Effectiveness of a smartphone app on improving immunization of children in rural Sichuan Province, China: a cluster randomized controlled trial

Effectiveness of Catch-Up Vaccination Interventions Versus Standard or Usual Care Procedures in Increasing Adherence to Recommended Vaccinations Among Different Age Groups: Systematic Review and Meta-Analysis of Randomized Controlled Trials and Before-After Studies

BACKGROUND

To address the global challenge of vaccine hesitancy, the Strategic Advisory Group of Experts on Immunization strongly promotes vaccination reminder and recall interventions. Coupled with the new opportunities presented by scientific advancements, these measures are crucial for successfully immunizing target population groups.

OBJECTIVE

This systematic review and meta-analysis aims to assess the effectiveness of various interventions in increasing vaccination coverage compared with standard or usual care. The review will cover all vaccinations recommended for different age groups.

METHODS

In February 2022, 2 databases were consulted, retrieving 1850 studies. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 79 manuscripts were included after the assessment phase. These comprised 46 trials/randomized controlled trials (RCTs) and 33 before-after studies. A meta-analysis using a random-effects model was performed with STATA software (version 14.1.2). The selected outcome was the risk ratio (RR) of vaccination coverage improvement effectiveness. Additionally, meta-regression analyses were conducted for the included manuscripts.

RESULTS

The analyses showed an overall efficacy of RR 1.22 (95% CI 1.19-1.26) for RCTs and RR 1.70 (95% CI 1.54-1.87) for before-after studies when considering all interventions cumulatively. Subgroup analyses identified multicomponent interventions (RR 1.58, 95% CI 1.36-1.85) and recall clinical interventions (RR 1.24, 95% CI 1.17-1.32) as the most effective in increasing vaccination coverage for RCTs. By contrast, educational interventions (RR 2.13, 95% CI 1.60-2.83) and multicomponent interventions (RR 1.61, 95% CI 1.43-1.82) achieved the highest increases for before-after studies. Meta-regression analyses indicated that the middle-aged adult population was associated with a higher increase in vaccination coverage (RCT: coefficient 0.54, 95% CI 0.12-0.95; before-after: coefficient 1.27, 95% CI 0.70-1.84).

CONCLUSIONS

Community, family, and health care-based multidimensional interventions, as well as education-based catch-up strategies, effectively improve vaccination coverage. Therefore, their systematic implementation is highly relevant for targeting undervaccinated population groups. This approach aligns with national vaccination schedules and aims to eliminate or eradicate vaccine-preventable diseases.

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Interventions addressing routine childhood immunization and its behavioral and social drivers

Introduction

Despite the advances in vaccination, there are still several challenges in reaching millions of children in low- and middle-income countries (LMICs). In this review, we present an extensive summary of the various strategies used for improving routine immunization in LMICs to aid program implementers in designing vaccination interventions.

Methods

Experimental and quasi-experimental impact evaluations conducted in LMICs evaluating the effectiveness of interventions in improving routine immunization of children aged 0-5 years or the intermediate outcomes were included from 3ie's review of systematic reviews. Some additional impact evaluation studies published in recent years in select LMICs with large number of unvaccinated children were also included. Studies were coded to identify interventions and the barriers in the study context using the intervention framework developed in 3ie's Evidence Gap Map and the WHO's Behavioral and Social Drivers (BeSD) of vaccination framework, respectively. Qualitative analysis of the content was conducted to analyze the intervention strategies and the vaccination barriers that they addressed.

Results and conclusion

One hundred and forty-two impact evaluations were included to summarize the interventions. To address attitudinal and knowledge related barriers to vaccination and to motivate caregivers, sensitization and educational programs, media campaigns, and monetary or non-monetary incentives to caregivers, that may or may not be conditional upon certain health behaviors, have been used across contexts. To improve knowledge of vaccination, its place, time, and schedule, automated voice messages and written or pictorial messages have been used as standalone or multicomponent strategies. Interventions used to improve service quality included training and education of health workers and providing monetary or non-monetary perks to them or sending reminders to them on different aspects of provision of vaccination services. Interventions like effective planning or outreach activities, follow-up of children, tracking of children that have missed vaccinations, pay-for-performance schemes and health system strengthening have also been used to improve service access and quality. Interventions aimed at mobilizing and collaborating with the community to impact social norms, attitudes, and empower communities to make health decisions have also been widely implemented.

