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

Rotavirus vaccine dose-two dropout and its associated factors among children who received rotavirus vaccine dose-one in Sub-Saharan African countries: A multilevel analysis of the recent demographic and health survey

Rotavirus is the most common cause of diarrhea in children worldwide. In 2016, rotavirus infection resulted in 258 173 300 episodes of diarrhea and 128 500 child deaths in the globe. The study aimed to assess the magnitude of Rotavirus vaccine dose-two dropout and associated factors among children who received rotavirus vaccine dose-one in sub-Saharan African countries. The appended and most recent demographic and health survey (DHS) dataset of 17 sub-Saharan African countries was used for data analysis. A total of 73,396 weighted samples were used. Factors associated with the outcome variable were considered significant if their p-values were ≤ .05 in the multilevel mixed-effect logistic regression model. The overall Rotavirus vaccine dose-two dropouts was 10.77% (95% CI 10.55%, 11.00%), which ranged from 2.77% in Rwanda to 37.67% in Uganda. Being younger, late birth order, having difficulty accessing health facilities, having no media exposure, having no work, having home delivery, having no antenatal follow-up, and having no postnatal checkup were factors significantly associated with the outcome variable. The overall Rotavirus vaccine dose-two dropout was higher in sub-Saharan African countries which implies that vaccine dropout is still a great issue in the region. Special attention should be given to those mothers who are young, who have no work, who give birth at home, who experienced difficulty in accessing health facilities, and late birth orders. Furthermore, targeted interventions should be considered for improving access and utilization of media, antenatal care, and postnatal care services.

Individual and community-level determinants of pentavalent vaccination dropouts among under-five children in the sub-Saharan African countries: A multilevel analysis of the recent demographic and health survey

Background

Globally, each year, about 3 million deaths among children are prevented by pentavalent vaccinations. However, in developing countries, particularly in Sub-Saharan Africa, pentavalent vaccination dropout rates are not well reported. Therefore, this study aimed to assess pentavalent vaccination dropout rates and their determinants among under-five children in Sub-Saharan Africa.

Methods

Data from the recent Demographic and Health Surveys in 33 Sub-Saharan African countries were used for analysis. The study used a total of 358,529 under-five children. The determinants of pentavalent vaccination dropout were determined using a multilevel mixed-effects logistic regression model. Significant factors associated with pentavalent vaccination dropout were declared significant at p-values < 0.05. A model with the lowest deviance and highest logliklihood ratio was selected as the best-fit model.

Results

In Sub-Saharan Africa, one in five under-five children had pentavalent vaccination dropout rates. Factors such as Age (AOR = 1.61, 95 % CI: 1.51, 1.72), educational level (AOR = 1.30, 95 % CI: 1.22, 1.40), place of delivery (AOR = 1.65, 95 % CI: 1.57, 1.73), ANC visits (AOR = 1.34, 95 % CI: 1.23, 1.45), postnatal check-up (AOR = 1.19, 95 % CI: 1.14, 1.25), wealth status (AOR = 1.09, 95 % CI: 1.04, 1.15), distance to health facility (AOR = 1.08, 95 % CI: 1.03, 1.13), media exposure (AOR = 1.12, 95 % 1.15), and geographical region (AOR = 1.60, 95 % CI: 1.49, 1.72) had higher odds of pentavalent vaccination dropouts.

Conclusions

Pentavalent vaccination dropout rates in sub-Saharan Africa among under-five children were high. Both individual and community-level variables were determinants of pentavalent vaccination dropout rates. Government and ministry of health in Sub-Saharan Africa should give attention to those mothers of under-five children who reported distance as a big problem in accessing health facilities and to women who do not utilise antenatal and postnatal check-ups while designing policies and strategies in sub-Saharan Africa.

Reminder design and childhood vaccination coverage

A major policy concern across public vaccination programs is non-compliance. Exploiting Danish population data and three national reforms in regression discontinuity designs, we document the effects of reminders for childhood vaccination coverage. Retrospective reminders are primarily effective for families with small children and when sent out close to the recommended vaccination age. Digital and postal reminders are equally effective. Prospective reminders increase timely vaccinations in later childhood and help reaching high coverage for new vaccines in increasingly complex vaccination programs. While reminders prompt additional preventive care for focal children, we find no spillovers to other health behaviors or relatives.

Integrated Immunization Information System in Indonesia: Prototype Design Using Quantitative and Qualitative Data

BACKGROUND

As the volume of immunization records increases, problems with fragmented records arise, especially since the majority of records in developing countries, including Indonesia, remain paper based. Implementing an immunization information system (IIS) offers a solution to this problem.

OBJECTIVE

In this study, we designed an integrated IIS prototype in Indonesia using the design science research (DSR) methodology.

METHODS

The stages of the DSR methodology followed in this study included identifying problems and motivating and defining objectives for a solution, design and development, demonstration, evaluation, communication, and drawing conclusions and suggestions. Specifically, this study began with problem formulation and a literature review. We then applied quantitative (questionnaire with 305 members of the public) and qualitative (interviews with 15 health workers including nurses, midwives, and doctors) data collection approaches.

RESULTS

The resulting high-fidelity prototype follows the 8 golden rules. There are 2 IIS designs, one for the public as immunization recipients and another for health workers. The functionalities include immunization history, schedule, recommendations, verification, certificates, reminders and recalls, coverage, monitoring, news, and reports of adverse events. Evaluation of the prototype was carried out through interviews and a questionnaire designed according to the System Usability Scale (SUS) and Post-Study System Usability Questionnaire (PSSUQ). The SUS value was 72.5 or "Good (Acceptable)," while the system usefulness, information quality, interface quality, and overall value on the PSSUQ were 2.65, 2.94, 2.48, and 2.71, respectively, which indicate it has an effective design.

CONCLUSIONS

This provides a guide for health facilities, health regulators, and health application developers on how to implement an integrated IIS in Indonesia.

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.

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.

Childhood Immunization and Competing Mortality Risks in Kenya: A Longitudinal Analysis for Multiparous Mothers

OBJECTIVE

To assess the relationship between childhood immunization and mortality risks for nonvaccine-preventable diseases (competing mortality risks, or CMR) in Kenya.

STUDY DESIGN

A combination of the Global Burden of Disease and Demographic Health Survey data was used to measure basic vaccination status, CMR, and control variables for each child in the Demographic Health Survey data. A longitudinal analysis was performed. This uses within-mother variation between children to compare the vaccine decisions for different children, who are exposed to different mortality risks. The analysis also distinguishes between overall and disease-specific risks.

RESULTS

The study included 15 881 children born between 2009 and 2013, who were at least 12 months old at the time of interview and not part of a twin birth. Mean basic vaccination rates ranged from 27.1% to 90.2% and mean CMR from 13.00 to 738.32 deaths per 100 000 across different counties. A one-unit increase in mortality risk from diarrhea, the most prevalent disease among children in Kenya, is associated with a 1.1 percentage point decline in basic vaccination status. In contrast, mortality risks for other diseases and HIV increase the likelihood of vaccination. The effect of CMR was found to be stronger for children with higher birth orders.

CONCLUSIONS

A significant negative correlation between severe CMR and vaccination status was found, which has important implications for immunization policies, particularly in Kenya. Interventions aimed at reducing the most severe CMR, such as diarrhea, and targeted toward multiparous mothers may improve childhood immunization coverage.

