Pandemic disruptions in vaccine uptake in a low-income setting: a qualitative inquiry.

BACKGROUND: While the COVID-19 pandemic has exposed the vulnerabilities of immunization delivery systems globally, the devastating impact of the pandemic on immunization delivery is most pronounced in low and middle-income countries like Pakistan. We conducted a qualitative study to capture the views and experiences of parents and healthcare workers (HWs) and assess the impact of the COVID-19 pandemic on childhood routine immunization (CRI) and COVID-19 vaccination in Pakistan. METHODS: We used a qualitative research design with a purposive sampling approach. Semi-structured interviews (via telephone) and focus group discussions (via Zoom) were conducted with parents/child caregivers and HWs, respectively. All qualitative interviews were conducted between February and July 2021 from three sites (two urban and one rural) in Sindh, Pakistan. Interviews were audio-recorded, transcribed, and coded for a team-based thematic analysis. RESULTS: Overall, most parents and HWs indicated a strong trust in the benefits of CRI; nonetheless, a substantial disruption in the delivery and uptake of these services was also reported. The barriers towards CRI included closed vaccination centers, drastic reduction in outreach programs, lack of information for parents/child caregivers on vaccine availability, fear in the community regarding vaccine safety, limited vaccine supply, and a lack of healthcare staff. For COVID-19 vaccines, challenges cited included skepticism about the reality of the pandemic and confusion over COVID-19 vaccines due to conflicting (or mis-or-dis) information. Both participant groups showed a willingness to integrate COVID-19 vaccination into Pakistan's Expanded Program for Immunization if required in the future. CONCLUSION: During the COVID-19 pandemic, disruptions of regular immunization delivery in Pakistan were not due to parental unwillingness to vaccinate, but rather to social and logistical challenges caused by a rapidly changing context and difficulties in providing vaccination services safely. Barriers to vaccine access and concerns about COVID-19 exposure during clinic visits also contributed to uncertainty regarding immunization services early in the pandemic. For catchup campaigns and future pandemics, more than focusing interventions on persuading people, strategic approaches to building resilience through system-based interventions, such as investing in surge capacity in the immunization workforce to bounce back quickly after the first shock are required.

Postmortem minimally invasive tissue sampling in communities: exploring perceptions of families, funeral workers, religious and community leaders and healthcare providers from Pakistan.

BACKGROUND: Minimally invasive tissue sampling (MITS) has increasingly been used to improve the diagnosis of disease and identification of the cause of death, particularly in underserved areas. However, there are multiple barriers to accessing those who die within the community, our study aimed to explore the perceptions and insights of community members and healthcare providers regarding the feasibility of implementing MITS in community settings. METHODS: A qualitative exploratory study was conducted. A total of twenty one in-depth interviews were conducted with deceased infants' parents, elders of the family, religious leaders, community leaders, and funeral workers. Focus group discussions were conducted with health care providers (n = 14) in two peri-urban slum areas of Karachi, Pakistan. The duration of this study was from August to October 2020. Data was analyzed using thematic analysis and was coded and merged into categories forming eight major themes. RESULTS: In general, participants viewed minimally invasive tissue sampling (MITS) as beneficial for improving child health, though some had concerns about disrespecting the deceased during sample collection. Misinformation, fear of needles, and medical procedures were major barriers to MITS implementation. To enhance acceptance, community and religious leaders suggested using religious rulings, obtaining parental consent, ensuring confidentiality, and increasing efforts of community engagement. Community healthcare providers, along with funeral workers, recommended providing community members with grief counseling to increase study participation. Besides concerns about sampling interfering with respect for the decease, community members also raised concerns about misinformation. Further, participants provided feedback on the design and appearance of the mobile van used to collect MITS samples from children under the age of five. CONCLUSION: This study is critical for understanding the challenges associated with implementation of community-based MITS sampling in Pakistan. Integrating the use of a mobile van for sample collection, grief counseling along with community engagement sessions and advocacy will help address community-based misinformation and develop community trust.

Characteristics of mobile phone access and usage among caregivers in Pakistan - A mHealth survey of urban and rural population.

