys conducted across six Latin American countries in January 2021, we experimentally assess messages designed to counteract informational deficiencies and collective action problems that may drive hesitancy. We first find that basic vaccine information persuades around 8% of hesitant individuals to become willing to vaccinate, reduces intended wait to vaccinate by 0.4 months, and increases willingness to encourage others to vaccinate. Rather than facilitating free riding, learning, or social conformity, additional information about others’ behavior increases vaccine acceptance when respondents expect herd immunity will be achieved. Finally, priming the social approval benefits of vaccinating also increases vaccine acceptance. These results suggest that providing information and shaping social expectations and incentives could both significantly increase vaccine uptake.

Characteristics of mobile phone access and usage among caregivers in Pakistan - A mHealth survey of urban and rural population

INTRODUCTION

Globally mobile ownership and access is becoming very common, and breakthroughs in mobile technology have shaped digital communication, with 7 billion mobile phone users globally. Developing countries account for 80% of newly purchased mobile phone devices with majority of such countries having low Routine Immunization coverage and a high risk of vaccine preventable diseases. The use of mobile phones provides a tremendous potential for public health involvement.

OBJECTIVE

The aim of this study is to assess the acceptability and usability of mobile phones among infant caregivers in a LMIC setup and to explore the role of mHealth to improve immunization uptake and coverage.

METHODS

This is a cross-sectional survey exploring the regional differences in mobile phone ownership, usability and preferences, along with level of trust with others while sharing a mobile phone. The study was conducted with caregivers of infants in an urban and rural sites of Pakistan.

RESULTS

A total of 4472 households were approached, of which 3337 participants were eligible for the study (74.61 %). The reasons for not participating in the study (n = 1135) included (i) household locked or refusal to participate for 594 families (52%), (ii) child older than 14 days of life in 409 cases (36%), (iii) 80 (7%) families did not have access to a functional mobile phone, (iv) 36 (3%)families did not provide a mobile phone number, and (v) 14 (1%) could not stay within the HDSS for 6 months. Access to mobile phone with SMS features was considerably high at both sites: 99.1% in Matiari (rural site) and 96.7% in Karachi (urban). In Matiari 96.6% of the respondents reported having daily access to the phone, contrasting with only 51.4% in Karachi. In Karachi, the predominant spoken language was Urdu, whereas majority of the respondents in Matiari spoke Sindhi (34.6% vs. 70.9%).

CONCLUSION

Our study indicates high access to mobile phone in both urban and rural setup, However access to smart phone is still limited, urban and rural setup. Further, the acceptance of overall health- and barrier-based child immunization messages through mobile phone were quite high in both settings. Lastly automated calls were preferred over SMS due to literacy and local settings. This bears important implications for improving child immunization uptake through mobile phones in developing regions such as Pakistan.

Designing an SMS reminder intervention to improve vaccination uptake in Northern Nigeria: a qualitative study

BACKGROUND

Penta3 coverage in Nigeria was low at 33 % in 2017. The most reported reason for non-vaccination was lack of knowledge about the immunization place, time, and need. To address knowledge gaps and improve vaccination uptake, we designed an Immunization Reminder and Information SMS System (IRISS) to educate and remind parents/caregivers about immunization using SMS. A formative study was conducted to understand the contextual and behavioural factors that would inform the IRISS intervention design and implementation.

METHODS

We conducted the study in four Local Government Areas (LGAs) of Kebbi State Nigeria in October 2018, amongst a diverse selection of participants. Data on social norms about vaccinations, barriers to immunization uptake, mobile phone use, SMS message testing, and willingness to accept SMS reminders were collected from focus group discussions (N = 11), in-depth interviews (N = 12), and key informant interviews (N = 13). In addition, we assessed 33 messages covering schedule reminders, normative, motivational, educational, and informative contents for clarity, comprehensibility, relevance, cultural appropriateness, and ability to motivate action among community members from Argungu and Fakai LGAs. All interviews were analyzed using a thematic analysis approach.

