Acceptability, Barriers and Facilitators of Mobile Text Message Reminder System Implementation in Improving Child Vaccination: A Qualitative Study in Northwest Ethiopia

"Findings from this study could guide the future implementation of mHealth initiatives in the routine immunization program..."

Among the factors contributing to sub-optimal vaccination coverage and timeliness in developing countries is missed attendance at scheduled vaccination appointments. In Ethiopia, reminder strategies such as vaccination cards and verbal reminders provided by health workers have been inadequate to achieve desired immunisation coverage targets set at a national level. Considering that, per the Ethiopia Demographic and Health Survey (EDHS), mobile phone ownership among urban households in Ethiopia was 88% and 47.2% in rural households in 2016, mHealth might hold promise with regard to vaccination reminders. This study is a continuation of a randomised controlled trial (RCT) that assessed the effectiveness of locally developed mobile text message reminders on timely completion of child vaccination in northwest Ethiopia. The qualitative study aimed to explore the acceptability, potential barriers, and facilitators to the implementation of that system.

Conducted in Gondar city administration north-west, Ethiopia, from July 28 to August 19 2020, the study purposively selected 23 participants for in-depth and key informant interviews.

The findings indicated that mothers were receptive to mobile text message reminders for their child's vaccination. Delivering a mobile text message that clients can read and understand easily was found to be important for the effective implementation of text message-based mHealth programmes. Mothers said they felt comfortable receiving mobile text messages sent before a child's vaccination due date during daytime hours. Facilitators for implementation include:

• Creation of collaborative platforms including key stakeholders, such as end-users, health workers, Ethio-Telecom, and other stakeholders in shaping the adoption process;
• Orientation/training for users on how to use and implement technologies; and
• Willingness by clients to pay for the reminder service.

Despite the potential, low mobile phone ownership, limited access to the mobile network, poor access to electricity (to charge phones), and illiteracy among were identified as barriers that could affect implementation.  Concerns regarding the confidentiality and security of personal health information residing on a mobile device were hypothesised to be barriers, but they were not found to be an inhibitor to use for the immunisation programme.

Some practical implications/options:

• For mothers who cannot read mobile text messages, adding a direct call or voice message option on the mHealth system could be an option. In addition, close family members could have a role to technically support mothers in this regard.
• With regard to low mobile phone ownership, alternative mitigation strategies like phone sharing among household members could be considered.
• Messages should be sent in a language that clients can read and better understand, with a preference for the received information to be in the local language.

In conclusion: "Future implementation should pay particular attention to potential barriers and leveraging the existing opportunities to optimize the implementation in resource-limited settings."