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

Dustin G Gibson,Orin S Levine,Daniel R Feikin,Joyce Were,E Wangeci Kagucia,Kyla Hayford,Lawrence H Moulton,Benard Ochieng,Katherine L O'Brien,Frank Odhiambo

doi:10.1016/s2214-109x(17)30072-4

Abstract

SummaryBackgroundAs mobile phone access continues to expand globally, opportunities exist to leverage these technologies to support demand for immunisation services and improve vaccine coverage. We aimed to assess whether short message service (SMS) reminders and monetary incentives can improve immunisation uptake in Kenya.MethodsIn this cluster-randomised controlled trial, villages were randomly and evenly allocated to four groups: control, SMS only, SMS plus a 75 Kenya Shilling (KES) incentive, and SMS plus 200 KES (85 KES = USD$1). Caregivers were eligible if they had a child younger than 5 weeks who had not yet received a first dose of pentavalent vaccine. Participants in the intervention groups received SMS reminders before scheduled pentavalent and measles immunisation visits. Participants in incentive groups, additionally, received money if their child was timely immunised (immunisation within 2 weeks of the due date). Caregivers and interviewers were not masked. The proportion of fully immunised children (receiving BCG, three doses of polio vaccine, three doses of pentavalent vaccine, and measles vaccine) by 12 months of age constituted the primary outcome and was analysed with log-binomial regression and General Estimating Equations to account for correlation within clusters. This trial is registered with ClinicalTrials.gov, number NCT01878435.FindingsBetween Oct 14, 2013, and Oct 17, 2014, we enrolled 2018 caregivers and their infants from 152 villages into the following four groups: control (n=489), SMS only (n=476), SMS plus 75 KES (n=562), and SMS plus 200 KES (n=491). Overall, 1375 (86%) of 1600 children who were successfully followed up achieved the primary outcome, full immunisation by 12 months of age (296 [82%] of 360 control participants, 332 [86%] of 388 SMS only participants, 383 [86%] of 446 SMS plus 75 KES participants, and 364 [90%] of 406 SMS plus 200 KES participants). Children in the SMS plus 200 KES group were significantly more likely to achieve full immunisation at 12 months of age (relative risk 1·09, 95% CI 1·02–1·16, p=0·014) than children in the control group.InterpretationIn a setting with high baseline immunisation coverage levels, SMS reminders coupled with incentives significantly improved immunisation coverage and timeliness. Given that global immunisation coverage levels have stagnated around 85%, the use of incentives might be one option to reach the remaining 15%.FundingBill & Melinda Gates Foundation.

Highlights

Immunisation programmes are estimated to save more than 2·5 million lives worldwide.[1]
We found no examples of randomised controlled trials that assessed the efficacy of short message service (SMS) reminders to improve immunisation coverage or immunisation timeliness in low-income and middle-income countries
The conduct, analysis, and reporting of results were done in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines adapted for cluster-randomised trials.[23]

Summary

Introduction

Immunisation programmes are estimated to save more than 2·5 million lives worldwide.[1]. Global coverage levels have stalled at about 85%.2. Innovative interventions that address the remaining 15% (ie, the last mile) are needed because this subpopulation represents a group of individuals at disproportionate risk of disease. The decade 2010–2019 has been designated the Decade of Vaccines, with a renewed focus on improving immunisation coverage by major international groups and the development of the Global Vaccine Action Plan (GVAP).[3] A key component of GVAP is the recognition that both supply-side and demand-side deficiencies need to be addressed to achieve universal immunisation.[4] Efforts to make vaccines accessable to children even in the most remote places have made great progress. Children remain undervaccinated, which might be, in part, because of residual demand-side constraints

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