RESULTS

We interviewed 135 people, and 90 % were community members. While we found positive perceptions about immunizations among those interviewed, pockets of misconceptions existed among community members. Lack of awareness on the importance of vaccination was a consistent reason for under-vaccination across the LGAs. In addition, most community members do not own phones, could not read SMS messages, and were unaware of how to check/open text messages received. Despite concerns about low literacy levels and phone ownership, community members still saw a role in SMS reminders when phone owners receive messages. For instance, community leaders can disseminate said messages to community members through existing channels such as town announcers and religious gatherings. Therefore, the SMS becomes a source of information, with phone owners acting as a conduit to community dissemination mechanisms. We generally found the tested messages to be relevant, motivating, and culturally acceptable.

CONCLUSIONS

SMS reminders have the potential to bridge the information gap in community awareness for vaccination, which can translate to improved immunization uptake. In rural communities with low literacy levels and phone ownership, immunization information can be disseminated when existing community leadership structures are engaged.

Does exposure to health information through mobile phones increase immunisation knowledge, completeness and timeliness in rural India?

Introduction

Immunisation plays a vital role in reducing child mortality and morbidity against preventable diseases. As part of a randomised controlled trial in rural Madhya Pradesh, India to assess the impact of Kilkari, a maternal messaging programme, we explored determinants of parental immunisation knowledge and immunisation practice (completeness and timeliness) for children 0–12 months of age from four districts in Madhya Pradesh.

Methods

Data were drawn from a cross-sectional survey of women (n=4423) with access to a mobile phone and their spouses (n=3781). Parental knowledge about immunisation and their child’s receipt of vaccines, including timeliness and completeness, was assessed using self-reports and vaccination cards. Ordered logistic regressions were used to analyse the factors associated with parental immunisation knowledge. A Heckman two-stage probit model was used to analyse completeness and timeliness of immunisation after correcting for selection bias from being able to produce the immunisation card.

Results

One-third (33%) of women and men knew the timing for the start of vaccinations, diseases linked to immunisations and the benefits of Vitamin-A. Less than half of children had received the basic package of 8 vaccines (47%) and the comprehensive package of 19 vaccines (44%). Wealth was the most significant determinant of men’s knowledge and of the child receiving complete and timely immunisation for both basic and comprehensive packages. Exposure to Kilkari content on immunisation was significantly associated with an increase in men’s knowledge (but not women’s) about child immunisation (OR: 1.23, 95% CI 1.02 to1.48) and an increase in the timeliness of the child receiving vaccination at birth (Probit coefficient: 0.08, 95% CI 0.08 to 0.24).

Conclusion

Gaps in complete and timely immunisation for infants persist in rural India. Mobile messaging programmes, supported by mass media messages, may provide one important source for bolstering awareness, uptake and timeliness of immunisation services.

Trial registration number

NCT03576157.

Short message service (SMS) reminders for childhood immunisation in low-income and middle-income countries: a systematic review and meta-analysis

Introduction

Childhood vaccine delivery services in the low- and middle-income countries (LMIC) are struggling to reach every child with lifesaving vaccines. Short message service (SMS) reminders have demonstrated positive impact on a number of attrition-prone healthcare delivery services. We aimed to evaluate the effectiveness of SMS reminders in improving immunisation coverage and timeliness in LMICs.

Methods

PubMed, Embase, Scopus, Cochrane CENTRAL, CINAHL, CNKI, PsycINFO and Web of Science including grey literatures and Google Scholar were systematically searched for randomised controlled trials (RCTs) and non-RCTs that evaluated the effect of SMS reminders on childhood immunisation and timeliness in LMICs. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 assessment tool for RCTs and Cochrane Risk of Bias in Non-randomised Studies of Interventions tool for non-RCTs. Meta-analysis was conducted using random-effects models to generate pooled estimates of risk ratio (RR).

Results

18 studies, 13 RCTs and 5 non-RCTs involving 32 712 infants (17 135 in intervention groups and 15 577 in control groups) from 11 LMICs met inclusion criteria. Pooled estimates showed that SMS reminders significantly improved childhood immunisation coverage (RR=1.16; 95% CI: 1.10 to 1.21; I²=90.4%). Meta-analysis of 12 included studies involving 25 257 infants showed that SMS reminders significantly improved timely receipt of childhood vaccines (RR=1.21; 95% CI: 1.12 to 1.30; I²=87.3%). Subgroup analysis showed that SMS reminders are significantly more effective in raising childhood immunisation coverage in lower middle-income and low-income countries than in upper middle-income countries (p<0.001) and sending more than two SMS reminders significantly improves timely receipt of childhood vaccines than one or two SMS reminders (p=0.040).