Outcomes and Costs of the Transition From a Paper-Based Immunization System to a Digital Immunization System in Vietnam: Mixed Methods Study

BACKGROUND

The electronic National Immunization Information System (NIIS) was introduced nationwide in Vietnam in 2017. Health workers were expected to use the NIIS alongside the legacy paper-based system. Starting in 2018, Hanoi and Son La provinces transitioned to paperless reporting. Interventions to support this transition included data guidelines and training, internet-based data review meetings, and additional supportive supervision visits.

OBJECTIVE

This study aims to assess (1) changes in NIIS data quality and use, (2) changes in immunization program outcomes, and (3) the economic costs of using the NIIS versus the traditional paper system.

METHODS

This mixed methods study took place in Hanoi and Son La provinces. It aimed to analyses pre- and postintervention data from various sources including the NIIS; household and health facility surveys; and interviews to measure NIIS data quality, data use, and immunization program outcomes. Financial data were collected at the national, provincial, district, and health facility levels through record review and interviews. An activity-based costing approach was conducted from a health system perspective.

RESULTS

NIIS data timeliness significantly improved from pre- to postintervention in both provinces. For example, the mean number of days from birth date to NIIS registration before and after intervention dropped from 18.6 (SD 65.5) to 5.7 (SD 31.4) days in Hanoi (P<.001) and from 36.1 (SD 94.2) to 11.7 (40.1) days in Son La (P<.001). Data from Son La showed that the completeness and accuracy improved, while Hanoi exhibited mixed results, possibly influenced by the COVID-19 pandemic. Data use improved; at postintervention, 100% (667/667) of facilities in both provinces used NIIS data for activities beyond monthly reporting compared with 34.8% (202/580) in Hanoi and 29.4% (55/187) in Son La at preintervention. Across nearly all antigens, the percentage of children who received the vaccine on time was higher in the postintervention cohort compared with the preintervention cohort. Up-front costs associated with developing and deploying the NIIS were estimated at US $0.48 per child in the study provinces. The commune health center level showed cost savings from changing from the paper system to the NIIS, mainly driven by human resource time savings. At the administrative level, incremental costs resulted from changing from the paper system to the NIIS, as some costs increased, such as labor costs for supportive supervision and additional capital costs for equipment associated with the NIIS.

CONCLUSIONS

The Hanoi and Son La provinces successfully transitioned to paperless reporting while maintaining or improving NIIS data quality and data use. However, improvements in data quality were not associated with improvements in the immunization program outcomes in both provinces. The COVID-19 pandemic likely had a negative influence on immunization program outcomes, particularly in Hanoi. These improvements entail up-front financial costs.

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.

Leveraging Community Health Workers and a Responsive Digital Health System to Improve Vaccination Coverage and Timeliness in Resource-Limited Settings: Protocol for a Cluster Randomized Type 1 Effectiveness-Implementation Hybrid Study

BACKGROUND

Tanzania is 1 of 20 countries where the majority of unvaccinated and undervaccinated children reside. Prior research identified substantial rural-urban disparities in the coverage and timeliness of childhood vaccinations in Tanzania, with children in rural settings being more likely to receive delayed or no vaccinations. Further research is necessary to identify effective and scalable interventions that can bridge rural-urban gaps in childhood vaccination while accounting for multifaceted barriers to vaccination.

OBJECTIVE

This protocol describes a type 1 effectiveness-implementation hybrid study to evaluate Chanjo Kwa Wakati (timely vaccination in Kiswahili), a community-based digital health intervention to improve vaccination timeliness. The intervention combines human resources (community health workers), low-cost digital strategies (electronic communication, digital case management, and task automation), a vaccination knowledge intervention, and insights from behavioral economics (reminders and incentives) to promote timely childhood vaccinations.