INTRODUCTION: Globally mobile ownership and access is becoming very common, and breakthroughs in mobile technology have shaped digital communication, with 7 billion mobile phone users globally. Developing countries account for 80% of newly purchased mobile phone devices with majority of such countries having low Routine Immunization coverage and a high risk of vaccine preventable diseases. The use of mobile phones provides a tremendous potential for public health involvement. OBJECTIVE: The aim of this study is to assess the acceptability and usability of mobile phones among infant caregivers in a LMIC setup and to explore the role of mHealth to improve immunization uptake and coverage. METHODS: This is a cross-sectional survey exploring the regional differences in mobile phone ownership, usability and preferences, along with level of trust with others while sharing a mobile phone. The study was conducted with caregivers of infants in an urban and rural sites of Pakistan. RESULTS: A total of 4472 households were approached, of which 3337 participants were eligible for the study (74.61 %). The reasons for not participating in the study (n = 1135) included (i) household locked or refusal to participate for 594 families (52%), (ii) child older than 14 days of life in 409 cases (36%), (iii) 80 (7%) families did not have access to a functional mobile phone, (iv) 36 (3%)families did not provide a mobile phone number, and (v) 14 (1%) could not stay within the HDSS for 6 months. Access to mobile phone with SMS features was considerably high at both sites: 99.1% in Matiari (rural site) and 96.7% in Karachi (urban). In Matiari 96.6% of the respondents reported having daily access to the phone, contrasting with only 51.4% in Karachi. In Karachi, the predominant spoken language was Urdu, whereas majority of the respondents in Matiari spoke Sindhi (34.6% vs. 70.9%). CONCLUSION: Our study indicates high access to mobile phone in both urban and rural setup, However access to smart phone is still limited, urban and rural setup. Further, the acceptance of overall health- and barrier-based child immunization messages through mobile phone were quite high in both settings. Lastly automated calls were preferred over SMS due to literacy and local settings. This bears important implications for improving child immunization uptake through mobile phones in developing regions such as Pakistan.

Usability and Acceptability of a Mobile App for Behavior Change and to Improve Immunization Coverage among Children in Pakistan: A Mixed-Methods Study.

BACKGROUND: Pakistan's immunization uptake rates are still significantly lower than anticipated despite several initiatives. Lack of awareness, forgetting about vaccination schedule, and vaccine misconception/misinformation are a few of the major drivers that mitigate the rates of immunization. The current COVID-19 pandemic emphasizes the importance of immunization. The significant reductions in regular childhood vaccination during pandemic have increased the risk of outbreaks of vaccine-preventable diseases. Concerns among parents over possibly exposing their children to COVID-19 during child visits may have contributed to the reported declines. Innovative and cost-effective mHealth interventions must be implemented in order to address the problem of inadequate immunization rates. In addition, it is also critical to understand the end user needs in order to reflect on the highly relevant essence of the customized healthcare experience. OBJECTIVE: The aim of this study was to learn about caregivers' attitudes toward the usability and acceptability of behavior-change smartphone applications (mobile phones) for improving immunization coverage in Pakistan. METHODS: A mixed-method design was employed for this study. The study was conducted at Aga Khan University, Hospital. Parents visiting the Community Health Center for 6-week vaccination of their children were recruited. The study was conducted in two stages. Stage 1 consisted of qualitative interviews that grasped the parent's attitudes and challenges to immunization, as well as their acceptability and accessibility of the smartphone-based behavior-change application to increase vaccine uptake. Stage 1 was followed by stage 2, in which data were collected through a questionnaire designed by using data from qualitative interviews. RESULTS: The majority of participants agreed that immunization serves an important role in protecting their child from illnesses that cause morbidity and mortality. Almost all of them emphasized the importance of using a pre-appointment method at vaccination center in order to reduce the waiting time. Furthermore, participants were also interested in AI-based behavior modification applications related to immunization. They also wanted to have applications in their native language for better understanding and communication of related information. In our study, approximately 95.2 percent of participants agreed to accept SMS immunization updates, which was also reasonably high. Lastly, the majority of them identified forgetfulness as a significant contributor to regular immunization. CONCLUSION: To enhance the uptake of childhood vaccines, overall vaccination rates, and overcome barriers related to vaccination coverage, cost-effective and user-friendly mHealth AI-based smart phone applications are required to raise awareness regarding the continuation of vaccination service and the importance of timely vaccination. Parents' experiences and attitudes must be considered while designing and evaluating the efficacy of mHealth-based interventions.

Respiratory Syncytial Virus-Associated Mortality Among Young Infants in Karachi, Pakistan: A Prospective Postmortem Surveillance Study.