Conclusion

Current evidence from LMICs, although with significant heterogeneity, suggests that SMS reminders can contribute to achieving high and timely childhood immunisation coverage.

PROSPERO registration number

CRD42021225843.

E-health roadmap for COVID-19 vaccine coverage in Iran

BACKGROUND

Vaccination is the effective and long-term pharmacological solution to deal with COVID-19. Information technology (IT) and electronic immunization can be effective in accelerating and improving vaccine coverage. The aim of this paper is to develop multi-dimensional framework of e-health roadmap to response Covod-19 pandemic and examine the role of IT for improving vaccine distribution in Iran.

METHODS

The study methodology was based on a two-stage Delphi method which included literature studies at the beginning. Key steps in creating a roadmap in this study include definition, development and evaluation. The initial conceptual model was developed after literature review. Proposed roadmap was reviewed and evaluated in two stages based on the Delphi method by experts in the fields of E-health.

RESULTS

In the e-health roadmap model, 14 stages of vaccine distribution were presented in three phases of vaccination and then were determined the type of technology in each phase. The 4 conceptual models were approved based on the two stages Delphi approach in a survey of 14 e-health experts. In the second phase of the Delphi process, the selected items were sent back to the specialists to verification. Then e-health roadmap was confirmed by experts and was finalized the approved model.

CONCLUSIONS

The technology-based roadmap is one plan in the form of a transfer strategy that aligns goals with specific technical solutions and helps to meet them. This roadmap empowers decision makers to decide on alternative paths and achieve goals.

Birth and death notification via mobile devices: a mixed methods systematic review

BACKGROUND

Ministries of health, donors, and other decision-makers are exploring how they can use mobile technologies to acquire accurate and timely statistics on births and deaths. These stakeholders have called for evidence-based guidance on this topic. This review was carried out to support World Health Organization (WHO) recommendations on digital interventions for health system strengthening.

OBJECTIVES

Primary objective: To assess the effects of birth notification and death notification via a mobile device, compared to standard practice. Secondary objectives: To describe the range of strategies used to implement birth and death notification via mobile devices and identify factors influencing the implementation of birth and death notification via mobile devices.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, the Global Health Library, and POPLINE (August 2, 2019). We searched two trial registries (August 2, 2019). We also searched Epistemonikos for related systematic reviews and potentially eligible primary studies (August 27, 2019). We conducted a grey literature search using mHealthevidence.org (August 15, 2017) and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies in Web of Science and Google Scholar (May 15, 2020). We searched for studies published after 2000 in any language.  SELECTION CRITERIA: For the primary objective, we included individual and cluster-randomised trials; cross-over and stepped-wedge study designs; controlled before-after studies, provided they have at least two intervention sites and two control sites; and interrupted time series studies. For the secondary objectives, we included any study design, either quantitative, qualitative, or descriptive, that aimed to describe current strategies for birth and death notification via mobile devices; or to explore factors that influence the implementation of these strategies, including studies of acceptability or feasibility. For the primary objective, we included studies that compared birth and death notification via mobile devices with standard practice. For the secondary objectives, we included studies of birth and death notification via mobile device as long as we could extract data relevant to our secondary objectives. We included studies of all cadres of healthcare providers, including lay health workers; administrative, managerial, and supervisory staff; focal individuals at the village or community level; children whose births were being notified and their parents/caregivers; and individuals whose deaths were being notified and their relatives/caregivers.

DATA COLLECTION AND ANALYSIS

For the primary objective, two authors independently screened all records, extracted data from the included studies and assessed risk of bias. For the analyses of the primary objective, we reported means and proportions, where appropriate. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a 'Summary of Findings' table. For the secondary objectives, two authors screened all records, one author extracted data from the included studies and assessed methodological limitations using the WEIRD tool and a second author checked the data and assessments. We carried out a framework analysis using the Supporting the Use of Research Evidence (SURE) framework to identify themes in the data. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in the evidence and we prepared a 'Summary of Qualitative Findings' table.