Vaccination dropout and wealth related inequality among children aged 12-35 months in remote and underserved settings of Ethiopia: a cross-sectional evaluation survey

Background

Vaccination is one of the most cost-effective public health interventions that prevents millions of deaths. Although immunization coverage is increasing globally, many children in low- and middle-income countries drop out of the vaccination continuum. This study aimed at determining vaccination dropout rates and predictors in children aged 12-35 months in remote and underserved areas of Ethiopia.

Methods

This study was part of a cross-sectional evaluation survey that was conducted in 2022 in Ethiopia. The study settings include pastoralist, developing & newly established regions, conflict affected areas, urban slums, internally displaced populations and refugees. A sample of 3,646 children aged 12-35 months were selected using a cluster sampling approach. Vaccination dropout was estimated as the proportion of children who did not get the subsequent vaccine among those who received the first vaccine. A generalized estimating equation was used to assess determinants of the dropout rate and findings were presented using an adjusted odds ratio with 95% confidence interval. Concentration curve and index were used to estimate wealth related inequality of vaccination dropout.

Results

A total of 3,646 caregivers of children participated in the study with a response rate of 97.7%. The BCG to Penta-3 (52.5%), BCG to MCV-2 (57.4%), and Penta-1 to Penta-3 (43.9%) dropouts were all high. The highest Penta-1 to Penta-3 dropout rate was found in developing regions (60.1%) and the lowest was in urban slums (11.2%). Caregivers who were working outside their homes [AOR (95% CI) = 3.67 (1.24-10.86)], who had no postnatal care follow-up visits [AOR (95%CI) = 1.66 (1.15-2.39)], who did not receive a service from a skilled birth attendant [AOR (95%CI) = 1.64 (1.21-2.27)], who were older than 45 years [AOR (95% CI) = 12.49 (3.87-40.33)], and who were less gender empowered [AOR (95%CI) = 1.63 (1.24-2.15)] had increased odds of Penta-1 to Penta-3 dropout. The odds of dropout for children from poor caregivers was nearly two times higher compared to their wealthy counterparts [AOR (95%CI) = 1.87 (1.38-2.52)].

Conclusion

Vaccination dropout estimates were high among children residing in remote and underserved settings. Poor wealth quintile, advanced maternal age, low women empowerment, and limited utilization of maternity care services contributed to vaccination dropout.

Malaria vaccine coverage estimation using age-eligible populations and service user denominators in Kenya

BACKGROUND

The World Health Organization approved the RTS,S/AS01 malaria vaccine for wider rollout, and Kenya participated in a phased pilot implementation from 2019 to understand its impact under routine conditions. Vaccine delivery requires coverage measures at national and sub-national levels to evaluate progress over time. This study aimed to estimate the coverage of the RTS,S/AS01 vaccine during the first 36 months of the Kenyan pilot implementation.

METHODS

Monthly dose-specific immunization data for 23 sub-counties were obtained from routine health information systems at the facility level for 2019-2022. Coverage of each RTS,S/AS01 dose was determined using reported doses as a numerator and service-based (Penta 1 and Measles) or population (projected infant populations from WorldPop) as denominators. Descriptive statistics of vaccine delivery, dropout rates and coverage estimates were computed across the 36-month implementation period.

RESULTS

Over 36 months, 818,648 RTSS/AS01 doses were administered. Facilities managed by the Ministry of Health and faith-based organizations accounted for over 88% of all vaccines delivered. Overall, service-based malaria vaccine coverage was 96%, 87%, 78%, and 39% for doses 1-4 respectively. Using a population-derived denominator for age-eligible children, vaccine coverage was 78%, 68%, 57%, and 24% for doses 1-4, respectively. Of the children that received measles dose 1 vaccines delivered at 9 months (coverage: 95%), 82% received RTSS/AS01 dose 3, only 66% of children who received measles dose 2 at 18 months (coverage: 59%) also received dose 4.

CONCLUSION

The implementation programme successfully maintained high levels of coverage for the first three doses of RTSS/AS01 among children defined as EPI service users up to 9 months of age but had much lower coverage within the community with up to 1 in 5 children not receiving the vaccine. Consistent with vaccines delivered over the age of 1 year, coverage of the fourth malaria dose was low. Vaccine uptake, service access and dropout rates for malaria vaccines require constant monitoring and intervention to ensure maximum protection is conferred.

Exploring the Pattern of Immunization Dropout among Children in India: A District-Level Comparative Analysis

The dropout rate is one of the determinants of immunization coverage and program performance, program continuity, and follow-up. The dropout rate refers to the proportion of vaccine recipients who did not finish their vaccination schedules, and it is determined by comparing the number of infants who started the schedule to the number who completed it. It is the rate difference between the first and final dosage or the rate difference between the first vaccination and the last vaccine dropout; thus, it denotes that the first recommended dose of vaccine was received, but that the subsequently recommended dose was missed. In India, immunization coverage has shown significant improvements over the last two decades, but full immunization coverage has remained stagnant at 76.5%, of which 19.9% are partially immunized, and 3.6% are children who have been left out. In India, the Universal Immunization Programme (UIP) is challenged with cases related to dropout in immunization. Although immunization coverage in India is improving, the program is challenged by vaccination dropouts. This study provides an analysis of the determinants of vaccination dropout in India using data from two rounds of the National Family Health Survey. The finding shows that the mother's age, education, family wealth, antenatal care visit, and place of delivery were some of the variables that significantly contributed to reducing the dropout rate of immunization among children. The findings of this paper show that the dropout rate has reduced over a certain period of time. The overall improvement in the rates of dropout and increase in full immunization coverage could be attributed to various policy measures taken in the last decade in India, which brought structural changes with a positive impact on full immunization coverage and its components.

Vaccination dropout among children in Sub-Saharan Africa: Systematic review and meta-analysis

Immunization is cost-effective preventive strategy for child morbidity and mortality. PubMed, Google Scholar, Scopus, Science Direct, and online institutional repository homes were searched. Data were extracted by Microsoft excel. Begg's rank test, and Egger's regression test was done. A pooled prevalence, Sub-group analysis, sensitivity analysis and meta-regression were conducted. A total of 12 articles were included in this study. The pooled prevalence of vaccination dropout was 26.06% (95% CI: 11.59, 30.53), I2 =91.2%. In sub-group analysis, Nigeria had the highest prevalence of immunization dropouts (33.59%). It was 18.01% and 29.25%, respectively, for published and unpublished research. Community-based studies and institutional-based studies also yield a prevalence of dropout 39.04% and 13.73% respectively. Dropout rate was 22.66% for sample sizes under 500 and 18.01% for sample sizes beyond 500. In Sub-Saharan Africa, the prevalence of vaccination dropout was high. Community education about vaccinations importance should be prioritized.

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.

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.

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.

Trends, projection and inequalities in full immunization coverage in Ethiopia: in the period 2000-2019

BACKGROUND

Immunization is among the most cost-effective health interventions to improve child survival. However, many countries in sub-Saharan Africa failed to achieve their national and international coverage targets repeatedly. The present study investigated trends of coverage and inequalities in coverage in Ethiopia.

METHODS

This study used data from five rounds of the Demographic and Health Surveys conducted in Ethiopia in 2000, 2005, 2011, 2016, and 2019. The surveys used a multistage cluster sampling procedure to obtain a nationally and sub-nationally representative data. The outcome variables included in the study were full immunization coverage and inequality. The World Health Organization's Health Equity Assessment Toolkit was used to conduct the inequality analysis. Projections for 2025 were based on smoothed averages generated using the demographic and health survey data from 2000 to 2019.

