Abstract
BackgroundThere 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.ObjectiveThis 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.MethodsAn 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.ResultsDigital 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 Taking twice the time to complete both manual and digital entries and outdated phones over time were considered constraints.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.ConclusionsEmbedding 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.
Highlights
Types of Vaccine Live attenuated– Virus, e.g., oral polio vaccine (OPV), measles, yellow fever – Bacteria, e.g., Bacillus Calmette– Freeze-dried Guérin (BCG) Inactivated Whole – Virus, e.g., inactivated polio vaccine (IPV) – Bacteria, e.g., whole-cell pertussis Fractional – Protein-based– Subunit, e.g., acellular pertussis – Toxoid, e.g., diphtheria and tetanus – Polysaccharide-based – Pure, e.g. meningococcal – Conjugate, e.g., Haemophilus influenzae type b (Hib) Recombinant, e.g., hepatitis B required for full protection
In this hypothetical population consisting of only susceptible individuals, the disease can spread through the population exponentially, eventually infecting everyone because everyone will come in contact with an infected individual
In this hypothetical population where 75% of the population has been immunized, some non-immunized and susceptible individuals will not become infected because of the fact that they will not come in contact with an infected individual
Summary
Immunization Essentials: A Practical Field Guide has been produced and funded by the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S Agency for International Development (USAID). HRN-C00-00-00004-00, and is managed by Jorge Scientific Corporation with Futures Group International and John Snow, Inc. USAID would like to thank the CHANGE Project and the BASICS II Project for contributing expert technical staff to the preparation of this Guide.
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