MAIN RESULTS

For the primary objective, we included one study, which used a controlled before-after study design. The study was conducted in Lao People's Democratic Republic and assessed the effect of using mobile devices for birth notification on outcomes related to coverage and timeliness of Hepatitis B vaccination. However, we are uncertain of the effect of this approach on these outcomes because the certainty of this evidence was assessed as very low. The included study did not assess resource use or unintended consequences. For the primary objective, we did not identify any studies using mobile devices for death notification. For the secondary objective, we included 21 studies. All studies were conducted in low- or middle-income settings. They focussed on identification of births and deaths in rural, remote, or marginalised populations who are typically under-represented in civil registration processes or traditionally seen as having poor access to health services. The review identified several factors that could influence the implementation of birth-death notification via mobile device. These factors were tied to the health system, the person responsible for notifying, the community and families; and include: - Geographic barriers that could prevent people's access to birth-death notification and post-notification services - Access to health workers and other notifiers with enough training, supervision, support, and incentives - Monitoring systems that ensure the quality and timeliness of the birth and death data - Legal frameworks that allow births and deaths to be notified by mobile device and by different types of notifiers - Community awareness of the need to register births and deaths - Socio-cultural norms around birth and death - Government commitment - Cost to the system, to health workers and to families - Access to electricity and network connectivity, and compatibility with existing systems - Systems that protect data confidentiality We have low to moderate confidence in these findings. This was mainly because of concerns about methodological limitations and data adequacy.

AUTHORS' CONCLUSIONS

We need more, well-designed studies of the effect of birth and death notification via mobile devices and on factors that may influence its implementation.

COVID-19 vaccine acceptance and hesitancy in low- and middle-income countries

Widespread acceptance of COVID-19 vaccines is crucial for achieving sufficient immunization coverage to end the global pandemic, yet few studies have investigated COVID-19 vaccination attitudes in lower-income countries, where large-scale vaccination is just beginning. We analyze COVID-19 vaccine acceptance across 15 survey samples covering 10 low- and middle-income countries (LMICs) in Asia, Africa and South America, Russia (an upper-middle-income country) and the United States, including a total of 44,260 individuals. We find considerably higher willingness to take a COVID-19 vaccine in our LMIC samples (mean 80.3%; median 78%; range 30.1 percentage points) compared with the United States (mean 64.6%) and Russia (mean 30.4%). Vaccine acceptance in LMICs is primarily explained by an interest in personal protection against COVID-19, while concern about side effects is the most common reason for hesitancy. Health workers are the most trusted sources of guidance about COVID-19 vaccines. Evidence from this sample of LMICs suggests that prioritizing vaccine distribution to the Global South should yield high returns in advancing global immunization coverage. Vaccination campaigns should focus on translating the high levels of stated acceptance into actual uptake. Messages highlighting vaccine efficacy and safety, delivered by healthcare workers, could be effective for addressing any remaining hesitancy in the analyzed LMICs.

Factors Associating Vaccination Delay among Jordanian Children under Two Years of Age

PURPOSE

This study examines the association between selected socio-demographic factors (gender, birth order, parents' educational levels, and parents' employment status) and reasons for vaccination delay among Jordanian children under two years of age.

DESIGN & METHODS

A cross-sectional, prospective study was conducted in the three comprehensive public health centres in Amman Governorate in Jordan from January-June, 2019. The electronic vaccination record was designed to collect socio- demographic information and reasons for vaccination delay in children. This data was collected from the medical records of those children.

RESULTS

The findings revealed that 150 (8.3%) children under two years of age were registered as vaccination-delayed cases. The factors associated with vaccination delay were age (Chi-square test [χ²] [6150] = 15.02, p-value [p] < 0.01), birth order (χ² [6150] = 15.02, p < 0.01), mother's educational level (χ² [2150] = 9.27, p < 0.05), and father's and mother's employment (χ² [2150] = 7.89, p < 0.05; χ² [2150] = 10.54, p < 0.01, respectively).

CONCLUSION

Timeliness of vaccination should be promoted to prevent illness outbreaks and provide specific protection for children, taking into consideration the significance of age and birth order.

PRACTICE IMPLICATIONS

Interventions and strategies need to implementation to reduce vaccination delay and improve timeliness.