RESULTS

The full (basic) immunization coverage in Ethiopia has increased steadily from 14.3% in 2000 to 44.1% in 2019. Based on the average past performance, the immunization coverage is projected to reach 53.6% by 2025, which will be short of the 75% national full (basic) immunization coverage target for the year 2025. Mothers with higher levels of education are more likely to get their children all basic vaccinations than those with lower levels of education. Similarly, the inequality gaps due to wealth and residency are significant; where children in the lowest wealth strata and those living in rural areas remained disadvantaged.

CONCLUSION

Despite a steady increase in immunization coverage in the past two decades the country is yet to achieve its immunization target. Thus, more efforts are needed to achieve the current and future national immunization targets. A more focused intervention targeting the disadvantaged groups could be an effective strategy to achieve coverage and minimize the inequality gaps in immunization.

Are children on track with their routine immunization schedule in a fragile and protracted conflict state of South Sudan? A community-based cross-sectional study

Objectives

The objective of this study was to assess if children aged 0–23 months in a conflict-affected state of South Sudan were on track with their immunization schedule and to identify predisposing factors that affected this study population from being on track with their routine immunization schedule.

Design

Community-based cross-sectional study using a semi-structured questionnaire. The binary outcome of interest was defined as being on or off track with routine vaccination schedule. Multivariable logistic regression was used to analyze for the association between the predisposing factors surveyed and being off track with one’s routine immunization schedule.

Setting

Rural communities in four counties (Rumbek Center, Rumbek North, Rumbek East and Wulu) of the Western Lakes state in South Sudan during January 10, 2020 to June 10, 2020.

Participants

We surveyed 428 children aged 0–23 months and their mothers/caregivers who lived in either of the four counties in the Western Lakes State. Participants were selected using random ballot sampling.

Results

More than three-quarters of the children surveyed (75.5%) were off track with their vaccination schedule. Children with an immunization card had 71% reduced odds of being off track with their immunization (AOR = 0.29; 95% CI 0.10–0.83, p-value = 0.021) compared to children without immunization cards. Children who reside near health facilities and do not require transportation to facilities had 87% reduced odds of being off track with their immunization compared to those who lived far and required transport to facilities. Giving an adequate immunization notice before conducting immunization outreach visits to communities was also associated with reduced odds (AOR = 0.27; 95% CI 0.09–0.78. p-value = 0.016) of children being off track with their immunization.

Conclusion

This study revealed that most children were off track with their vaccination schedule in South Sudan, which is not only influenced by maternal characteristics but mainly by community- and state-level immunization service delivery mechanisms. Policies and interventions to improve child immunization uptake should prioritize these contextual characteristics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03213-5.

Determinants of pentavalent and measles vaccination dropouts among children aged 12-23 months in The Gambia

Background

Every year, vaccination averts about 3 million deaths from vaccine-preventable diseases (VPDs). However, despite that immunization coverage is increasing globally, many children in developing countries are still dropping out of vaccination. Thus, the present study aimed to identify determinants of vaccination dropouts among children aged 12–23 months in The Gambia.

Methods

The study utilized cross-sectional data obtained from the Gambia Demographic and Health Survey 2019–20 (GDHS). The percentage of children aged 12–23 months who dropped out from pentavalent and measles vaccination were calculated by (1) subtracting the third dose of pentavalent vaccine from the first dose of Pentavalent vaccine, and (2) subtracting the first dose of measles vaccine from the first dose Pentavalent vaccine. Generalized Estimating Equation models (GEE) were constructed to examine the risk factors of pentavalent and measles vaccinations dropout.

Results

Approximately 7.0% and 4.0% of the 1,302 children aged 12–23 months had dropped out of measles and pentavalent vaccination respectively. The multivariate analyses showed that when caregivers attended fewer than four antenatal care sessions, when children had no health card or whose card was lost, and resided in urban areas increased the odds of pentavalent dropout. On the other hand, when women gave birth in home and other places, when children had no health card, and being an urban areas dweller increased the odds of measles dropout.

Conclusion

Tailored public health interventions towards urban residence and health education for all women during ANC are hereby recommended.

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.

Understanding the complexity of demand-side determinants on vaccine uptake in sub-Saharan Africa

Routine vaccination annually prevents millions of deaths worldwide but is underutilized in sub-Saharan Africa (SSA). The complexity of socio-cultural factors impacting vaccine uptake is not well understood. Hence, this paper aims to review the socio-cultural determinants of vaccine uptake and visualize their interrelationships. We conducted a literature search using Pubmed and Embase databases, including articles published from 2000 to 2019 describing socio-cultural demand-side determinants for vaccine uptake. Using the Andersen and Newman Framework of Health Services Utilization, demand-side determinants were categorized as predisposing, enabling or need factors. A qualitative system dynamics approach was employed to visualize how these factors and their dynamic interrelationships influence vaccine uptake. This visualization, by means of a causal-loop diagram (CLD), was mostly based on a qualitative input, with the majority being statements of the authors. These statements were abstracted from the papers found in the review. Quantification was done by counting direct (statistical) associations between each determinant and 'timely and full routine immunization coverage'. A total of 90 articles, primarily from Nigeria (n = 23), Ethiopia (n = 17) and Kenya (n = 11), met the inclusion criteria. We find that maternal autonomy and the perceived benefits caregivers attach to vaccination and exert their influences on many other factors through several feedback loops, thereby influencing timely and full routine immunization coverage. Utilization of health services (supply-related) and access to information (demand-related) were considered as high-potential leverage points. Quantification has shown that maternal autonomy and perceived benefit have an unclear evidence base. Future research should focus on these key players as they play a central role in multiple complex pathways, through which they could influence the uptake of vaccines in SSA.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

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.

Promoting, seeking, and reaching vaccination services: A systematic review of costs to immunization programs, beneficiaries, and caregivers

INTRODUCTION

Understanding the costs to increase vaccination demand among under-vaccinated populations, as well as costs incurred by beneficiaries and caregivers for reaching vaccination sites, is essential to improving vaccination coverage. However, there have not been systematic analyses documenting such costs for beneficiaries and caregivers seeking vaccination.

METHODS

We searched PubMed, Scopus, and the Immunization Delivery Cost Catalogue (IDCC) in 2019 for the costs for beneficiaries and caregivers to 1) seek and know how to access vaccination (i.e., costs to immunization programs for social mobilization and interventions to increase vaccination demand), 2) take time off from work, chores, or school for vaccination (i.e., productivity costs), and 3) travel to vaccination sites. We assessed if these costs were specific to populations that faced other non-cost barriers, based on a framework for defining hard-to-reach and hard-to-vaccinate populations for vaccination.

RESULTS

We found 57 studies describing information, education, and communication (IEC) costs, social mobilization costs, and the costs of interventions to increase vaccination demand, with mean costs per dose at $0.41 (standard deviation (SD) $0.83), $18.86 (SD $50.65) and $28.23 (SD $76.09) in low-, middle-, and high-income countries, respectively. Five studies described productivity losses incurred by beneficiaries and caregivers seeking vaccination ($38.33 per person; SD $14.72; n = 3). We identified six studies on travel costs incurred by beneficiaries and caregivers attending vaccination sites ($11.25 per person; SD $9.54; n = 4). Two studies reported social mobilization costs per dose specific to hard-to-reach populations, which were 2-3.5 times higher than costs for the general population. Eight studies described barriers to vaccination among hard-to-reach populations.

CONCLUSION

Social mobilization/IEC costs are well-characterized, but evidence is limited on costs incurred by beneficiaries and caregivers getting to vaccination sites. Understanding the potential incremental costs for populations facing barriers to reach vaccination sites is essential to improving vaccine program financing and planning.

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

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.

