Elsevier

Vaccine

Volume 34, Issue 2, 4 January 2016, Pages 276-283
Vaccine

Use of mobile phones for improving vaccination coverage among children living in rural hard-to-reach areas and urban streets of Bangladesh

https://doi.org/10.1016/j.vaccine.2015.11.024Get rights and content

Abstract

In Bangladesh, full vaccination rates among children living in rural hard-to-reach areas and urban streets are low. We conducted a quasi-experimental pre-post study of a 12-month mobile phone intervention to improve vaccination among 0–11 months old children in rural hard-to-reach and urban street dweller areas. Software named “mTika” was employed within the existing public health system to electronically register each child's birth and remind mothers about upcoming vaccination dates with text messages. Android smart phones with mTika were provided to all health assistants/vaccinators and supervisors in intervention areas, while mothers used plain cell phones already owned by themselves or their families. Pre and post-intervention vaccination coverage was surveyed in intervention and control areas. Among children over 298 days old, full vaccination coverage actually decreased in control areas – rural baseline 65.9% to endline 55.2% and urban baseline 44.5% to endline 33.9% – while increasing in intervention areas from rural baseline 58.9% to endline 76*8%, difference +18.8% (95% CI 5.7–31.9) and urban baseline 40.7% to endline 57.1%, difference +16.5% (95% CI 3.9–29.0). Difference-in-difference (DID) estimates were +29.5% for rural intervention versus control areas and +27.1% for urban areas for full vaccination in children over 298 days old, and logistic regression adjusting for maternal education, mobile phone ownership, and sex of child showed intervention effect odds ratio (OR) of 3.8 (95% CI 1.5–9.2) in rural areas and 3.0 (95% CI 1.4–6.4) in urban areas. Among all age groups, intervention effects on age-appropriate vaccination coverage were positive: DIDs +13.1–30.5% and ORs 2.5–4.6 (p < 0.001 in all comparisons). Qualitative data showed the intervention was well-accepted. Our study demonstrated that a mobile phone intervention can improve vaccination coverage in rural hard-to-reach and urban street dweller communities in Bangladesh. This small-scale successful demonstration should serve as an example to other low-income countries with high mobile phone usage.

Introduction

Childhood immunization reduces child mortality from preventable diseases; however, children living in remote rural areas and on urban streets have lower immunization rates and worse health outcomes [1], [2], [3], [4], [5]. Bangladesh has a robust Expanded Programme on Immunization (EPI) with full vaccination coverage in 12–23 months old children of 81% nationally, but only 42–60% in 22 rural hard-to-reach districts and 70% in Dhaka city slums [1], [6], [7]. Prior interventions in Bangladesh to increase vaccinations have included improving EPI services with extended EPI times, additional training for service providers, and active screening for unimmunized children in acute care facilities as well as improving community health-seeking behavior with education, immunization support groups, and health provider outreach to communities [6], [7], [8], [9]. These interventions can successfully increase vaccination coverage, however, they are not cost-effective at large scale [9].

One considerable challenge is accurately tracking children and vaccinations, especially in remote rural and urban street dweller populations [2], [6]. A recent systematic review found poor agreement between parental recall, EPI cards, and official health records for vaccination history, but only 5 studies were in low-mid income countries (LMICs) [10], [11], [12]. A separate review of Demographic and Health Surveys and UNICEF's Multiple Indicator Cluster Sample surveys in 101 countries, mostly LMICs, found only 55% of children had available EPI cards, but good correlation existed between maternal report (not general household report) and EPI cards [13]. While mothers without cards can over or underestimate vaccinations depending on social desirability, education, and/or misremembering multiple doses, many studies show consistency in maternal recall and underestimation of true vaccination coverage if using only EPI cards [11], [13], [14]. Moreover, children who have never received vaccines would not have EPI cards. Studies in Asia and Bangladesh show high correlation between maternal recall and EPI cards, and most EPI programs in LMICs use maternal recall with EPI cards to better track vaccination coverage [1], [13], [14].

