Applying a governance barometer to vaccine delivery systems: Lessons from a rural district of Pakistan

Zaidi, Shehla; Riaz, Atif; Hussain, Syed Shahzad; Omer, Saad B.; Ali, Syed Asad

doi:10.1016/j.vaccine.2019.10.052

Cited by 4 publications

(5 citation statements)

References 22 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The immunization app was developed over a 6-month field testing period in 2014-2015 and was implemented in 2015-2017. The principal investigator (SZ) conducted a baseline assessment of routine immunization delivery in the district and identified the reporting of incomplete, questionable immunization EPI data and poor use in the TMK district [19]. During the assessment, management information system records were reviewed, and EPI officials, vaccinators, health workers, and health facility managers were interviewed.…”

Section: Mhealth Interventionmentioning

confidence: 99%

“…Despite the proliferation of mHealth apps, not all digital health programs perform as intended, and assessments of the technology, health systems, and behavioral factors need careful consideration [18]. In particular, mHealth programs that rely on the performance of health workers would benefit from qualitative research to understand the extent to which end users and decision makers are prepared to engage with mHealth technology [19,20]. Experience from high-income settings emphasizes a user-centric approach to the development of digital technology [21].…”

Section: Introductionmentioning

confidence: 99%

“…However, paper records are poorly maintained and have questionable data. In addition, evidence suggests that vaccinators make too few outreach visits, provide little routine immunization education for parents, and maintain poor records [19]. Anecdotal evidence also suggests that vaccinators are resistant to supervision and often enjoy political patronage from local legislators protecting them from accountability on work performance [24].…”

Section: Introductionmentioning

confidence: 99%

“…Improvement in the vaccine coverage rate from 2014 to 2017 during the Health Systems Strengthening (HSS) immunization pilot study[19].…”

mentioning

confidence: 99%

See 3 more Smart Citations

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

Zaidi¹,

Shaikh²,

Sayani³

et al. 2019

Preprint

Self Cite

View full text Add to dashboard Cite

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.

show abstract

Section: Mhealth Interventionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…Improvement in the vaccine coverage rate from 2014 to 2017 during the Health Systems Strengthening (HSS) immunization pilot study[19].…”

mentioning

confidence: 99%

See 2 more Smart Citations

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

Zaidi¹,

Shaikh²,

Sayani³

et al. 2019

Preprint

Self Cite

View full text Add to dashboard Cite

show abstract

“…Hayat app is a mobile-based application for CHWs piloted in remote areas of Pakistan and Afghanistan for reporting and tracking community-based immunization and maternity services. The application is a scale-up version of the Teeko application earlier piloted by the Aga Khan University for immunization performance tracking of government vaccinators (9) and was one of a package of interventions that led to enhancement in immunization coverage (10). The detailed methodology of the Hayat app was published in our previous paper (6) and involved the provision of mobile Android phones for reporting the frequency of household visits, services provided during household visits as well as household immunization and maternity care status.…”

Section: Introductionmentioning

confidence: 99%

End User Experience of Hayat App and Dashboard: A Qualitative Assessment of Usability, Community Engagement, and Validity of Data for Antenatal Care Provision And Routine Immunization in Rural Pakistan And Afghanistan

Nawaz,

Zaidi,

Rashid

et al. 2023

Preprint

Self Cite

View full text Add to dashboard Cite

Introduction Pakistan and Afghanistan have an extensive network of community health workers (CHWs) who provide counseling to rural households on basic maternal and child care (MCH), report household service coverage, and provide referrals to health centers. An android-based mobile health application for maternal and child health was piloted in underserved remote areas within Northern Pakistan and bordering Bamyan and Badakshan provinces of Afghanistan to enable community health workers in Afghanistan and both community health workers and vaccinators in Pakistan, to report real-time data on outreach visits as well as immunization and maternity health coverage of eligible clients. A qualitative assessment of health worker experience with the Mobile App was carried out as part of the end-line assessment of the pilot. Objective The objective was to examine the end-user perceptions of the usability of the digital application data, community acceptability of the data, and use of data supervision and management decisions. The purpose was to identify barriers and enablers to inform the integration of the mhealth application for reporting by community health workers within the district health systems in an LMIC setting. Methods Primary data was collected through focus group discussions with frontline health workers and key informant interviews with field supervisors as well as sub-national managers. Seventeen focus group discussions were carried out within purposely selected study catchment sites. These included 9 FGDs with community-based Lady Health Workers (LHWs), LHW supervisors, and vaccinators in Northern Pakistan; and 8 FGDs with Community Health Workers (CHWs) and CHW supervisors. Additionally, 28 key informant interviews were carried out with field supervisors, immunization, and MCH managers at the district and provincial levels. Deductive thematic content analysis was undertaken based on an adapted framework from the World Health Organization guide for “Monitoring and Evaluating Digital Health Interventions” and the Technology Acceptance Model (TAM). Findings Frontline health workers perceived the application to be highly usable and the use of Android phones for reporting was reported to be acceptable to the communities as long as photographic evidence was not collected. Increased workload due to both paper and digital reporting, occasional connectivity issues, and security issues with the use of mobile phones in certain areas were key primary barriers, whereas low motivation and increasing task load of frontline health workers were secondary issues reported. Supervisors and health managers perceived an improvement in the timeliness of data reporting by frontline health workers as well as more complete reporting. The app-collected data was perceived to facilitate data verification on the ground and managers were more confident of the reliability of digital reporting as compared to paper-based records. Conclusion: The use of the smartphone-based application has good acceptability among frontline health workers and their managers and was perceived to provide more reliable data timely data as compared to paper-based reporting benefits. The duplicative paper-based system, security in remote areas, and chronic issues with health worker programs are challenges that need to be encountered for embedding within the health system.

show abstract

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

Zaidi

Shaikh

Sayani

et al. 2020

JMIR Mhealth Uhealth

View full text Add to dashboard Cite

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.

show abstract

Applying a governance barometer to vaccine delivery systems: Lessons from a rural district of Pakistan

Cited by 4 publications

References 22 publications

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

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

End User Experience of Hayat App and Dashboard: A Qualitative Assessment of Usability, Community Engagement, and Validity of Data for Antenatal Care Provision And Routine Immunization in Rural Pakistan And Afghanistan

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

Contact Info

Product

Resources

About