The impact of child health interventions and risk factors on child survival in Kenya, 1993-2014: a Bayesian spatio-temporal analysis with counterfactual scenarios

BACKGROUND

During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined.

METHODS

Sub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993-2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993.

RESULTS

Nationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors.

CONCLUSION

Contributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

Associated Factors for Dropout of First Vs Third Doses of Diphtheria Tetanus Pertussis (DPT) Vaccination in Nepal

Background

Immunization acts as a key intervention to reduce under-five mortality and morbidity. Despite global progress on vaccination, difficulties in the utilization of this service in developing countries have been observed. According to Nepal Demographic and Health Survey (NDHS) 2016, only 78% of children received a complete dose of vaccine among which the first-dose receiver of DPT is 98%, whereas only 83% received a third dose. This study aims to explore the influencing factors of DPT vaccination dropout in Nepal.

Methods

The explorative study was done through secondary data analysis of NDHS 2016. The KR file was used for the analysis of information for 2883 children. Factors influencing dropout of DPT vaccination were explored against the independent variables such as external environment, predisposing factors, and enabling resources. All the analyses were weighted before the analysis. The descriptive, bivariate, and multivariate analyses were performed. The variables showing collinearity have been removed in the final model.

Results

A higher dropout was reported in Terai (18.9%) and province 2 (22.0%), among uneducated mothers (18.1%) and uneducated fathers (19.4%), less than once a week internet users (22.2%), the nonradio listener (17.4%), who had <4 ANC visits (22.7%), home delivery (19.2%), no advised SBA (19.1%), long distance to health facility (17.9%), no iron supplementation in pregnancy (24.3%), and PNC by TBA/others (21.1%). All these tested relationships were found statistically significant (P value <0.05). The aOR for dropout was found to be 7.94 (4.07–15.51) for mothers with less than 4 or no ANC visit, long distance to health facility 4.68 (1.98–10.67), province 2 3.53 (1.13–11.03), and mother without formal employment 2.33 (1.52–3.55).

Conclusion

Factors related to health services, distance, provinces, and socioeconomic status of the family were influencers for vaccine dropout. Targeted intervention towards disadvantaged regions, counseling the mother during ANC, improving the education status of parents, access to the health facility, and use of mass media for advocacy are hereby recommended.

Subnational estimates of factors associated with under-five mortality in Kenya: a spatio-temporal analysis, 1993-2014

BACKGROUND

To improve child survival, it is necessary to describe and understand the spatial and temporal variation of factors associated with child survival beyond national aggregates, anchored at decentralised health planning units. Therefore, we aimed to provide subnational estimates of factors associated with child survival while elucidating areas of progress, stagnation and decline in Kenya.

METHODS

Twenty household surveys and three population censuses conducted since 1989 were assembled and spatially aligned to 47 subnational Kenyan county boundaries. Bayesian spatio-temporal Gaussian process regression models accounting for inadequate sample size and spatio-temporal relatedness were fitted for 43 factors at county level between 1993 and 2014.

RESULTS

Nationally, the coverage and prevalence were highly variable with 38 factors recording an improvement. The absolute percentage change (1993-2014) was heterogeneous ranging between 1% and 898%. At the county level, the estimates varied across space and over time with a majority showing improvements after 2008 which was preceded by a period of deterioration (late-1990 to early-2000). Counties in Northern Kenya were consistently observed to have lower coverage of interventions and remained disadvantaged in 2014 while areas around Central Kenya had and historically have had higher coverage across all intervention domains. Most factors in Western and South-East Kenya recorded moderate intervention coverage although having a high infection prevalence of both HIV and malaria.

CONCLUSION

The heterogeneous estimates necessitates prioritisation of the marginalised counties to achieve health equity and improve child survival uniformly across the country. Efforts are required to narrow the gap between counties across all the drivers of child survival. The generated estimates will facilitate improved benchmarking and establish a baseline for monitoring child development goals at subnational level.

Evaluating a Mobile Phone-Delivered Text Message Reminder Intervention to Reduce Infant Vaccination Dropout in Arua, Uganda: Protocol for a Randomized Controlled Trial

Background

Globally, suboptimal vaccine coverage is a public health concern. According to Uganda’s 2016 Demographic and Health Survey, only 49% of 12- to 23-month-old children received all recommended vaccinations by 12 months of age. Innovative ways are needed to increase coverage, reduce dropout, and increase awareness among caregivers to bring children for timely vaccination.

Objective

This study evaluates a personalized, automated caregiver mobile phone–delivered text message reminder intervention to reduce the proportion of children who start but do not complete the vaccination series for children aged 12 months and younger in select health facilities in Arua district.

Methods

A two-arm, multicenter, parallel group randomized controlled trial was conducted in four health facilities providing vaccination services in and around the town of Arua. Caregivers of children between 6 weeks and 6 months of age at the time of their first dose of pentavalent vaccine (Penta1; containing diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b antigens) were recruited and interviewed. All participants received the standard of care, defined as the health worker providing child vaccination home-based records to caregivers as available and providing verbal instruction of when to return for the next visit. At the end of each day, caregivers and their children were randomized by computer either to receive or not receive personalized, automated text message reminders for their subsequent vaccination visits according to the national schedule. Text message reminders for Penta2 were sent 2 days before, on the day of, and 2 days after the scheduled vaccination visit. Reminders for Penta3 and the measles-containing vaccine were sent on the scheduled day of vaccination and 5 and 7 days after the scheduled day. Study personnel conducted postintervention follow-up interviews with participants at the health facilities during the children’s measles-containing vaccine visit. In addition, focus group discussions were conducted to assess caregiver acceptability of the intervention, economic data were collected to evaluate the incremental costs and cost-effectiveness of the intervention, and health facility record review forms were completed to capture service delivery process indicators.

Results

Of the 3485 screened participants, 1961 were enrolled from a sample size of 1962. Enrollment concluded in August 2016. Follow-up interviews of study participants, including data extraction from the children’s vaccination cards, data extraction from the health facility immunization registers, completion of the health facility record review forms, and focus group discussions were completed by December 2017. The results are expected to be released in 2021.

Conclusions

Prompting health-seeking behavior with reminders has been shown to improve health intervention uptake. Mobile phone ownership continues to grow in Uganda, so their use in vaccination interventions such as this study is logical and should be evaluated with scientifically rigorous study designs.

Trial Registration

ClinicalTrials.gov NCT04177485; https://clinicaltrials.gov/ct2/show/NCT04177485

International Registered Report Identifier (IRRID)

DERR1-10.2196/17262

Mobile phone reminders for enhancing uptake, completeness and timeliness of routine childhood immunization in low and middle income countries: A systematic review and meta-analysis

Immunization remains one of the most effective public health interventions offering protection for children from vaccine preventable diseases. However, many children living in low- and- middle income countries do not get adequate immunization due to several factors. Mobile phone reminder interventions have shown great potential in enhancing a number of immunization outcomes. However, the evidence supporting its use in these countries is vague. This systematic review was conducted to provide evidence for mobile phone reminder in enhancing immunization uptake, completeness and timeliness. This review was conducted in accordance to the PRISMA recommendations. Three online databases; PubMed, Cochrane Library and African Journals Online, were systematically searched for potentially relevant studies. Screening of records (titles/abstracts from and full-texts) was done using Covidence. Meta-analyses were conducted using the Cochrane Collaboration Review Manager (v5.4). The GRADEpro was used to evaluate the certainty of evidence/summary of findings. Eleven RCTs assessing immunization uptake, completeness and/or timeliness by means of SMS, phone calls or a combination of voice message and SMS were included in both quantitative and qualitative synthesis. Overall, the included studies were of moderate quality. Majority of the included studies indicated that mobile phone reminders were beneficial. Meta-analyses indicated that using mobile phone reminder interventions for the review outcomes was of variable effect with high level of heterogeneity. A combination of voice message and SMS has a greater effect followed by phone calls then SMS reminders for immunization completeness. The use of SMS for immunization uptake and timeliness were largely insignificant (p > 0.05). Furthermore, evidence to support the efficacy of mobile phone reminder from the GRADE synthesis was between low and moderate. Mobile phone reminders, particularly a combination of voice message + SMS and perhaps phone calls appears to be more effective in enhancing immunization outcomes. However, more studies are required in view of methodological inadequacies in existing studies.

