Educating Parents about the Vaccination Status of Their Children: A User-Centered Mobile Application

"Well-informed parents who support and maintain vaccination records will have an improved sense of control and the gratification of playing an active role in keeping their children healthy..."

Concerned that parents are often uncertain about the vaccination status of their children and convinced that, in times of vaccine hesitancy, vaccination programmes could benefit from active patient participation, a group of researchers studied the ability of parents to understand the content of a standard vaccination record with the help of a mobile application ("app"). The results were compared to professional data entry into a standard clinical database using a copy of the same vaccination record. Different applications and text message services for appointment reminders have shown promising results in increasing the vaccination rate among users but did not test the knowledge of parents regarding the vaccination status of their children. The key finding from this study is that technical innovation may help parents to understand the vaccination status of their children.

Specifically, to enable parents to report accurate vaccination histories, the Vienna Vaccine Safety Initiative (ViVI) has developed a digital vaccine education and empowerment tool (VAccApp) to be used on smartphones or tablet computers. It helps parents learn about the vaccination status of their children, including 25 different routine, special indication, and travel vaccines listed in the World Health Organization (WHO) Immunization Certificate of Vaccination (WHO-ICV), sometimes referred to as "the yellow card". In many European countries, centralised vaccination registries are not available; in Germany, the WHO-ICV is used as the standard vaccination record, but parents rushing their children to the emergency department (ED) often forget to bring the WHO-ICV with them. The VAccApp was designed to invite parents to take a look at the WHO-ICV and to engage in a virtual dialogue covering all aspects of vaccines administered to their children, thereby making parents an active partner in protecting their family. The development of this educational intervention was informed by the data gathered from a separate group of parents, who tried to remember the vaccination status of their child in the absence of a vaccination record ("Recall Group"). The verbal immunisation histories generated awareness of knowledge gaps among parents and additional insight into how parents are remembering different kinds of vaccination events. This feedback was leveraged to create the user-friendly mobile application. The visual language of the VAccApp is non-threatening and playful, using graphical representations of health care practitioners and vaccine recipients (avatars) keeping the user engaged. The VAccApp provides reminders for booster immunisations and motivates parents to remain well informed about the vaccination status of their children. The visual clues of the app help parents to see where they are in the process, to keep appointments, and to prevent unnecessary delays in immunisations. At the same time, parents generate information to be stored on their smartphones, which may be helpful at any time when the vaccination record may not be at hand.

This report presents the results of a validation study testing the VAccApp in the typical user-group of parents waiting for their child to be seen at a paediatric emergency room in Berlin, Germany. The reported validation project, conducted between March 2012 and August 2014 in collaboration with the Robert Koch Institute, was thus designed to assess the status quo and to test a practical means for improving the status quo using a beta version of the VAccApp. As part of the process, parents of 178 children were asked to transfer the immunisation data of their children from the WHO-ICV into the VAccApp. The respective WHO-ICV was photocopied for independent, professional data entry (gold standard). Demonstrating the status quo in vaccine information reporting, a Recall Group of 278 parents underwent structured interviews for verbal immunisation histories, without the respective WHO-ICV. Only 9% of the Recall Group were able to provide a complete vaccination status; on average, 39% of the questions were answered correctly. Using the WHO-ICV with the help of the VAccApp resulted in 62% of parents providing a complete vaccination status; on average, 95% of the questions were answered correctly. These results indicate that with the help of the WHO-ICV and the VAccApp, the majority of parents are able to understand and interpret the vaccination history of their children accurately. Furthermore, after using the VAccApp, parents were more likely to remember key aspects of the vaccination history.

The VAccApp is available in German language, and translation into multiple additional languages is underway. The VAccApp will also need to be adjusted to accommodate different vaccination schedules across Europe and beyond. Future versions will provide "need clarification" signifiers reminding the parent to ask clarifying questions during upcoming physician visits, thereby improving data. The learning effect with the initial version of the VAccApp showed promise for future developments. The researchers say that, going forward, it will be important to engage older children and adolescents to learn more about their own health and vaccination status. Future studies evaluating the VAccApp in schools or adolescent clinics are being developed. Additional multi-centre validation studies assessing differences in various settings, geographic regions, and population strata are planned. For those using regular telephones rather than smartphones, the VAccApp could be made available online for password-protected data entry via short message service or public computers.

In short, the study shows the benefits of a user-centred education and empowerment tool that allows parents to understand the content of the vaccination record and to store the data in a safe place. User-friendly mobile applications empower parents to take a closer look at the vaccination record, thereby taking an active role in providing accurate vaccination histories. Parents may become motivated to ask informed questions and to keep vaccinations up-to-date. Furthermore, those who have an active interest in vaccinations "will likely encourage their peers to do the same, thereby improving public knowledge and appreciation of immunization programs."