Impact of mobile phone delivered reminders and unconditional incentives on measles-containing vaccine timeliness and coverage: a randomised controlled trial in western Kenya

Introduction

Short message service (SMS) reminders coupled with a small monetary incentive conditioned on prompt vaccination have been shown to improve first-dose measles-containing vaccine (MCV1) uptake. We assessed whether SMS reminders and unconditional monetary incentives—more amenable to programmatic implementation—can improve MCV1 uptake in Kenya.

Methods

Caregivers of eligible infants aged 6–8 months were enrolled into an individually randomised controlled trial and assigned to receive either: no intervention (control), two SMS reminders (SMS) sent 3 days, and 1 day before the scheduled MCV1 date, or SMS reminders coupled with a Kenya Shilling (KES) 150 incentive (SMS +150 KES) sent 3 days before the scheduled MCV1 date. Study staff conducted a household follow-up visit at age 12 months to ascertain vaccination status. Log-binomial regression was used to estimate the relative and absolute difference in MCV1 timely coverage (by age 10 months), the primary outcome.

Results

Between 6 December 2016 and 31 March 2017, 179 infants were enrolled into each of the three study arms. Follow-up visits were completed between 19 April 2017 and 8 October 2017 for control (n=170), SMS (n=157) and SMS + 150 KES (n=158) children. MCV1 timely coverage was 68% among control arm infants compared with 78% in each intervention arm. This represented a non-statistically significant increase in the SMS arm (adjusted relative risk 1.13; 95% CI 0.99 to 1.30; p=0.070; adjusted risk difference 9.2%; 95% CI: −0.6 to 19.0%; p=0.066), but a statistically significant increase in the SMS + 150 KES arm (1.16; 95% CI 1.01 to 1.32; p=0.035; 10.6%; 95% CI 0.8 to 20.3%; p=0.034).

Conclusion

These findings suggest that the effect of SMS reminders coupled with a small unconditional monetary incentive on MCV1 uptake is comparable to that of SMS reminders alone, limiting their utility. Further studies in the absence of unexpected supply-side constraints are needed.

Trial registration number

NCT02904642

High Rate of Bacterial Contamination on Healthcare Worker's Mobile Phone and Potential Role in Dissemination of Healthcare-Associated Infection at Debre Berhan Referral Hospital, North Shoa Zone, Ethiopia

BACKGROUND

Mobile Phone (MP) handling by healthcare workers (HCWs) in hospital is an open breeding place for the transmission of bacteria and healthcare-associated infection (HCAI). This HCAI is a huge problem to the healthcare system worldwide.

METHODS

A laboratory-based cross-sectional study design was conducted from January 2020 to January 2021 in Debre Berhan Referral Hospital, North Shoa Zone, Ethiopia. A total of 65 swab samples were collected from HCWs mobiles phone. Other important data were collected using a self-administered questionnaire. The collected samples were processed for bacteriological identification and drug susceptibility testing. Data obtained were entered and cleaned into MS Excel spreadsheet and analyzed using SPSS version 21.

RESULTS

From the total of 65 swab sample, 84 bacterial isolates were detected. Of these bacterial isolates, 46.4% were Gram-positive bacteria while 53.6% were Gram-negative bacteria. The overall MDR prevalence was found to be 42.9%. The proportion of MP contamination was higher in males (67.9%) and the age groups of 20-35 years (50%). All the MP carried by HCWs was contaminated with at least one bacterial pathogen. The high rate of MP contamination was observed in the intensive care unit (ICU) (22.6%) followed by surgical ward (17.8) and laboratory rooms (17.8%). The rate of bacterial contamination of MP was higher among HCWs working in ICU, who did not disinfect or clean their phone regularly and who did not wash their hands regularly.

CONCLUSION

Healthcare worker's MP was contaminated with pathogenic bacteria. Since MP could serve as a vehicle and a reservoir for pathogenic bacteria, HCWs should be aware of the public health risks of HCAI, and appropriate intervention mechanisms should be practiced to reduce the burden and cross-transmission.