Cost-effectiveness of SMS appointment reminders in increasing vaccination uptake in Lagos, Nigeria: A multi-centered randomized controlled trial

OBJECTIVE

It is expected that mHealth largely contribute to increasing the coverages of key maternal and child health services. This study aims to estimate the cost-effectiveness of the SMS text reminders in clients' return visits to the health facilities for child vaccinations (incl. vitamin A supplementations), antenatal care (ANC) and family planning (FP), in urban communities of Lagos, Nigeria.

METHODS

A multi-centered randomized control trial was conducted at 33 primary health centers (PHCs) in Lagos, Nigeria. All the clients having visited any of the 33 PHCs for child vaccinations, ANC and FP were randomly assigned either to intervention group or to control group. The participants in the intervention group were sent an SMS text reminder two days before their appointments. Those not having showed up on the appointment dates received an additional SMS text reminder seven days after original appointment dates as defaulter tracing. The primary outcome was whether a client made return visit to PHCs for the upcoming appointments.

RESULTS

Of 12,779 appointments for 9,368 clients during the period of 1stApril to 30thJune 2019, 12,175 were included in the analysis. The return rate for child vaccinations in the intervention group was significantly higher (p < 0.001) by 4.8% - 6.0% than that in the control group, consistently across all the five different timings (on time as scheduled, and by 7 days, 14 days, 30 days, and 3 months after appointment dates). No significant difference between the two groups was detected in the increase in return rates for ANC and FP services. The incremental recurrent cost was estimated at 7.90 US Dollars per return case.

CONCLUSION

SMS text reminders led to a significant increase in the number of return visits for child vaccinations, Lagos, Nigeria, while no significant increase in return visits was confirmed for ANC and FP appointments.

Targeted client communication via mobile devices for improving maternal, neonatal, and child health

BACKGROUND

The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH.

OBJECTIVES

To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second.

MAIN RESULTS

We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences.

AUTHORS' CONCLUSIONS

The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

Associations of maternal resources with care behaviours differ by resource and behaviour

Care is important for children's growth and development, but lack or inadequacy of resources for care can constrain appropriate caregiving. The objectives of this study were to examine whether maternal resources for care are associated with care behaviours specifically infant and young child feeding, hygiene, health-seeking, and family care behaviours. The study also examined if some resources for care are more important than others. This study used baseline Alive & Thrive household surveys from Bangladesh, Vietnam, and Ethiopia. Measures of resources for care were maternal education, knowledge, height, nourishment, mental well-being, decision-making autonomy, employment, support in chores, and perceived instrumental support. Multiple regression analyses were conducted to examine the associations of resources for care with child-feeding practices (exclusive breastfeeding, minimum meal frequency, dietary and diversity), hygiene practices (improved drinking water source, improved sanitation, and cleanliness), health-seeking (full immunization), and family care (psychosocial stimulation and availability of adequate caregiver). The models were adjusted for covariates at child, parents, and household levels and accounted for geographic clustering. All measures of resources for care had positive associations with care behaviours; in a few instances, however, the associations between the resources for care and care behaviours were in the negative direction. Improving education, knowledge, nutritional status, mental well-being, autonomy, and social support among mothers would facilitate provision of optimal care for children.

Use of mobile phones for behavior change communication to improve maternal, newborn and child health: a scoping review

Background

Behavior change communication (BCC) to improve health and caring practices is an integral component of efforts to improve maternal, newborn and child health (MNCH). Mobile phones are widely available in low- and middle-income countries (LMIC), presenting new opportunities for BCC delivery. There is need for delivery science to determine how best to leverage mobile phone technology for BCC to improve MNCH practices.

Methods

We conducted a scoping review of studies and project reports documenting the feasibility, implementation or effectiveness of using mobile phones for BCC delivery related to MNCH in LMIC. Data were extracted and synthesized from three sources: i) systematic search of three electronic databases (PubMed, MedLine, Scopus); ii) grey literature search, including mHealth databases and websites of organizations implementing mHealth projects; iii) consultation with researchers and programme implementers. Records were screened using pre-determined inclusion criteria and those selected were categorized according to their primary intervention delivery approaches. We then performed a descriptive analysis of the evidence related to both effectiveness and implementation for each delivery approach.

Results

The systematic literature search identified 1374 unique records, 64 of which met inclusion criteria. The grey literature search added 32 records for a total of 96 papers in the scoping review. Content analysis of the search results identified four BCC delivery approaches: direct messaging, voice counseling, job aid applications and interactive media. Evidence for the effectiveness of these approaches is growing but remains limited for many MNCH outcomes. The four approaches differ in key implementation elements, including frequency, length and complexity of communication, and potential for personalization. These elements influence resource allocation and are likely to impact effectiveness for BCC targeting complex, habitual MNCH practices.

Conclusions

This scoping review contributes to the evidence-base on the opportunities and limitations of using mobile phones for BCC delivery aiming to improve MNCH practices. The incorporation of mobile phone technology in BCC interventions should be guided by formative research to match both the content and delivery approach to the local context. We recommend five areas for further research, including both effectiveness and implementation studies on specific delivery approaches.

A randomised controlled trial of SMS messaging and calendar reminders to improve vaccination timeliness in infants

BACKGROUND

The effectiveness of SMS reminders in improving vaccination coverage has been assessed previously, with effectiveness varying between settings. However, there are very few studies on their effect on the timeliness of vaccination.

DESIGN

Unblinded, randomised controlled trial with blocked sampling.

METHODS

1594 Australian infants and young children were recruited to assess the impact of (1) SMS reminders only, (2) a personalised calendar, (3) SMS reminder and personalised calendar and (4) no intervention, on receipt of vaccine within 30 days of the due date. Outcomes were measured for receipt of vaccines due at 2, 4, 6, 12 and 18 months of age. A post-hoc assessment was also conducted of the impact of a new national "No jab No Pay" policy introduced during the trial, which removed philosophical objections as an exemption for financial penalties for non-vaccination.

RESULTS

There was a statistically significant improvement in on-time vaccination only at the 12 month schedule point amongst infants who received SMS reminders alone (RR 1.09, 95% CI 1.01-1.18) or in combination with a personalised calendar (1.11, CI 1.03-1.20) compared to controls. This impact was limited to participants who had received one or more previous doses late. No statistically significant impacts of calendar interventions alone were seen. There was a high rate of on-time compliance amongst control participants - 95%, 86%, 80%, 74% at the 4, 6, 12 and 18 month schedule points respectively, which increased more than 10 percentage points after implementation of the "No Jab, No Pay" policy.

CONCLUSIONS

SMS reminders are more effective in improving timeliness where pre-existing compliance is lower, but the 18 month schedule point appeared to be less amenable to intervention. Australia and New Zealand Clinical Trial Registration No. ACTRN12614000970640.

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.

