Scaling the Children Immunization App (CIMA) to Support Child Refugees and Parents in the Time of the COVID-19 Pandemic: A Social Capital Approach to Scale a Smartphone Application in Zaatari Camp, Jordan

"...digital solutions can be used to provide access to critical health information to hard-to-reach vulnerable populations such as...refugee... parents and their children."

War and forced displacement represents a direct threat to the wellbeing of caregivers and their children. Syrian refugees in Jordan's Zaatari refugee camp are vulnerable in terms of access to healthcare services, including mental health support. Due to the limited access to the camp during the COVID-19 pandemic, there was a need to create a safe space for dissemination of and access to reliable health information via a remote support service for the refugees, who are known to have a high level of technology literacy rate. Thus, to support parents and caregivers in Zaatari camp during the COVID-19 pandemic, the United Nations Office on Drugs and Crime (UNODC) developed a leaflet on caregiving that was delivered using an existing smartphone application (app) called the Children Immunization App (CIMA). This report describes the participatory initiative and refugees' perspectives on it.

Children's vaccination registration is done manually in refugee camps, and there is no built-in mechanism to send reminders to parents to come back on time. In response, the CIMA vaccination reminder app was developed using service-dominant logic. This process included collecting feedback from various users and updating the app accordingly; materials from various international sources that provide services to refugee children and caregivers were integrated and used. The app, which was implemented in Zaatari camp in 2019, includes (i) health education sheets provided by the United Nations Children's Fund - UNICEF, (ii) registration of children's vaccination schedule, (iii) an automated reminder for parents for the upcoming vaccination appointment for their children, and (iv) an automated reminder for those parents who missed the vaccination appointment of their child. The idea behind the intervention described here was to boost vaccination through use of CIMA while also providing parents with useful parenting skills-building resources in a time of COVID-19-related stress.

In March 2020, Jordan recorded its first case of COVID-19 in Mafraq governorate, which includes the Zaatari refugees' camp, leading to a curfew that suspended mass preventive vaccination campaigns and prevented parents from visiting health facilities for vaccinations, especially in the early stages of the pandemic. In addition, COVID-19 measures contributed to the worsening of some mental illnesses or even the emergence of new ones in Syrian refugees and parents.

As part of the intervention, organisers incorporated UNODC Parenting Skills material into the CIMA app. These materials are available in over 40 languages; in Jordan, they used the published material in Arabic and English languages. They then recruited 1,100 children up to 15 months of age during a period of two months (February and March 2021). The eligibility criteria included accepting to participate in the pilot, have one child qualified for vaccination, and have access to at least one smartphone per household.

A team of two nurses from the local population and two volunteers (one trained nurse and one trained social worker), from the camp, was formed. After training by staff from the Ministry of Health (MoH), the team promoted the CIMA app at two clinics and through households visits in Zaatari refugee camp. During these encounters, they showed the parents how to install and use the app, including its vaccination features, health promotion materials for vaccination, and parenting skills resources. Qualitative data on impressions and observations of the interactions with the Zaatari camp community were collected.

During the household visits, the volunteers identified a total of 70 children with an incomplete history of vaccination records (n = 42/70 girls, 60%). The parents expressed their trust in the app due to its clear privacy statement during installation; the engagement of locals from the camp and MoH staff also increased trust in the app. The parents appreciated the app's parenting skills materials, particularly during the lockdowns. Opportunities and challenges for scaling the app were also documented. For example, some parents requested the addition of information about COVID-19 and its vaccination for the adults.

Reflecting on the process, the organisers explain that they "created the values of the app through the active participation of both the clinic staff and the parents. This collaborative work between all stakeholders, as active participants in the process of the health promotion was a key ingredient for a holistic approach to family-focussed public health promotion. Such an approach leads to a mutual 'win-win' situation between all stakeholders, where everyone feels their input is being considered and all can see its impact..." In part because of this process, "The CIMA app became a trustworthy platform for parents to receive verified information about immunization, health promotion and parenting skills."

As a reflection of this trust, inside the Zaatari camp, the parents are sharing locally the app by recommending it to each other. The organisers stress the need to pilot the app in other resource-limited settings outside the refugee camps (e.g., in rural areas among non-smartphone users, where they will test an SMS (text message)-based modality).

In conclusion: "The app, and its concept, is becoming a platform for a holistic support for families (immunization reminders, immunization schedule tool, health education regarding immunization and trustworthy source for COVID-19 and COVID-19 vaccinations). The role of the vaccination app is growing, where it is becoming more inclusive to the health education needs of the parents and their children. Such progress was possible due to the growing trust between all engaged stakeholders in the process."