METHODS

The study will be conducted in 2 predominantly rural regions in Tanzania with large numbers of unvaccinated or undervaccinated children: Shinyanga and Mwanza. Forty rural health facilities and their catchment areas (clusters) will be randomized to an early or delayed onset study arm. From each cluster, 3 cohorts of mother-child dyads (1 retrospective cohort and 2 prospective cohorts) will be enrolled in the study. The timeliness and coverage of all vaccinations recommended during the first year of life will be observed for 1200 children (n=600, 50% intervention group children and n=600, 50% nonintervention group children). The primary effectiveness outcome will be the timeliness of the third dose of the pentavalent vaccine (Penta3). Quantitative surveys, vaccination records, study logs, fidelity checklists, and qualitative interviews with mothers and key informants will inform the 5 constructs of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. The results will be used to develop an implementation blueprint to guide future adaptations and scale-up of Chanjo Kwa Wakati.

RESULTS

The study was funded in August 2022. Data collection is expected to last from February 2024 to July 2027.

CONCLUSIONS

This study will address the lack of rigorous evidence on the effectiveness of community-based digital health interventions for promoting vaccination coverage and timeliness among children from sub-Saharan Africa and identify potential implementation strategies to facilitate the deployment of vaccination promotion interventions in low- and middle-income countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06024317; https://www.clinicaltrials.gov/study/NCT06024317.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52523.

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.

Digitalized to reach and track: a retrospective comparison between traditional and conditional estimate of vaccination coverage and dropout rates using e-Tracker data below one-year children in Bangladesh during-COVID and pre-COVID period

Background

With an impressive track record in expanding childhood immunization and an inclination to adopt digitalization in healthcare service delivery, Expanded Program on Immunization (EPI) Bangladesh piloted the e-Tracker intervention in Moulvibazar district and Dhaka South City Corporation (Zone-5) from 2019 till the end of 2021.

Methods

We retrieved and analyzed the digitalized e-Tracker data of 114,194 infants born between January 1, 2019 and December 31, 2020, with help from Health Management Information System (HMIS) and UNICEF Bangladesh. Childhood vaccination coverage and dropout rates were determined using a 'Traditional approach' traditionally used by WHO and a 'Conditional technique' with a modified denominator. Using a multiple logistic regression model, we examined the effects of COVID-19, birth-cohorts, mother education, and location on vaccination rates (coverages & dropouts) to aid with informed decision-making by the policymakers.

Findings

The conditional estimation method yielded a lower full vaccination coverage during pre-COVID period than the national and global reported coverage derived using the 'traditional method' (73.4% vs. 89.0% & 81.0%). As expected, while the coverage has decreased, the dropout rate increased "during-COVID" compared to the "pre-COVID" period. However, dropouts were estimated lower in the 'conditional method.' The average age (in months) for getting BCG was higher in Moulvibazar (∼2.5 months) than that in Dhaka (∼1.4 months). All birth-cohorts from 'the during-COVID period had about 30% lower odds of getting fully vaccinated than those from the 'pre-COVID' period.

Interpretations

Age-cohort-specific analysis showed a decline in coverage rates before and during COVID, but e-Tracker didn't have enough data to draw additional conclusions. The server only stored the child's gender, the caregiver's monthly salary, and the mother's education. It didn't track any other factors related to dropout rates. The e-Tracker is an excellent tool for measuring real coverage and should be scaled nationwide.

Funding

UNICEF, Bangladesh.

Design, Development, and Deployment of an Electronic Immunization Registry: Experiences From Vietnam, Tanzania, and Zambia

INTRODUCTION

There is growing interest among low- and middle-income countries to introduce electronic immunization registries (EIRs) that capture individual-level vaccine data. We compare the design, development, and deployment of EIRs in Vietnam, Tanzania, and Zambia. Through desk review and the authors' firsthand implementation experiences, we describe experiences related to timeline, partnerships, financial costs, and technology and infrastructure.

IMPLEMENTATION EXPERIENCE

The country cases highlight the multi-year timeline required to implement an EIR at scale and the benefit of multiple iterative cycles to pilot and redesign the system before achieving scale. Of the 3 countries, only Vietnam has achieved nationwide scale of the EIR, which took 7 years. In all 3 countries, national government leadership as part of an interdisciplinary team (with experience in leadership, technology, and immunization) was important to ensure country ownership and sustainability. Where international software developers were contracted, partnering with a local software company helped improve responsiveness and sustainability. Across all 3 countries, governments contributed significant in-kind time in addition to investments from donors. Cost savings were observed in Tanzania and Zambia, largely driven by health worker time savings from using the EIR. All 3 case countries underscore the need to understand the local technology and infrastructure context and design the EIR to fit the context. In Vietnam, an initial landscape assessment was conducted to assess technology and infrastructure, whereas in Tanzania and Zambia, user advisory groups provided insights. Existing infrastructure informed EIR design decisions, such as choosing a system with offline functionality in Tanzania and Zambia. All 3 countries have a local partner to provide ongoing technical support.