BACKGROUND: Respiratory syncytial virus (RSV) is an important cause of infant morbidity and mortality and a potential target for maternal immunization strategies. However, data on the role of RSV in young infant deaths in developing countries are limited. METHODS: We conducted a community-based mortality surveillance from August 2018-March 2020 for infants ≤6 months in Karachi, Pakistan. We tested (reverse transcription-polymerase chain reaction) nasopharyngeal swabs from deceased infants for presence of RSV. We performed verbal autopsies and calculated odds of RSV-associated mortality with 95% CIs and used multivariable logistic regression to evaluate associations. RESULTS: We collected 490 nasopharyngeal specimens from 1280 eligible infant deaths. There were 377/490 (76.9%) live births and 14/377 (3.7%; 95% CI: 1.8-5.6) were RSV positive. Most deaths occurred in neonates (254/377; 67.4%), males (226/377; 59.9%), and respiratory illnesses (206/377; 54.6%). Postneonatal age (10/14, 71.4%; OR: 5.5; 95% CI: 1.7-18.0), respiratory symptoms (12/14, 85.7%; OR: 5.2; 1.2-23.7), and high RSV season (9/14, 64.3%; OR: 4.4; 1.4-13.3) were associated with RSV mortality. In multivariable logistic regression analysis, respiratory symptoms (OR: 6.6; 95% CI: 1.3-32.5), RSV seasonality (6.1; 1.8-20.4), and age (9.2; 2.6-33.1) were significant predictors of RSV-associated mortality. CONCLUSIONS: RSV has a significant mortality burden in early infancy in Karachi, Pakistan. Age, RSV seasonality, and respiratory symptoms were significant predictors of RSV-associated mortality. Our findings have implications for clinical management of young infants with cold-like symptoms, policy development, and research regarding maternal immunization against RSV during pregnancy, in resource-constrained, low-income, and vaccine-hesitant populations.

An Artificial Intelligence-Based, Personalized Smartphone App to Improve Childhood Immunization Coverage and Timelines Among Children in Pakistan: Protocol for a Randomized Controlled Trial.

BACKGROUND: The immunization uptake rates in Pakistan are much lower than desired. Major reasons include lack of awareness, parental forgetfulness regarding schedules, and misinformation regarding vaccines. In light of the COVID-19 pandemic and distancing measures, routine childhood immunization (RCI) coverage has been adversely affected, as caregivers avoid tertiary care hospitals or primary health centers. Innovative and cost-effective measures must be taken to understand and deal with the issue of low immunization rates. However, only a few smartphone-based interventions have been carried out in low- and middle-income countries (LMICs) to improve RCI. OBJECTIVE: The primary objectives of this study are to evaluate whether a personalized mobile app can improve children's on-time visits at 10 and 14 weeks of age for RCI as compared with standard care and to determine whether an artificial intelligence model can be incorporated into the app. Secondary objectives are to determine the perceptions and attitudes of caregivers regarding childhood vaccinations and to understand the factors that might influence the effect of a mobile phone-based app on vaccination improvement. METHODS: A mixed methods randomized controlled trial was designed with intervention and control arms. The study will be conducted at the Aga Khan University Hospital vaccination center. Caregivers of newborns or infants visiting the center for their children's 6-week vaccination will be recruited. The intervention arm will have access to a smartphone app with text, voice, video, and pictorial messages regarding RCI. This app will be developed based on the findings of the pretrial qualitative component of the study, in addition to no-show study findings, which will explore caregivers' perceptions about RCI and a mobile phone-based app in improving RCI coverage. RESULTS: Pretrial qualitative in-depth interviews were conducted in February 2020. Enrollment of study participants for the randomized controlled trial is in process. Study exit interviews will be conducted at the 14-week immunization visits, provided the caregivers visit the immunization facility at that time, or over the phone when the children are 18 weeks of age. CONCLUSIONS: This study will generate useful insights into the feasibility, acceptability, and usability of an Android-based smartphone app for improving RCI in Pakistan and in LMICs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04449107; https://clinicaltrials.gov/ct2/show/NCT04449107. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/22996.

Current Challenges of Digital Health Interventions in Pakistan: Mixed Methods Analysis.