One strategy yet to be researched in Bangladesh is using mobile phones to increase child immunizations by better tracking and reminders. Mobile health (mHealth) programs have gained popularity worldwide to communicate health information at low cost to large groups of people, including hard-to-reach or geographically remote communities [15], [16], [17], [18], [19]. Mobile phones have been shown to increase vaccination of underserved populations in Thailand, India, and Brazil [20], [21], [22]. Moreover, mobile phone parental reminders linked to electronic medical records and immunization registries can be used in large populations at low cost [23], [24], [25]. In Bangladesh, mobile phone ownership increased from 32% in 2007 to 78% in 2011, and mHealth services have increased for several years [26]. However, there is little published research on health impacts of mHealth interventions in Bangladesh [17], [18], [19], [27], [28].

We hypothesized that a mobile phone vaccination registration and reminder system could improve child vaccination coverage in rural hard-to-reach and urban street dweller populations of Bangladesh. Our overall objective was to develop and test a mechanism to use mobile phones to improve child vaccination coverage using the existing Bangladesh public health system, and our specific aims were to assess feasibility and effectiveness of our mobile phone system of vaccination registry, newborn tracking, and parental reminders in rural hard-to-reach and urban street dweller areas.

Section snippets

Study design and sites

We conducted a quasi-experimental pre-post study to compare vaccination coverage before and after our mobile phone intervention in rural hard-to-reach and urban street dweller populations. We conducted this study through the existing Bangladesh public health system from April 2013 to March 2014. We selected two control and two intervention areas first by geography and then by demographic and health characteristics. We chose two rural hard-to-reach upazilas (sub-districts) in Sunamgonj district,

Intervention

We adapted an Android smartphone application connected with a web database named “mTika” created by a research team working with the Bangladesh Ministry of Health and Family Welfare's (MOHFW) Management Information System department. mTika included: (i) smart phone-based registration of pregnant women, (ii) short message service (SMS) birth notifications from mothers, (iii) automated SMS vaccination reminders to mothers, (iv) vaccination reminders for health workers, and (v) smart phone and

Results

Sociodemographic characteristics of the study population are shown in Table 1. We sampled between 518 and 522 children across all urban and rural, control and intervention groups at baseline and endline. Approximately half of mothers were under 25 years old and 11–26% had completed primary education or higher. Mobile phones were accessible to over 70% of mothers, with 28–51% owning phones and 42–53% sharing phones. χ2 tests revealed statistically significant differences across groups in

Discussion

This quasi-experimental pre-post intervention study demonstrated that use of a mHealth approach to strengthen routine immunization programs in the existing public health system in Bangladesh was acceptable and successful in increasing vaccination coverage among children in rural hard-to-reach and urban street dweller communities. Using information and communications technology for health systems strengthening is a fast-growing arena of global health, but many interventions lack rigorous

Conclusions

Use of mobile phone for improving vaccination coverage in rural hard-to-reach and urban street dweller communities in Bangladesh is feasible and has measurable health impact. Key next steps are research in mechanisms to increase mTika intervention's health impacts, scalability, sustainability, and cost-effectiveness. This small-scale successful demonstration could serve as an example to other low-income countries with high mobile phone usage and robust EPI programs.

Contributors

JU was the Principal Investigator of the study and was involved in every aspect of the study and manuscript from conceptualization to implementation to manuscript writing and submission. MS was involved in study implementation and data analysis. LH and NA were involved in literature review, data analysis and manuscript writing. AL contributed to the adaptation of mTika and manuscript review. MC, LV, and KZ contributed to study implementation and manuscript review. CP and DB are senior

Conflict of interest

The authors report no conflicts of interest.

Acknowledgments

This research was funded by Grand Challenges Canada (GCC). The icddr,b and the authors acknowledge with gratitude the commitment of GCC. The authors acknowledge with gratitude the support of Directors of Management Information System and Primary Health Care of MOHFW who supported using their central server and implementation of the study. The authors acknowledge the support of Ms. Tahmina Sultana, Mr. Wazed Ali, Ms. Sharmin Louis, Mr. Shahabuddin Ahmed and Ms. Roksana Karim of icddr,b who

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