CONCLUSION

Comparing implementation factors across these cases highlights practical experience and recommendations that complement existing EIR guidance documents. The findings and recommendations from this study can inform other countries considering or in the process of implementing an EIR.

Structural Determinants of Child Health in Rural China: The Challenge of Creating Health Equity

Over the past two decades, the literature has shown a clear gradient between child health and wealth. The same health-wealth gradient is also observed among children in China, with a large gap in health between rural and urban children. However, there are still unanswered questions about the main causes of China's rural-urban child health inequality. This paper aims to review the major factors that have led to the relatively poor levels of health among China's rural children. In addition to the direct income effect on children's health, children in rural areas face disadvantages compared with their urban counterparts from the beginning of life: Prenatal care and infant health outcomes are worse in rural areas; rural caregivers have poor health outcomes and lack knowledge and support to provide adequate nurturing care to young children; there are large disparities in access to quality health care between rural and urban areas; and rural families are more likely to lack access to clean water and sanitation. In order to inform policies that improve health outcomes for the poor, there is a critical need for research that identifies the causal drivers of health outcomes among children. Strengthening the pediatric training and workforce in rural areas is essential to delivering quality health care for rural children. Other potential interventions include addressing the health needs of mothers and grandparent caregivers, improving parenting knowledge and nurturing care, improving access to clean water and sanitation for remote families, and most importantly, targeting poverty itself.

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.

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

Community health worker-based mobile health (mHealth) approaches for improving management and caregiver knowledge of common childhood infections: A systematic review

Background

Children in lower middle-income countries (LMICs) are more at risk of dying, than those in High Income Countries (HICs), due to highly prevalent deadly yet preventable childhood infections. Alongside concerns about the incidence of these infections, there has been a renewed interest in involving community health workers (CHWs) in various public health programs. However, as CHWs are increasingly asked to take on different tasks there is a risk that their workload may become unmanageable. One solution to help reduce this burden is the use of mobile health (mHealth) technology in the community through behaviour change. Considering there are various CHWs based mHealth approaches on illness management and education, therefore, we aimed to appraise the available literature on effectiveness of these mHealth approaches for caregivers to improve knowledge and management about common under-five childhood infections with respect to behaviour change.

Methods

We searched six databases between October to December 2019 using subject heading (Mesh) and free text terms in title or abstract in US English. We included multiple study types of children under-five or their caregivers who have been counselled, educated, or provided any health care service by CHWs for any common paediatric infectious diseases using mHealth. We excluded articles published prior to 1990 and those including mHealth technology not coming under the WHO definition. A data extraction sheet was developed and titles, abstracts, and selected full text were reviewed by two reviewers. Quality assessment was done using JBI tools.

Results

We included 23 articles involving around 300 000 individuals with eight types of study designs. 20 studies were conducted in Africa, two in Asia, and one in Latin America mainly on pneumonia or respiratory tract infections followed by malaria and diarrhoea in children. The most common types of Health approaches were mobile applications for decision support, text message reminders and use of electronic health record systems. None of the studies employed the use of any behaviour change model or any theoretical framework for selection of models in their studies.

Conclusions

Coupling mhealth with CHWs has the potential to benefit communities in improving management of illnesses in children under-five. High quality evidence on impact of such interventions on behaviour is relatively sparse and further studies should be conducted using theoretically informed behaviour change frameworks/models.

Registration

PROPSERO Registration number: CRD42018117679

Use of Apps to Promote Childhood Vaccination: Systematic Review

BACKGROUND

Vaccination is a critical step in reducing child mortality; however, vaccination rates have declined in many countries in recent years. This decrease has been associated with an increase in the outbreak of vaccine-preventable diseases. The potential for leveraging mobile platforms to promote vaccination coverage has been investigated in the development of numerous mobile apps. Although many are available for public use, there is little robust evaluation of these apps.

OBJECTIVE

This systematic review aimed to assess the effectiveness of apps supporting childhood vaccinations in improving vaccination uptake, knowledge, and decision making as well as the usability and user perceptions of these apps.