BACKGROUND: Digital health is well-positioned in low and middle-income countries (LMICs) to revolutionize health care due, in part, to increasing mobile phone access and internet connectivity. This paper evaluates the underlying factors that can potentially facilitate or hinder the progress of digital health in Pakistan. OBJECTIVE: The objective of this study is to identify the current digital health projects and studies being carried out in Pakistan, as well as the key stakeholders involved in these initiatives. We aim to follow a mixed-methods strategy and to evaluate these projects and studies through a strengths, weaknesses, opportunities, and threats (SWOT) analysis to identify the internal and external factors that can potentially facilitate or hinder the progress of digital health in Pakistan. METHODS: This study aims to evaluate digital health projects carried out in the last 5 years in Pakistan with mixed methods. The qualitative and quantitative data obtained from field surveys were categorized according to the World Health Organization's (WHO) recommended building blocks for health systems research, and the data were analyzed using a SWOT analysis strategy. RESULTS: Of the digital health projects carried out in the last 5 years in Pakistan, 51 are studied. Of these projects, 46% (23/51) used technology for conducting research, 30% (15/51) used technology for implementation, and 12% (6/51) used technology for app development. The health domains targeted were general health (23/51, 46%), immunization (13/51, 26%), and diagnostics (5/51, 10%). Smartphones and devices were used in 55% (28/51) of the interventions, and 59% (30/51) of projects included plans for scaling up. Artificial intelligence (AI) or machine learning (ML) was used in 31% (16/51) of projects, and 74% (38/51) of interventions were being evaluated. The barriers faced by developers during the implementation phase included the populations' inability to use the technology or mobile phones in 21% (11/51) of projects, costs in 16% (8/51) of projects, and privacy concerns in 12% (6/51) of projects. CONCLUSIONS: We conclude that while digital health has a promising future in Pakistan, it is still in its infancy at the time of this study. However, due to the coronavirus disease 2019 (COVID-19) pandemic, there is an increase in demand for digital health and implementation of health outcomes following global social distancing protocols, especially in LMICs. Hence, there is a need for active involvement by public and private organizations to regulate, mobilize, and expand the digital health sector for the improvement of health care systems in countries.

Personalized Text Messages and Automated Calls for Improving Vaccine Coverage Among Children in Pakistan: Protocol for a Community-Based Cluster Randomized Clinical Trial.

BACKGROUND: A major reason for poor childhood vaccine coverage in developing countries is the lack of awareness among parents and caregivers regarding the need for immunization and the importance of completing the entire series of vaccines. Short message service (SMS)-based interventions have been quite effective in different programs such as smoking cessation, treatment adherence, health care scheduled appointment attendance, antenatal care attendance, and compliance to immunization. However, there are limited data from low- and middle-income countries on the role of SMS and automated call-based messages and interventions to improve routine immunization (RI) coverage. OBJECTIVE: The primary objective of this study is to evaluate whether automated mobile phone-based personalized messages (SMS or automated call) can improve RI uptake at 6, 10, and 14 weeks of age per the expanded program immunization schedule, compared with a usual care control group. Secondary objectives include assessing the effects of different types of automated SMS text or calls on RI coverage at 20 weeks of age. METHODS: This is a mixed methods study using a clustered randomized controlled trial with 4 intervention arms and 1 control arm, augmented by qualitative interviews for personalizing the message. The study is being conducted in Pakistan (an urban site in Karachi and a rural site Matiari). In Karachi, 250 administrative structures are taken as 1 cluster, whereas in Matiari, a catchment area of 4 Lady Health Workers is considered as 1 cluster. The intervention targets families to receive weekly 1-way or 2-way (interactive) personalized automated SMS or automated phone call messages regarding vaccination. Possible barriers to vaccination are assessed in each family at the time of inclusion to determine the type of personalized messages that should be sent to the family to increase the chance of a positive response. Finally, in-depth interviews using purposive sampling are conducted before and after the trial to determine the family's vaccination experience and related factors. RESULTS: All study participants for the cluster randomized trial were enrolled by January 14, 2019. Study exit interviews at 20-weeks follow-up visits will be completed by June 2019. CONCLUSIONS: The results of this study will be useful to understand the respective effects of SMS text messages versus automated phone-based communication to improve RI coverage and timelines. Moreover, information regarding families' perceptions of vaccination and the daily life challenges for timely visits to the vaccine clinic will be used for developing more complex interventions that use mobile phone messages and possibly other approaches to overcome barriers in the uptake of correct and timely immunization practices. TRIAL REGISTRATION: ClinicalTrials.gov NCT03341195; https://clinicaltrials.gov/ct2/show/NCT03341195 (Archived by WebCite at http://www.webcitation.org/78EWA56Uo). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12851.