Operability, Acceptability, and Usefulness of a Mobile App to Track Routine Immunization Performance in Rural Pakistan: Interview Study Among Vaccinators and Key Informants

BACKGROUND

There has been a recent spate of mobile health (mHealth) app use for immunizations and other public health concerns in low- and middle-income countries. However, recent evidence has largely focused on app development or before-and-after effects on awareness or service coverage. There is little evidence on the factors that facilitate adoption of mHealth programs, which is critical to effectively embed digital technology into mainstream health systems.

OBJECTIVE

This study aimed to provide the qualitative experiences of frontline health staff and district managers while engaging with real-time digital technology to improve the coverage of routine childhood immunization in an underserved rural district in Pakistan.

METHODS

An Android-based app was iteratively developed and used for a 2-year period in 11 union councils of the Tando Muhammad Khan district, an underserved rural district with poor immunization coverage in Pakistan. We used iterative methods to examine the (1) acceptability and operability of the app, (2) validity of the collected data, and (3) use of the collected data. In addition, we collected the barriers and enablers for uptake of the mHealth app. Each of these topics was further explored related to changes in work as well as the enabling factors for and barriers to app use. In-depth interviews were conducted with the 26 vaccinators posted in the 11 union councils and 7 purposively selected key informants (government district managers) involved with the Expanded Program for Immunization. Findings were triangulated in line with the three broad research areas.

RESULTS

Digital immunization tracking was considered acceptable by vaccinators and district managers. Real-time immunization data were used to monitor vaccination volume, track children with incomplete vaccinations, develop outreach visit plans, correct existing microplans, and disburse a fuel allowance for outreach sessions. The validity of the app data was perceived to be superior to that of data from manual records. Ease of operability, satisfaction with data, personal recognition, links to field support, and a sense of empowerment served as powerful enablers. Taking twice the time to complete both manual and digital entries and outdated phones over time were considered constraints. An unintended knock-on effect was improved coordination and strengthening of Expanded Program for Immunization review platforms across district stakeholders through digitalized data.

CONCLUSIONS

Embedding digital technology into mainstream health systems relies on use by both end users and district stakeholders. Ease of operability, satisfaction with data reliability, personal recognition, links to field support, and empowerment are powerful enablers, whereas improved coordination as a result of easy, transparent data access can be an important by-product of digitalization. Findings are relevant not only for wide-scale implementation of immunization tracking apps in Pakistan but also for informing the use of digital technology for results-based delivery by frontline health workers.

Effect of mobile phone text message reminders on improving completeness and timeliness of routine childhood vaccinations in North-West, Ethiopia: a study protocol for randomised controlled trial

INTRODUCTION

Non-attendance and delay in vaccination schedules remain a big challenge to healthcare workers. With the continuous growth of mobile network coverage and exponential penetration of mobile devices in the developing world, adoption of short message service has been shown to increase attendance for health services by targeting participant characteristics such as forgetfulness. Therefore, the aim of this trial is to determine the effect of mobile text message reminders on completeness and timeliness of childhood vaccination in North-West, Ethiopia.

METHODS AND ANALYSIS

A two-arm, parallel, superiority, randomised controlled trial study will be employed. The study arms are the intervention group (text message reminders plus routine care) and the control group (routine care only). Mother-infant pairs will be randomised to one of the groups during enrolment. The trial will consider a sample size of 434 mother-infant pairs with 1:1 allocation ratio. Mothers assigned to the intervention group will receive text message reminder 1 day before the scheduled vaccination visit at 6 weeks, 10 weeks, 14 weeks and at 9 months. Initially, descriptive statistics will be computed. For the primary outcome log-binomial regression model will be used to identify associated factors, and relative risk with 95% CI will be reported. Primarily, iIntention-to-treat analysis principle will be applied. STATA V.14 software will be used for the analysis.

ETHICS AND DISSEMINATION

This study obtained ethical approval from the University of Gondar Institutional Ethical Review Board. The trial findings on the effectiveness of mobile text message reminders in improving vaccination uptake will help to inform decision makers on the use of mobile health interventions in developing countries like Ethiopia. The scientific findings of the trial will also be published in reputable journals.

TRIAL REGISTRATION NUMBER

PACTR201901533237287.

Association between access to a health facility and continuum of vaccination behaviors among Nigerian children

Background: This paper examines the association between access to a health facility and the continuum of child vaccination behaviors, which include: uptake of each vaccine, dropout, and timing of vaccine take-up in Nigeria.Methods: The health facility census data (2014) were merged into the Nigeria Demographic and Health Survey (2013) to calculate the distance between respondents' locations and the nearest health facility, and to evaluate its impact on the series of vaccination behaviors, using logistic and OLS regression.Results: Among 21,369 children aged 12 to 59 months old, 78.2% of them were ever vaccinated. An additional distance of 1 km to the nearest clinic reduces the likelihood that one receives a vaccine by about 5% [OR: 0.952, 95% CI = 0.935-0.969]. Distance to the nearest clinic is mostly not associated with dropout rates in the vaccination series, but it delays the timing of vaccination, especially in the later stages of the vaccination series and Polio vaccination which require the mobilization from the supply side.Conclusion: A longer distance to the nearest health facility is associated with lower vaccine take-up and delayed timing of vaccinations, but not with vaccine dropout. More studies should focus on the dynamics of vaccination decisions, in particular, the different determinants of vaccine take-up and dropout.

Effect of vaccine reminder and tracker bracelets on routine childhood immunization coverage and timeliness in urban Pakistan: protocol for a randomized controlled trial

Background

Inability to track children’s vaccination history coupled with parents’ lack of awareness of vaccination due dates compounds the problem of low immunization coverage and timeliness in developing countries. Traditional Reminder/Recall (RR) interventions such as paper-based immunization cards or mHealth based platforms do not yield optimal results in resource-constrained settings. There is thus a need for a low-cost intervention that can simultaneously stimulate demand and track immunization history to help reduce drop-outs and improve immunization coverage and timeliness. The objective of this study is to evaluate the impact of low-cost vaccine reminder and tracker bracelets for improving routine childhood immunization coverage and timeliness in Pakistani children under 2 years of age.

Methods

The study is an individually randomized, three-arm parallel Randomized Controlled Trial with two intervention groups and one control group. Infants in the two intervention groups will be given two different types of silicone bracelets at the time of recruitment, while infants in the control group will not receive any intervention. The two types of bracelets consist of symbols and/or numbers to denote the EPI vaccination schedule and each time the child will come for vaccination, the study staff will perforate a hole in the appropriate symbol to denote vaccine administration. Therefore, by looking at the bracelet, caregivers will be able to see how many vaccines have been received. Our primary outcome measure is the increase in coverage and timeliness of Pentavalent-3/PCV-3/Polio-3 and Measles-1 vaccine in the intervention versus control groups. A total of 1446 participants will be recruited from 4 Expanded Program on Immunization (EPI) centers in Landhi Town, Karachi. Each enrolled child will be followed up till the Measles-1 vaccine is administered, or till eleven months have elapsed since enrolment.

Discussion

Participant recruitment commenced on July 19, 2017, and was completed on October 10, 2017. Proposed duration of the study is 18 months and expected end date is December 1, 2018. This study constitutes one of the first attempts to rigorously evaluate an innovative, low-cost vaccine reminder bracelet.

Trial registration

ClinicalTrials.gov NCT03310762. Retrospectively Registered on October 16, 2017.