METHODS

PubMed, Excerpta Medica Database (EMBASE), Web of Science, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Education Resources Information Center (ERIC) databases were systematically searched for studies published between 2008 and 2019 that evaluated childhood vaccination apps. Two authors screened and selected studies according to the inclusion and exclusion criteria. Data were extracted and analyzed, and the studies were assessed for risk of bias.

RESULTS

A total of 28 studies evaluating 25 apps met the inclusion criteria and were included in this analysis. Overall, 9 studies assessed vaccination uptake, of which 4 reported significant benefits (P<.001 or P=.03) of the implementation of the app. Similarly, 4 studies indicated a significant (P≤.054) impact on knowledge and on vaccination decision making. Patient perceptions, usability, and acceptability were generally positive. The quality of the included studies was found to be moderate to poor, with many aspects of the methodology being unclear.

CONCLUSIONS

There is little evidence to support the use of childhood vaccination apps to improve vaccination uptake, knowledge, or decision making. Further research is required to understand the dichotomous effects of vaccination-related information provision and the evaluation of these apps in larger, more robust studies. The methodology of studies must be reported more comprehensively to accurately assess the effectiveness of childhood vaccination apps and the risk of bias of studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16929.

Impact on child vaccination completion rates of short message services (SMS) reminders in developing countries

Introduction

The Expanded Programme on Immunization has, since its inception, struggled to achieve high completion rates for child immunizations. The introduction of 2YL (second year of life) immunizations presents the programme with fresh challenges to assuring high completion rates.

Methods

Using the same procedures as those employed in the 2017 article on SMS reminders, of which this is an update, I searched the NLM database for all recent articles from developing countries on SMS reminders for reduction of vaccination dropout rates. I summarized these and earlier articles in tabular form.

Results

The freshly reviewed articles are confirmatory of earlier studies which show an improvement in vaccination completion rates when SMS reminders are sent to mothers and other caregivers.

Conclusion

All of the studies reviewed were based on pilot projects. It is time, and past time, to go to scale with SMS reminders, perhaps stand alone, or as part of a larger system of electronic immunization registers. There may be potential for use of WhatsApp in dropout reduction, thus far documented only in other public health applications.

Use of Apps to Promote Childhood Vaccination: Protocol for a Systematic Review

Background

The decline in the uptake of routine childhood vaccinations has resulted in outbreaks of vaccine-preventable diseases. Vaccination apps can be used as a tool to promote immunization through the provision of reminders, dissemination of information, peer support, and feedback.

Objective

The aim of this review is to systematically review the evidence on the use of apps to support childhood vaccination uptake, information storage, and record sharing.

Methods

We will identify relevant papers by searching the following electronic databases: PubMed, Embase by Ovid, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Education Resources Information Center (ERIC). We will review the reference lists of those studies that we include to identify relevant additional papers not initially identified using our search strategy. In addition to the use of electronic databases, we will search for grey literature on the topic. The search strategy will include only terms relating to or describing the intervention, which is app use. As almost all titles and abstracts are in English, 100% of these will be reviewed, but retrieval will be confined to papers written in the English language. We will record the search outcome on a specifically designed record sheet. Two reviewers will select observational and intervention studies, appraise the quality of the studies, and extract the relevant data. All studies will involve the use of apps relating to child vaccinations. The primary outcome is the uptake of vaccinations. Secondary outcomes are as follows: (1) use of app for sharing of information and providing vaccination reminders and (2) use of app for storage of vaccination information; knowledge and decision making by parents regarding vaccination (ie, risks and benefits of vaccination); costs and cost-effectiveness of vaccination apps; use of the app and measures of usability (eg, usefulness, acceptability, and experiences of different users: parents and health care professionals); use of technical standards for development of the app; and adverse events (eg, data leaks and misinformation). We will exclude studies that do not study an app. We anticipate a limited scope for meta-analysis and will provide a narrative overview of findings and tabular summaries of extracted data.

Results

This project was funded by the Sir David Cooksey Fellowship in Healthcare Translation at the University of Oxford, Oxford, United Kingdom. We will submit the full systematic review for publication in the Journal of Medical Internet Research.

