Evaluating Zindagi Mehfooz- Electronic Immunization Registry and suite of digital health interventions to improve the coverage and timeliness of immunization services : A mixed methods study in Sindh, Pakistan.

BACKGROUND: Zindagi Mehfooz (Safe Life) Electronic Immunization Registry (ZM-EIR) is a comprehensive suite of digital health interventions that aims to improve equitable access, timeliness, and coverage of child immunizations through a smartphone-based application (app) for vaccinators, web-based dashboards for supervisors and managers, text message alerts and reminders for caregivers, and a call center. It has been implemented at scale in Sindh Province in Pakistan. OBJECTIVE: This paper presents findings from an evaluation of Zindagi Mehfooz, electronic immunization registry (ZM-EIR) and suite of digital health interventions, aimed at improving data availability and use as a contribution among other immunization program interventions to improved immunization outcomes for children 12-23 months in Sindh Province, Pakistan. METHODS: The mixed-methods study included a) Analysis of ZM-EIR system data to identify high- moderate- and low- adoption and compliance sites, b) In-depth interviews with caregivers, vaccinators, supervisors, and managers; and c) Pre-post outcome evaluation using vaccine coverage from the Multiple Indicator Cluster Surveys (MICS) 2014 and 2018-2019. Key outcomes of interest were improved data availability and use and contributions to immunization outcomes, including receipt of individual antigens (BCG, Penta I-III, Measles), full immunization (all antigens), and zero dose children defined as children aged 6 to 23 months that have not received the first dosage of DPT1/Penta. RESULTS: By registering newborns, providing alerts and reminders, and tracking their immunization completion, ZM-EIR improved data availability and use within the Essential Program for Immunization (EPI) in Sindh, Province. ZM-EIR was well received by EPI administrators, supervisors, vaccinators, and caregivers. The key benefit highlighted by ZM-EIR users is a list of children who missed scheduled vaccines (defaulters). Through greater availability and use of data, the ZM-EIR implementation as part of a broader package of immunization program strengthening activities in Sindh Province may have contributed to an increase in immunization coverage and timeliness for BCG and decrease in zero-dose children in 2018-2019 from 2014. Additional findings from the study included the dual burden of reporting on paper and gender-related considerations of female caregivers not wanting to give their phone numbers to male vaccinators, creating barriers to greater uptake of ZM-EIR. CONCLUSIONS: ZM-EIR is a promising technology platform that has increased the availability and use of immunization data that may have contributed along with other intensive immunization program investments to improvements in immunization outcomes through systematic registration of children, alerts and reminders, and increased use of data for planning and monitoring by the EPI Program.

Integrating humanities in healthcare: a mixed-methods study for development and testing of a humanities curriculum for front-line health workers in Karachi, Pakistan.

Lady health workers (LHWs) provide lifesaving maternal and child health services to >60% of Pakistan's population but are poorly compensated and overburdened. Moreover, LHWs' training does not incorporate efforts to nurture attributes necessary for equitable and holistic healthcare delivery. We developed an interdisciplinary humanities curriculum, deriving its strengths from local art and literature, to enhance character virtues such as empathy and connection, interpersonal communication skills, compassion and purpose among LHWs. We tested the curriculum's feasibility and impact to enhance character strengths among LHWs.We conducted a multiphase mixed-methods pilot study in two towns of Karachi, Pakistan. We delivered the humanities curriculum to 48 LHWs via 12 weekly sessions, from 15 June to 2 September 2021. We developed a multiconstruct character strength survey that was administered preintervention and postintervention to assess the impact of the training. In-depth interviews were conducted with a subset of randomly selected participating LHWs.Of 48 participants, 47 (98%) completed the training, and 34 (71%) attended all 12 sessions. Scores for all outcomes increased between baseline and endline, with highest increase (10.0 points, 95% CI 2.91 to 17.02; p=0.006) observed for empathy/connection. LHWs provided positive feedback on the training and its impact in terms of improving their confidence, empathy/connection and ability to communicate with clients. Participants also rated the sessions highly in terms of the content's usefulness (mean: 9.7/10; SD: 0.16), the success of the sessions (mean: 9.7/10; SD: 0.17) and overall satisfaction (mean: 8.2/10; SD: 3.3).A humanities-based training for front-line health workers is a feasible intervention with demonstrated impact of nurturing key character strengths, notably empathy/connection and interpersonal communication. Evidence from this study highlights the value of a humanities-based training, grounded in local literature and cultural values, that can ultimately translate to improved well-being of LHWs thus contributing to better health outcomes among the populations they serve.