Clients' perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis

BACKGROUND

Governments and health systems are increasingly using mobile devices to communicate with patients and the public. Targeted digital client communication is when the health system transmits information to particular individuals or groups of people, based on their health or demographic status. Common types of targeted client communication are text messages that remind people to go to appointments or take their medicines. Other types include phone calls, interactive voice response, or multimedia messages that offer healthcare information, advice, monitoring, and support.

OBJECTIVES

To explore clients' perceptions and experiences of targeted digital communication via mobile devices on topics related to reproductive, maternal, newborn, child, or adolescent health (RMNCAH).

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-Process & Other Non-Indexed Citations (OvidSP), Embase (Ovid), World Health Organization Global Health Library, and POPLINE databases for eligible studies from inception to 3-6 July 2017 dependant on the database (See appendix 2).

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; that explored clinets' perceptions and experiences of targeted digital communication via mobile device in the areas of RMNCAH; and were from any setting globally.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, employing a three-step sampling frame. We conducted a framework thematic analysis using the Supporting the Use of Research Evidence (SURE) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether potential implementation barriers identified in our synthesis had been addressed in the trials included in the related Cochrane Reviews of effectiveness.

MAIN RESULTS

We included 35 studies, from a wide range of countries on six continents. Nineteen studies were conducted in low- and middle-income settings and sixteen in high-income settings. Some of the studies explored the views of people who had experienced the interventions, whereas others were hypothetical in nature, asking what people felt they would like from a digital health intervention. The studies covered a range of digital targeted client communication, for example medication or appointment reminders, prenatal health information, support for smoking cessation while pregnant, or general sexual health information.Our synthesis showed that clients' experiences of these types of programmes were mixed. Some felt that these programmes provided them with feelings of support and connectedness, as they felt that someone was taking the time to send them messages (moderate confidence in the evidence). They also described sharing the messages with their friends and family (moderate confidence).However, clients also pointed to problems when using these programmes. Some clients had poor access to cell networks and to the internet (high confidence). Others had no phone, had lost or broken their phone, could not afford airtime, or had changed their phone number (moderate confidence). Some clients, particularly women and teenagers, had their access to phones controlled by others (moderate confidence). The cost of messages could also be a problem, and many thought that messages should be free of charge (high confidence). Language issues as well as skills in reading, writing, and using mobile phones could also be a problem (moderate confidence).Clients dealing with stigmatised or personal health conditions such as HIV, family planning, or abortion care were also concerned about privacy and confidentiality (high confidence). Some clients suggested strategies to deal with these issues, such as using neutral language and tailoring the content, timing, and frequency of messages (high confidence).Clients wanted messages at a time and frequency that was convenient for them (moderate confidence). They had preferences for different delivery channels (e.g. short message service (SMS) or interactive voice response) (moderate confidence). They also had preferences about message content, including new knowledge, reminders, solutions, and suggestions about health issues (moderate confidence). Clients' views about who sent the digital health communication could influence their views of the programme (moderate confidence).For an overview of the findings and our confidence in the evidence, please see the 'Summary of qualitative findings' tables.Our matrix shows that many of the trials assessing these types of programmes did not try to address the problems we identified, although this may have been a reporting issue.

AUTHORS' CONCLUSIONS

Our synthesis identified several factors that can influence the successful implementation of targeted client communication programmes using mobile devices. These include barriers to use that have equity implications. Programme planners should take these factors into account when designing and implementing programmes. Future trial authors also need to actively address these factors and to report their efforts in their trial publications.

Development of automated text-message reminder system to improve uptake of child vaccination in Ethiopia

INTRODUCTION

Non-attendance and delay for vaccination schedules remains a big challenge to healthcare workers. Among the frequently mentioned reasons for missed vaccination in children is forgetfulness of caretakers to show up in vaccination schedules. This necessitates developing an automated reminder system with integration of mobile technologies.

OBJECTIVES

This paper aimed to develop and test an automated mobile text message reminder system in the local context of Ethiopia.

METHODS

This system is developed using iterative development process through phases of requirement analysis, design, development, testing and refinement. Requirement gathering was done before development of the system. Front end application was developed using java technologies while back end applications were developed with oracle database. Finally, pilot testing of the automated reminder system was done on 30 participants.

RESULTS

The automated system has been developed based on requirements. The text message reminder system has two components: 1. Web based application for client registration and automatic reminder scheduling; 2. SMS application for automatic SMS text messaging. In the pilot testing, all the text messages (100%) were dispatched from the automated system to the respective participants. Finally, the system has shown a notification that the text messages have been sent successfully.

CONCLUSION

Text message reminder system has been developed for routine childhood immunization program in Ethiopian context. Text message based mHealth interventions should be carefully designed, developed, tested and refined before actual implementation.

Text message reminders to improve infant immunization in Guatemala: A randomized clinical trial

OBJECTIVE

Millions of infants worldwide remain under-immunized and at risk for unnecessary morbidity and mortality. Text messaging may offer a low-cost solution. We aimed to evaluate text message reminders to improve infant immunization in Guatemala.

METHODS

A randomized clinical trial was conducted at four public health clinics in rural and urban Guatemala. Infants ages six weeks to six months presenting for the first visit of the primary immunization series were randomly and equally allocated to an intervention or usual care group. Intervention participants were sent three text reminders before the second and third vaccine visits. The main outcome was timeliness of the second and third visits of the primary immunization series.

RESULTS

Of 1088 families approached for enrollment between March to November 2016, 871 were eligible and 720 (82.7%) participated; only 54 families did not own a cell phone. Due to country-wide vaccine shortages, visit completion was used as a proxy for overall immunization coverage. In intention to treat analysis, both intervention and usual care groups had high rates of visit completion, but intervention participants presented on the scheduled date more often (151 [42.2%] of 358 intervention vs. 111 [30.7%] of 362 usual care participants for visit 2, p = 0.001, and 112 [34.0%] of 329 intervention vs. 90 [27.0%] of 333 usual care participants for visit 3, p = 0.05). Intervention caregivers were significantly more likely to want to receive future text message reminders for vaccines and other appointments and were more willing to pay for these reminders.

CONCLUSION

Caregivers who were sent text message reminders in urban and rural Guatemala were less delayed for their child's immunization visits and reported high user satisfaction. Text message reminders may be an effective tool to increase infant vaccination coverage in low-income settings by reminding parents to vaccinate.

TRIAL REGISTRATION

NCT02567006 at clinicaltrials.gov.

Effect of mobile text message reminders on routine childhood vaccination: a systematic review and meta-analysis

BACKGROUND

The World Health Organization estimates that 29% of under-five mortality could be prevented with existing vaccines. However, non-consistent attendance for immunization appointments remains a global challenge to healthcare providers. Thus, innovative strategies are required to reach the last mile where technology could be effectively utilized to achieve better compliance with children immunization schedules. Therefore, the aim of the review was to systematically collect and summarize the available evidence on the effectiveness of text message reminders on childhood vaccination.

METHODS

This review was conducted according to a priori published protocol on PROSPERO. A systematic literature search of databases (PubMed/MEDLINE, EMBASE, Cochrane/Wiley library, and Science direct) was conducted. Eligibility and risk of bias assessments were performed independently by two reviewers. PRISMA flow diagrams were used to summarize the study selection process. Taking into account the level of heterogeneity, a random effects model was used and risk ratios with their 95% CI were used to present the pooled estimates. To investigate the sources of heterogeneity, subgroup analysis and meta-regression analysis were also considered. In this review, publication bias was assessed statistically using Harbord test.