Conclusions

This review will follow, where possible, the Cochrane Collaboration and the Centre for Review and Dissemination methodologies for conducting systematic reviews. We will report our findings based on guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The review results will be used to inform the development of a vaccination app.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16929

Evaluation of digital vaccine card in nursing practice in vaccination room

OBJECTIVE

develop and evaluate a vaccine application for mobile devices, with update integrated with the National Immunization Program Information System, for care in vaccination rooms.

METHOD

methodological research based on the Pressman System Development Life Cycle theory developed in three stages: integrative literature review, computational development, and application evaluation. The product was evaluated as to satisfaction, using a validated questionnaire, and as to usability by the System Usability Scale.

RESULTS

the application functionalities were based on the survey of technological Innovations on immunization, published in the scientific literature. It displays user vaccines directly from the National Immunization Program Information System, notifies about upcoming vaccines, and enables the inclusion of vaccine cards of dependents. The evaluation resulted in users' mean score of 90.5 ± 11.1 and health professionals' mean score of 84.2 ± 19.4.

CONCLUSION

the application is a technological tool with potential to improve the work process in vaccination rooms and to reach the goals of vaccine coverage. It synchronizes data with the National Immunization Program Information System, thus enabling the maintenance of people's vaccination history.

A systematic review of mobile health interventions in China: Identifying gaps in care

INTRODUCTION

Mobile health has a promising future in the healthcare system in most developed countries. China's rapidly developing mobile technology infrastructure offers an unprecedented opportunity for wide adoption of mobile health interventions in the delivery of effective and timely healthcare services. However, there is little data on the current extent of the mobile health landscape in China. The aim of this study was to systematically review the existing mobile health initiatives in China, characterise the technology used, disease categories targeted, location of the end user (urban versus rural), and examine the potential effects of mobile health on health system strengthening in China. Furthermore, we identified gaps in development and evaluation of the effectiveness of mobile health interventions.

METHODS

A systematic review of the literature published from 18 December 2015 - 3 April 2019 was conducted and yielded 2863 articles from English and Chinese retrieval database and trial registries, including PubMed, EMBASE, China National Knowledge of Infrastructure and World Health Organization International Clinical Trials Registry Platform. Studies were included if they used mobile health to support patient healthcare outcomes.

RESULTS

A total of 1129 full-text articles were assessed and 338 were included in this study. The review found that most studies targeted client education and behaviour change via applications (apps) (65.4%), including WeChat, and text messaging (short text messages) (19.8%) to improve patient medical treatment outcomes such as compliance and appointment reminders. The most common disease-specific mobile health interventions focused primarily on chronic disease management and behaviour change in cardiology (13.3%), endocrinology/diabetes (12.1%), behavioural health (11.8%), oncology (11.2%) and neurology (6.8%). The mobile health interventions related to nutrition (0.6%) and chronic respiratory diseases (1.6%) are underrepresented in mobile health in comparison to the burden of disease in China. The majority (90.0%) of the mobile health interventions were conducted exclusively in urban areas, with few opportunities reaching rural populations.

CONCLUSIONS

Overall, mobile health has a promising future in China, with recent rapid growth in initiatives. The majority are focused on education and behaviour change in the realm of chronic diseases and target patients in urban areas. The imbalance in mobile health between the urban and rural areas, as well as between population disease spectrum and health service delivery, pose substantial dilemmas. However, mobile health may be redirected to correct this imbalance, possibly improving access to healthcare services, and filling the gaps in order to improve health equity for the underserved populations in China.

Usefulness of a systematic approach at listing for vaccine prevention in solid organ transplant candidates

Solid organ transplant (SOT) candidates may not be immune against potentially vaccine-preventable diseases because of insufficient immunizations and/or limited vaccine responses. We evaluated the impact on vaccine immunity at transplant of a systematic vaccinology workup at listing that included (1) pneumococcal with and without influenza immunization, (2) serology-based vaccine recommendations against measles, varicella, hepatitis B virus, hepatitis A virus, and tetanus, and (3) the documentation of vaccines and serology tests in a national electronic immunization registry (www.myvaccines.ch). Among 219 SOT candidates assessed between January 2014 and November 2015, 54 patients were transplanted during the study. Between listing and transplant, catch-up immunizations increased the patients' immunity from 70% to 87% (hepatitis A virus, P = .008), from 22% to 41% (hepatitis B virus, P = .008), from 77% to 91% (tetanus, P = .03), and from 78% to 98% (Streptococcus pneumoniae, P = .002). Their immunity at transplant was significantly higher against S. pneumoniae (P = .006) and slightly higher against hepatitis A virus (P = .07), but not against hepatitis B virus, than that of 65 SOT recipients transplanted in 2013. This demonstrates the value of a systematic multimodal serology-based approach of immunizations of SOT candidates at listing and the need for optimized strategies to increase their hepatitis B virus vaccine responses.

