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

Abstract

Background

Demand-side strategies could contribute to achieving high and timely vaccine coverage in rural Africa, but require platforms to deliver either messages or conditional cash transfers (CCTs). We studied the feasibility of using short message services (SMS) reminders and mobile phone-based conditional cash transfers (CCTs) to reach parents in rural Western Kenya.

Methods

In a Health and Demographic Surveillance System (HDSS), mothers with children aged 0–3 weeks old were approached to determine who had access to a mobile phone. SMS reminders were sent three days prior to and on the scheduled day of immunization for 1st (age 6 weeks) and 2nd doses (age 10 weeks) of DTP-HepB-Hib (Pentavalent) vaccine, using open-source Rapid SMS software. Approximately $2.00 USD was sent as cash using mPESA, a mobile money transfer platform (2/3 of mothers), or airtime (1/3 of mothers) via phone if the child was vaccinated within 4 weeks of the scheduled date. Follow-up surveys were done when children reached 14 weeks of age.

Results

We approached 77 mothers; 72 were enrolled into the study (26% owned a phone and 74% used someone else's). Of the 63 children with known vaccination status at 14 weeks of age, 57 (90%) received pentavalent1 and 54 (86%) received pentavalent2 within 4 weeks of their scheduled date. Of the 61 mothers with follow-up surveys administered at 14 weeks of age, 55 (90%) reported having received SMS reminders. Of the 54 women who reported having received SMS reminders and answered the CCT questions on the survey, 45 (83%) reported receiving their CCT. Most (89%) of mothers in the mPESA group obtained their cash within 3 days of being sent their credit via mobile phone. All mothers stated they preferred CCTs as cash via mobile phone rather than airtime. Of the 9 participants who did not vaccinate their children at the designated clinic 2(22%) cited refusals by husbands to participate in the study.

Conclusion

The data show that in rural Western Kenya mobile phone-based strategies are a potentially useful platform to deliver reminders and cash transfers. Follow-up studies are needed that provide evidence for the effectiveness of these strategies in improving vaccine coverage and timeliness.

Introduction

Despite clear evidence that immunization is an efficient and cost-effective intervention for improving child survival [1], children in many parts of the world, including much of sub-Saharan Africa, are either unvaccinated or vaccinated late [2]. Much of the efforts to augment immunization over the past decade have improved vaccine supply-side issues (e.g., cold chain, transportation, procurement, and staff training). As coverage improves, lingering deficits and barriers remain to achieving optimal immunization status, many of which cannot be overcome with more supply-side interventions. In particular, demand-side barriers, such as lack of knowledge, forgetfulness, prohibitive transport cost, and competing priorities come to play a more prominent role in impoverished populations with persistently low vaccine uptake.

The access and ownership of mobile phones in Africa is rapidly rising [3]. Mobile phones are increasingly being used for health applications (mHealth) and mobile money services (mMoney) [4], [5], [6], [7], [8]. We believe some of these new applications, could potentially be harnessed to administer interventions to achieve high, timely and sustainable immunization coverage. Short message services (SMSs) have been successfully employed for various health applications, such as promoting adherence to drug treatments for chronic diseases [9], [10], [11], uptake of screening tests [12], [13], [14], [15], immunization coverage [16], [17], [18], clinical appointment attendance [19], [20], and training health workers in malaria treatment [21].

mMoney refers to the technology that facilitates cash transfers through mobile phones. In many developing countries, mMoney provides an opportunity to reach rural and/or low-income population with limited access to formal financial institutions. In Kenya, the mPESA system is a leader in offering mobile financial services, currently claiming 14 million users [22], approximately 30–35% of the total population (43 million) [23].

Economic incentives targeting both health care providers [24] and the general population have been used to improve health outcomes by encouraging use of various health services, including immunizations [25], [26], [27]. A specific type of incentive is conditional cash transfers (CCTs), which are the provision of money (or other valuable goods) upon completion of a particular health behavior [26], [27], [28], [29].

Evidence is needed before scaling up mobile-phone based strategies for immunization. We undertook a feasibility study of using automated SMS reminders and mobile-phone based CCTs for timely immunization among mothers in rural Western Kenya.