RESULTS

A total of 1771 articles were searched. Out of those 1771 articles, 558 duplicated articles were removed. About 1213 articles were further screened, and finally, ten articles met the inclusion criteria. The meta-analysis showed that there is a significant effect of text message reminders on childhood vaccination coverage (RR = 1.11; 95% CI 1.05-1.17) with a moderate level of heterogeneity (I² = 64.3%, P = 0.003). The results from the Harbord test suggested that there is no evidence for publication bias (P = 0.340).

CONCLUSION

This review highlights the potential benefits of incorporating mobile text message reminders into the standard management of childhood immunizations, especially in low- and middle-income countries. The frequency and timing of the text message reminders are also crucial in determining the effectiveness of text message reminders. Hence, mHealth interventions deserve more attention as a potential innovation to improve healthcare programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074230.

Understanding the use of digital technology to promote human papillomavirus vaccination - A RE-AIM framework approach

The human papillomavirus virus (HPV) vaccine is effective at preventing various cancers, but coverage falls short of targets that are needed for community protection. Here, we use the RE-AIM implementation framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to understand how text, email, and electronic health record (EHR) reminders and social media campaigns can be used as part of policy and practice interventions to increase HPV vaccination. These technology-based interventions could be used together and mainstreamed into clinical and system-based practice to have the greatest impact. Of the interventions explored, text-based, email-based, and EHR reminders have the most evidence behind them to support their effectiveness. While there are several studies of promotion of the HPV vaccine on social media, more studies are needed to demonstrate their effects and better methods are needed to be able to attribute results to these interventions.

One-way SMS and healthcare outcomes in Africa: Systematic review of randomised trials with meta-analysis

Background

The impact of one-way SMS on health outcomes in Africa is unclear. We aimed to conduct a systematic review of one-way SMS randomised trials in Africa and a meta-analysis of their effect on healthcare appointments attendance and medicine adherence.

Methods

PubMed, Embase, CENTRAL, The Global Health Library, ClinicalTrials.gov, ICTRP, and PACTR were searched for published and unpublished trials in Africa without language restriction (up to April 2018). Trials reporting effect estimates on healthcare appointment attendance and medicine adherence were assessed for risk of bias and included in meta-analyses using random-effects models. Other outcomes were reported descriptively. The protocol is registered in PROSPERO, ID:CRD42018081062.

Results

We included 38 one-way SMS trials conducted in Africa within a broad range of clinical conditions. Eighteen trials were included in the meta-analyses, and four were assessed as overall low risk of bias. One-way SMS improved appointment attendance, OR:2·03; 95% CI:1·40–2·95 (12 trials, 6448 participants), but not medicine adherence, RR:1·10; 95% CI:0·98–1·23 (nine trials, 4213 participants). Subgroup analyses showed that one-way SMS had the highest impact on childhood immunization attendance, OR:3·69; 95% CI:1·67–8·13 (three trials, 1943 participants). There was no clear evidence of one-way SMS improving facility delivery, knowledge level (reproductive/antenatal health, hypertension), diabetes- and hypertension management.

Conclusion

In an African setting, the clinical effect of one-way SMS is uncertain except for appointment attendance where the effect seems to vary depending on which clinical condition it is used in.

Personalized Text Messages and Automated Calls for Improving Vaccine Coverage Among Children in Pakistan: Protocol for a Community-Based Cluster Randomized Clinical Trial

BACKGROUND

A major reason for poor childhood vaccine coverage in developing countries is the lack of awareness among parents and caregivers regarding the need for immunization and the importance of completing the entire series of vaccines. Short message service (SMS)-based interventions have been quite effective in different programs such as smoking cessation, treatment adherence, health care scheduled appointment attendance, antenatal care attendance, and compliance to immunization. However, there are limited data from low- and middle-income countries on the role of SMS and automated call-based messages and interventions to improve routine immunization (RI) coverage.

OBJECTIVE

The primary objective of this study is to evaluate whether automated mobile phone-based personalized messages (SMS or automated call) can improve RI uptake at 6, 10, and 14 weeks of age per the expanded program immunization schedule, compared with a usual care control group. Secondary objectives include assessing the effects of different types of automated SMS text or calls on RI coverage at 20 weeks of age.

METHODS

This is a mixed methods study using a clustered randomized controlled trial with 4 intervention arms and 1 control arm, augmented by qualitative interviews for personalizing the message. The study is being conducted in Pakistan (an urban site in Karachi and a rural site Matiari). In Karachi, 250 administrative structures are taken as 1 cluster, whereas in Matiari, a catchment area of 4 Lady Health Workers is considered as 1 cluster. The intervention targets families to receive weekly 1-way or 2-way (interactive) personalized automated SMS or automated phone call messages regarding vaccination. Possible barriers to vaccination are assessed in each family at the time of inclusion to determine the type of personalized messages that should be sent to the family to increase the chance of a positive response. Finally, in-depth interviews using purposive sampling are conducted before and after the trial to determine the family's vaccination experience and related factors.

RESULTS

All study participants for the cluster randomized trial were enrolled by January 14, 2019. Study exit interviews at 20-weeks follow-up visits will be completed by June 2019.

CONCLUSIONS

The results of this study will be useful to understand the respective effects of SMS text messages versus automated phone-based communication to improve RI coverage and timelines. Moreover, information regarding families' perceptions of vaccination and the daily life challenges for timely visits to the vaccine clinic will be used for developing more complex interventions that use mobile phone messages and possibly other approaches to overcome barriers in the uptake of correct and timely immunization practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03341195; https://clinicaltrials.gov/ct2/show/NCT03341195 (Archived by WebCite at http://www.webcitation.org/78EWA56Uo).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12851.

Automated phone call and text reminders for childhood immunisations (PRIMM): a randomised controlled trial in Nigeria

Background

Sub-Saharan Africa has high under-5 mortality and low childhood immunisation rates. Vaccine-preventable diseases cause one-third of under-5 deaths. Text messaging reminders improve immunisation completion in urban but not rural settings in sub-Saharan Africa. Low adult literacy may account for this difference. The feasibility and impact of combined automated voice and text reminders on immunisation completion in rural sub-Saharan Africa is unknown.

Methods

We randomised parturient women at the Mother and Child Hospitals Ondo State, Nigeria, owning a mobile phone and planning for child immunisation at these study sites to receive automated call and text immunisation reminders or standard care. We assessed the completion of the third pentavalent vaccine (Penta-3) at 18 weeks of age, immunisation completion at 12 months and within 1 week of recommended dates. We assessed selected demographic characteristics associated with completing immunisations at 12 months using a generalised binomial linear model with ‘log’ link function. Feasibility was assessed as proportion of reminders received.

Results

Each group had 300 mother−baby dyads with similar demographic characteristics. At 18 weeks, 257 (86%) and 244 (81%) (risk ratio (RR) 1.05, 95% CI 0.98 to 1.13; p=0.15) in the intervention and control groups received Penta-3 vaccine. At 12 months, 220 (74%) and 196 (66%) (RR 1.12, 95% CI 1.01 to 1.25; p=0.04) in the intervention and control groups received the measles vaccine. Infants in the intervention group were more likely to receive Penta-3 (84% vs 78%, RR 1.09, 95% CI 1.01 to 1.17; p=0.04), measles (73% vs 65%, RR 1.13, 95% CI 1.02 to 1.26; p=0.02) and all scheduled immunisations collectively (57% vs 47%, RR 1.13, 95% CI 1.02 to 1.26; p=0.01) within 1 week of the recommended date. No demographic character predicted immunisation completion. In the intervention group, 92% and 86% reported receiving a verification reminder and at least one reminder during the study period, respectively.

Conclusion

Paired automated call and text reminders significantly improved immunisation completion and timeliness.

Trial registration number

NCT02819895.