Effect of Mobile Phone Text Message Reminders on the Completion and Timely Receipt of Routine Childhood Vaccinations: Superiority Randomized Controlled Trial in Northwest Ethiopia

BACKGROUND

Nonattendance at vaccination appointments is a big challenge for health workers as it is difficult to track routine vaccination schedules. In Ethiopia, 3 out of 10 children have incomplete vaccination and the timely receipt of the recommended vaccines is low. Thus, innovative strategies are required to reach the last mile where mobile technology can be effectively utilized to achieve better compliance. Despite this promising technology, little is known about the role of text message-based mobile health interventions in improving the complete and timely receipt of routine childhood vaccinations in Ethiopia.

OBJECTIVE

This trial aimed to determine the effect of mobile phone text message reminders on the completion and timely receipt of routine childhood vaccinations in northwest Ethiopia.

METHODS

A two-arm, parallel, superiority randomized controlled trial was conducted in 9 health facilities in northwest Ethiopia. A sample size of 434 mother-infant pairs was considered in this trial. Randomization was applied in selected health facilities during enrollment with a 1:1 allocation ratio by using sealed and opaque envelopes. Participants assigned to the intervention group received mobile phone text message reminders one day before the scheduled vaccination visits. Owing to the nature of the intervention, blinding of participants was not possible. Primary outcomes of full and timely completion of vaccinations were measured objectively at 12 months. A two-sample test of proportion and log-binomial regression analyses were used to compare the outcomes between the study groups. A modified intention-to-treat analysis approach was applied and a one-tailed test was reported, considering the superiority design of the trial.

RESULTS

A total of 426 participants were included for the analysis. We found that a higher proportion of infants in the intervention group received Penta-3 (204/213, 95.8% vs 185/213, 86.9%, respectively; P<.001), measles (195/213, 91.5% vs 169/213, 79.3%, respectively; P<.001), and full vaccination (176/213, 82.6% vs 151/213, 70.9%, respectively; P=.002; risk ratio 1.17, 95% lower CI 1.07) compared to infants in the usual care group. Similarly, a higher proportion of infants in the intervention group received Penta-3 (181/204, 88.7% vs 128/185, 69.2%, respectively; P<.001), measles (170/195, 87.1% vs 116/169, 68.6%, respectively; P<.001), and all scheduled vaccinations (135/213, 63.3% vs 85/213, 39.9%, respectively; P<.001; risk ratio 1.59, 95% lower CI 1.35) on time compared to infants in the usual care group. Of the automatically sent 852 mobile phone text messages, 764 (89.7%) were delivered successfully to the participants.

CONCLUSIONS

Mobile phone text message reminders significantly improved complete and timely receipt of all recommended vaccines. Besides, they had a significant effect in improving the timely receipt of specific vaccines. Thus, text message reminders can be used to supplement the routine immunization program in resource-limited settings. Considering different contexts, studies on the implementation challenges of mobile health interventions are recommended.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR201901533237287; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5839.

Effects of call reminders, short message services (SMS) reminders, and SMS immunization facts on childhood routine vaccination timing and completion in Ilorin, Nigeria

BACKGROUND

Reminders via mobile devices deployed as short message services (SMS) or calls have been identified to be a useful strategy in improving routine immunization uptake in several countries.

OBJECTIVE

To identify the timeliness of appointments with reminders (calls or SMS), SMS health education and the routine care, and the vaccination completion rates in Ilorin, Nigeria.

METHOD

Mother-infant pairs presenting for the first vaccination appointment were randomized into four (three interventions, one control) groups, each consisting of 140 participants. Intervention groups were reminders via calls (A), SMS reminders (B), immunization fact SMS messages (C) and controls on usual care (D). Reminders were made a day before the appointment while SMS immunization facts were sent at five weeks, nine weeks and eight months. Appropriate timing was defined as the scheduled visit ±3 days.

RESULTS

The immunization completion rates after the nine months' visit were 99.2%, 99.3%, 97% and 90.4% for Groups A, B, C and D respectively. Compared with controls, Group A had the highest odds [AOR 8.78 (6.10, 12.63)] of presenting at an appropriate time, followed by Group B [AOR 2.56 (1.96, 3.35)], then Group C [AOR 2.44 (1.87, 3.18)].

CONCLUSION

Reminders/SMS immunization facts improve vaccination completion rates.