The use of technology to promote vaccination: A social ecological model based framework

Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.

Delivery of public health services by community health workers (CHWs) in primary health care settings in China: a systematic review (1996-2016)

BACKGROUND

Community Health Workers (CHWs) have been widely used in response to the shortage of skilled health workers especially in resource limited areas. China has a long history of involving CHWs in public health intervention project. CHWs in China called village doctors who have both treatment and public health responsibilities. This systematic review aimed to identify the types of public health services provided by CHWs and summarized potential barriers and facilitating factors in the delivery of these services.

METHODS

We searched studies published in Chinese or English, on Medline, PubMed, Cochrane, Google Scholar, and CNKI for public health services delivered by CHWs in China, during 1996-2016. The role of CHWs, training for CHWs, challenges, and facilitating factors were extracted from reviewed studies.

RESULTS

Guided by National Basic Public Health Service Standards, services provided by CHW covered five major areas of noncommunicable diseases (NCDs) including diabetes and/or hypertension, cancer, mental health, cardiovascular diseases, and common NCD risk factors, as well as general services including reproductive health, tuberculosis, child health, vaccination, and other services. Not many studies investigated the barriers and facilitating factors of their programs, and none reported cost-effectiveness of the intervention. Barriers challenging the sustainability of the CHWs led projects were transportation, nature of official support, quantity and quality of CHWs, training of CHWs, incentives for CHWs, and maintaining a good rapport between CHWs and target population. Facilitating factors included positive official support, integration with the existing health system, financial support, considering CHW's perspectives, and technology support.

CONCLUSION

CHWs appear to frequently engage in implementing diverse public health intervention programs in China. Facilitators and barriers identified are comparable to those identified in high income countries. Future CHWs-led programs should consider incorporating the common barriers and facilitators identified in the current study to maximize the benefits of these programs.

Effect of Mobile Phone Text Message Reminders on Routine Immunization Uptake in Pakistan: Randomized Controlled Trial

Background

Improved routine immunization (RI) coverage is recommended as the priority public health strategy to decrease vaccine-preventable diseases and eradicate polio in Pakistan and worldwide.

Objective

The objective of this study was to ascertain whether customized, automated, one-way text messaging (short message service, SMS) reminders delivered to caregivers via mobile phones when a child is due for an RI visit can improve vaccination uptake and timelines in Pakistan.

Methods

This was a randomized controlled trial, conducted in an urban squatter settlement area of Karachi, Pakistan. Infants less than 2 weeks of age with at least one family member who had a valid mobile phone connection and was comfortable receiving and reading SMS text messages were included. Participants were randomized to the intervention (standard care + one-way SMS reminder) or control (standard care) groups. The primary outcome was to compare the proportion of children immunized up to date at 18 weeks of age. Vaccine given at 6, 10, and 14 weeks schedule includes DPT-Hep-B-Hib vaccine (ie, diphtheria, pertussis, and tetanus; hepatitis B; and Haemophilus influenza type b) and oral poliovirus vaccine (OPV). Data were analyzed using chi-square tests of independence and tested for both per protocol (PP) and intention-to-treat (ITT) analyses.

Results

Out of those approached, 84.3% (300/356) of the participants were eligible for enrollment and 94.1% (318/338) of the participants had a working mobile phone. Only children in the PP analyses, who received an SMS reminder for vaccine uptake at 6 weeks visit, showed a statistically significant difference (96.0%, 86/90 vs 86.4%, 102/118; P=.03).The immunization coverage was consistently higher in the intervention group according to ITT analyses at the 6 weeks scheduled visit (76.0% vs 71.3%, P=.36). The 10 weeks scheduled visit (58.7% vs 52.7%, P=.30) and the 14 weeks scheduled visit (31.3% vs 26.0%, P=.31), however, were not statistically significant.

