Implementing SMS reminders for routine immunization in Northern Nigeria: a qualitative evaluation using the RE-AIM framework.

BACKGROUND: Short Message Service (SMS) reminders have improved vaccine uptake in low- and middle-income countries (LMICs). However, the limited use of SMS reminders in LMICs requires evaluating the intervention's internal and external validity to improve adoption and sustainability. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we qualitatively assessed the impact of a SMS reminder intervention implemented in Kebbi State, Northwest Nigeria between May 20, 2019 and May 31, 2020. This will guide and inform future SMS reminder interventions to improve childhood immunization uptake in LMICs. METHODS: In June 2020, we conducted 14 focus group discussions, 13 in-depth interviews, and 20 key informant interviews among 144 purposively selected participants from five local government areas of Kebbi State. For analysis, we used a deductive approach to develop preliminary codes based on the RE-AIM framework and the inductive approach to generate themes that emerged from the interviews. RESULTS: The perceived importance and impact of the SMS reminder in improving demand and uptake for vaccinations were the consistent contributing factors that encouraged participants' participation. Other facilitators included the involvement of health workers in supporting SMS reminder registration and community gatekeepers using existing structures to convey messages on scheduled immunization services. Policymakers adopted the intervention because it aligns with the state's priority to improve immunization coverage. Similarly, the SMS reminder appealed to health workers and program managers because it reduced their workload and served as a performance monitoring tool to track immunization and intervention defaulters. Despite these, low mobile phone ownership and the inability to read text messages due to the low literacy level were the main barriers during implementation. Finally, data availability on cost-effectiveness and the intervention's impact on improving coverage was critical for scalability. CONCLUSIONS: Our study demonstrated that SMS reminders in local languages could improve vaccination demand and uptake in resource-constrained settings due to their perceived importance and impact. Addressing the cited implementation barriers and promoting the facilitators is critical to its adoption and sustainability. Costing and impact data are needed to collaborate findings on the effectiveness of the SMS reminder to improve childhood vaccination uptake.

Designing an SMS reminder intervention to improve vaccination uptake in Northern Nigeria: a qualitative study.

BACKGROUND: Penta3 coverage in Nigeria was low at 33 % in 2017. The most reported reason for non-vaccination was lack of knowledge about the immunization place, time, and need. To address knowledge gaps and improve vaccination uptake, we designed an Immunization Reminder and Information SMS System (IRISS) to educate and remind parents/caregivers about immunization using SMS. A formative study was conducted to understand the contextual and behavioural factors that would inform the IRISS intervention design and implementation. METHODS: We conducted the study in four Local Government Areas (LGAs) of Kebbi State Nigeria in October 2018, amongst a diverse selection of participants. Data on social norms about vaccinations, barriers to immunization uptake, mobile phone use, SMS message testing, and willingness to accept SMS reminders were collected from focus group discussions (N = 11), in-depth interviews (N = 12), and key informant interviews (N = 13). In addition, we assessed 33 messages covering schedule reminders, normative, motivational, educational, and informative contents for clarity, comprehensibility, relevance, cultural appropriateness, and ability to motivate action among community members from Argungu and Fakai LGAs. All interviews were analyzed using a thematic analysis approach. RESULTS: We interviewed 135 people, and 90 % were community members. While we found positive perceptions about immunizations among those interviewed, pockets of misconceptions existed among community members. Lack of awareness on the importance of vaccination was a consistent reason for under-vaccination across the LGAs. In addition, most community members do not own phones, could not read SMS messages, and were unaware of how to check/open text messages received. Despite concerns about low literacy levels and phone ownership, community members still saw a role in SMS reminders when phone owners receive messages. For instance, community leaders can disseminate said messages to community members through existing channels such as town announcers and religious gatherings. Therefore, the SMS becomes a source of information, with phone owners acting as a conduit to community dissemination mechanisms. We generally found the tested messages to be relevant, motivating, and culturally acceptable. CONCLUSIONS: SMS reminders have the potential to bridge the information gap in community awareness for vaccination, which can translate to improved immunization uptake. In rural communities with low literacy levels and phone ownership, immunization information can be disseminated when existing community leadership structures are engaged.

Human placenta processed for encapsulation contains modest concentrations of 14 trace minerals and elements.

Maternal placentophagy has recently emerged as a rare but increasingly popular practice among women in industrialized countries who often ingest the placenta as a processed, encapsulated supplement, seeking its many purported postpartum health benefits. Little scientific research, however, has evaluated these claims, and concentrations of trace micronutrients/elements in encapsulated placenta have never been examined. Because the placenta retains beneficial micronutrients and potentially harmful toxic elements at parturition, we hypothesized that dehydrated placenta would contain detectable concentrations of these elements. To address this hypothesis, we analyzed 28 placenta samples processed for encapsulation to evaluate the concentration of 14 trace minerals/elements using inductively coupled plasma mass spectrometry. Analysis revealed detectable concentrations of arsenic, cadmium, cobalt, copper, iron, lead, manganese, mercury, molybdenum, rubidium, selenium, strontium, uranium, and zinc. Based on one recommended daily intake of placenta capsules (3300 mg/d), a daily dose of placenta supplements contains approximately 0.018 ± 0.004 mg copper, 2.19 ± 0.533 mg iron, 0.005 ± 0.000 mg selenium, and 0.180 ± 0.018 mg zinc. Based on the recommended dietary allowance (RDA) for lactating women, the recommended daily intake of placenta capsules would provide, on average, 24% RDA for iron, 7.1% RDA for selenium, 1.5% RDA for zinc, and 1.4% RDA for copper. The mean concentrations of potentially harmful elements (arsenic, cadmium, lead, mercury, uranium) were well below established toxicity thresholds. These results indicate that the recommended daily intake of encapsulated placenta may provide only a modest source of some trace micronutrients and a minimal source of toxic elements.

Health effects following subacute exposure to geogenic dusts from arsenic-rich sediment at the Nellis Dunes Recreation Area, Las Vegas, NV.

Geogenic dust from arid environments is a possible inhalation hazard for humans, especially when using off-road vehicles that generate significant dust. This study focused on immunotoxicological and neurotoxicological effects following subacute exposure to geogenic dust generated from sediments in the Nellis Dunes Recreation Area near Las Vegas, Nevada that are particularly high in arsenic; the naturally-occurring arsenic concentrations in these surficial sediments ranged from 4.8 to 346µg/g. Dust samples from sediments used in this study had a median diameter of 4.5µm and also were a complex mixture of naturally-occurring metals, including aluminum, vanadium, chromium, manganese, iron, cobalt, copper, zinc, strontium, cesium, lead, uranium, and arsenic. Adult female B6C3F1 mice exposed via oropharyngeal aspiration to 0.01 to 100mg dust/kg body weight, four times, a week apart, for 28days, were evaluated 24h after the last exposure. Peripheral eosinophils were increased at all concentrations, serum creatinine was dose responsively increased beginning at 1.0mg/kg/day, and blood urea nitrogen was decreased at 10 and 100mg/kg/day. Antigen-specific IgM responses and natural killer cell activity were dose-responsively suppressed at 0.1mg/kg/day and above. Splenic CD4+CD25+ T cells were decreased at 0.01, 0.1, 10, and 100mg/kg/day. Antibodies against MBP, NF-68, and GFAP were selectively reduced. A no observed adverse effect level of 0.01mg/kg/day and a lowest observed adverse effect level of 0.1mg/kg/day were determined from IgM responses and natural killer cell activity, indicating that exposure to this dust, under conditions similar to our design, could affect these responses.