Development and feasibility testing of an artificially intelligent chatbot to answer immunization-related queries of caregivers in Pakistan: A mixed-methods study.

BACKGROUND: Gaps in information access impede immunization uptake, especially in low-resource settings where cutting-edge and innovative digital interventions are limited given the digital inequity. Our objective was to develop an Artificially Intelligent (AI) chatbot to respond to caregiver's immunization-related queries in Pakistan and investigate its feasibility and acceptability in a low-resource, low-literacy setting. METHODS: We developed Bablibot (Babybot), a local language immunization chatbot, using Natural Language Processing (NLP) and Machine Learning (ML) technologies with Human in the Loop feature. We evaluated the bot through a sequential mixed-methods study. We enrolled caregivers visiting the 12 selected immunization centers for routine childhood vaccines. Additional caregivers were reached through targeted text message communication. We assessed Bablibot's feasibility and acceptability by tracking user engagement and technological metrics, and through thematic analysis of in-depth interviews with 20 caregivers. FINDINGS: Between March 9, 2020, and April 15, 2021, 2,202 caregivers were enrolled in the study, of which, 677 (30.7%) interacted with Bablibot (users). Bablibot responded to 1,877 messages through 874 conversations. Conversation topics included vaccination due dates (32.4%; 283/874), side-effect management (15.7%;137/874), or delaying vaccination due to child's illness or COVID-lockdown (16.8%;147/874). Over 90% (277/307) of responses to text-based exit surveys indicated satisfaction with Bablibot. Qualitative analysis showed caregivers appreciated Bablibot's usefulness and provided feedback for further improvement of the system. CONCLUSION: Our results demonstrate the feasibility and acceptability of local-language NLP chatbots in providing real-time immunization information in low-resource settings. Text-based chatbots canminimize the workload on helpline operators, in addition to instantaneously resolving caregiver queries that otherwise lead to delay or default.

Evaluating an immunization carpool service for women in rural areas for facilitating routine childhood immunizations in Pakistan -a feasibility study on acceptability, demand, and implementation.

Introduction: Poor accessibility of immunization services coupled with limited options for transportation and socio-cultural norms that hinder women's mobility are among the key factors contributing to poor immunization coverage in rural areas. We assessed the feasibility and acceptability of establishing a free-of-cost, women-only carpool service for immunization in a rural setting in Pakistan and evaluated its preliminary impact on immunization coverage and timeliness among children. Methods: We conducted a feasibility study in four selected immunization facilities in Shikarpur District, Sindh. A local transport vehicle was hired and branded as an immunization carpool service. Women having un- or under-immunized children aged ≤2 years were invited to visit immunization facilities using carpool vehicles. Information on demographic indicators and service experience was collected. Child immunization details were extracted using the government's provincial electronic immunization registry to estimate immunization coverage and timeliness. Results: Between January and October 2020, six immunization carpool vehicles provided uninterrupted service and transported 2422 women-child pairs, completing 4691 immunization visits. Majority of women reported that the carpool service improved accessibility (99.6%) by offering group travel (82.9%) and reducing their dependency on family members (93.4%). Preliminary estimates reported an increase in immunization coverage and timeliness across antigens among participating children compared to non-participating children, with significant increase in proportion for BCG coverage (38.1%; p < 0.001, CI: 32.8%, 43.4%) and measles-2 timeliness (18%; p < 0.001, CI: 13.3%, 22.4%). Conclusion: A women-only immunization carpool service implemented within a rural setting is feasible and highly acceptable. Key factors contributing to the model's success include increased mobility and independence of women, cost-savings, and a culturally and contextually appropriate mechanism of transport embedded within the local setting. Increased accessibility to health services also contributed to improved immunization coverage and timeliness among children.