Conclusions

Automated simple one-way SMS reminders in local languages might be feasible for improving routine vaccination coverage. Whether one-way SMS reminders alone can have a strong impact on parental attitudes and behavior for improvement of RI coverage and timeliness needs to be further evaluated by better-powered studies and by comparing different types and content of text messages in low-and middle-income countries (LMICs).

Trial Registration

ClinicalTrials.gov NCT01859546; https://clinicaltrials.gov/ct2/show/NCT01859546 (Archived by WebCite at http://www.webcitation.org/6xFr57AOc)

Patient reminder and recall interventions to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.

OBJECTIVES

To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.

SELECTION CRITERIA

We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.

MAIN RESULTS

The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).

AUTHORS' CONCLUSIONS

Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Thailand's national universal developmental screening programme for young children: action research for improved follow-up

Introduction

In low-income and middle-income countries, it is estimated that one in every three preschool-age children are failing to meet cognitive or socioemotional developmental milestones. Thailand has implemented a universal national developmental screening programme (DSPM) for young children to enable detection of developmental disorders and early intervention that can improve child health outcomes. DSPM implementation is being hampered by low attendance at follow-up appointments when children fail the initial screening.

Methods

Action research, using qualitative methods was conducted with 19 caregivers, 5 health workers and 1 chief at two Health Promotion Hospitals to explore the factors affecting attendance at follow-up appointments. Transcripts and notes were analysed using descriptive content analysis. Findings were then discussed with 48 health workers, managers, researchers and policymakers.

Results

The high workload of health workers during busy vaccination clinics, and inadequate materials prevented clear communication with caregivers about the screening, how to stimulate child development and the screening result. Caregivers, particularly grandparents, had a lack of understanding about how to stimulate child development, and did not fully understand failed screening results. Caregivers felt blamed for not stimulating their child’s development, and were either worried that their child was severely disabled, or they did not believe the screening result and therefore questioned its usefulness. This led to a lack of attendance at follow-up appointments.

Conclusion

Task-sharing, mobile health (mhealth), community outreach and targeted interventions for grandparent caregivers might increase awareness about child development and screening, and allow health workers more time to communicate effectively. Sharing best practices, communication training and mentoring of DSPM workers coupled with mhealth job aids could also improve caregiver attendance at follow-up. Engagement of caregivers in understanding the barriers to attendance at follow-up and engagement of stakeholders in the design and implementation of interventions is important to ensure their effectiveness.

Acceptability of and willingness to pay for using a smartphone-based vaccination application in a Vietnamese cohort

BACKGROUND

The increasing accessibility of smartphone in Vietnam shows potential in using smartphone applications for vaccination management to improve compliance. However, the acceptability and financial feasibility of using this application in Vietnam have not yet been understood. This study measured the general perception of and willingness to pay (WTP) for using smartphone-based vaccination management applications and their associated factors in Vietnam.

SUBJECTS AND METHODS

A cross-sectional study was conducted between March and April 2016 in an urban vaccination clinic at the Hanoi Medical University in Vietnam. Convenience sampling was used to recruit 429 adult participants who had received vaccinations or whose children were vaccinated. Sociodemographic characteristics and the acceptability of and WTP for using smartphone-based vaccination management applications were evaluated.

RESULTS

Among participants who used smartphone applications, 5% were aware of existing vaccination management applications, of whom 57.9% had previously used the applications. About 69.6% of participants believed that the applications were necessary, 93.7% of them were also willing to use the applications, and 79.1% were willing to pay 92.7 thousand Vietnamese dong (VND) for the applications on average. Participants who were older, unemployed, earned more household income, and having knowledge about functions and benefits of vaccination were less likely to use the vaccination applications. Participants who brought their children to get vaccinated at younger age and with higher level of education were willing to pay more for vaccination applications.

CONCLUSION

High levels of acceptability of, willingness to use, and WTP for smartphone-based vaccination management applications among Vietnamese participants are reported. Increased education and awareness about the benefits of vaccination and vaccination management applications through community health workers might increase the feasibility of implementing such applications and perception toward their usage among young adult smartphone users. In addition, building a stronger relationship with health care providers at hospitals might improve the application's visibility and adoption.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Bill & Melinda Gates Foundation.