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We conducted a randomized controlled trial to assess the effect of providing mothers with mobile voice or text (SMS) reminder messages on health facility attendance at five infant immunization and vitamin A supplementation (VAS) visits. The study was conducted at 29 health facilities in Korhogo district. Mothers were randomized to receive a voice or text reminder message two days prior to each scheduled visit and two additional reminders for missed doses (n=798; intervention group), or no phone reminder messages (n=798; control group). Infants in the intervention group were 2.85 (95% CI: 1.85-4.37), 2.80 (95% CI: 1.88-4.17), 2.68 (95% CI: 1.84- 3.91), and 4.52 (95% CI: 2.84-7.20) times more likely to receive pentavalent 1-3 and MMR/yellow fever doses, respectively, and 5.67 (95% CI: 3.48-9.23) times more likely to receive VAS, as compared to the control group. In the reminder group, 58.3% of infants completed all five visits, compared to 35.7% in the control group (P<0.001). Providing mothers mobile phone message reminders is a potentially effective strategy for improving immunization and VAS coverage in Côte d℉Ivoire.
The study was a randomized controlled trial conducted at 29 health facilities in Korhogo district in the north-central region of Cote d’Ivoire. Mothers (or caretakers) in the intervention group were provided SMS or voice message reminders, based on their preference, prior to each scheduled facility visit and two additional reminders in the event of non-attendance. Mothers in the control group were not provided any reminder messages. The five visits were: pentavalent 1 (DPT+ Hep B + Hib) immunization at 6 weeks, pentavalent 2 at 10 weeks, pentavalent 3 at 14 weeks, VAS at 6 months, and MMR/yellow fever immunizations at 9 months of age delivered at publicsector facilities. The sample size was based on detecting a 10% difference in coverage between the intervention and control groups, with β = 0.80, α = 0.05, and a 10% inflation factor to account for potential errors at registration (e.g., non-eligible participants). Block randomization was used to allocate motherchild pairs to the intervention or control group based on rural, semi-urban, or urban (Korhogo town) health facility location. Randomization was performed using an automated system and randomization schedules were concealed from health facility personnel. In each setting, purposive sampling was used to select health facilities based on sufficient population density and a well-functioning mobile phone network. Of the 29 facilities, 10 were located in rural areas, 12 in semi-urban areas, and 7 in Korhogo town. During July 2014 to June 2015, motherchild pairs were recruited at all 29 health facilities at the time of the child’s BCG immunization visit, which occurred within five weeks of the child’s birth. If the mother was not present, the accompanying caretaker was invited to participate. To be eligible for the study, the mother/caretaker and child had to be residents of Korhogo district and the mother had to have primary access to a functioning mobile phone. Sociodemo – graphic characteristics were collected for each mother-child pair by health facility staff at the time of enrollment. The study was approved by the Cote d’Ivoire National Research Ethics Committee (Comité national d’éthique et de la recherche). All mothers/caretakers provided written informed consent for their and the child’s participation. At study enrollment, mothers were informed of subsequent dates for their infant’s pentavalent 1-3 and MMR/yellow fever doses and VAS visit, which were also recorded on the child’s health card that the mother took home. Dates for immunization sessions were arranged according to the EPI schedule13 and child’s date of birth, excluding days when health facilities did not provide routine services (e.g., weekends, holidays). Mothers in the intervention group were given the option to receive either an SMS or voice message reminder in their preferred language (French, Senoufo, or Dioula) prior to each scheduled visit. Messages were devised in collaboration with local EPI personnel and informed mothers to take their child for immunization or VAS in two days to protect the child’s health. The content of SMS and voice messages was identical. In the event the child was not brought to the facility on the scheduled date, another reminder was provided to the mother/caretaker three days after the missed appointment. If the child did not present a second time, a final reminder was sent two days before the next scheduled visit, in an attempt to catch the child up on the missed dose. Mothers in the control group were not provided any SMS or voice messages and were instructed to refer to the child’s health card for appointment dates, as per the standard of care in Cote d’Ivoire. A mobile web service platform (IvocarteR, Abidjan) was used to register the mother’s mobile phone number and child’s visit schedule. SMS and voice messages were then automatically generated and transmitted to recipients at designated times. Attendance records for each visit were transmitted directly from facility staff to study personnel via the IvocarteR platform. The study outcome measure was attendance at each visit and included children who were brought to the health facility on the scheduled appointment date or any other time during the study period. We conducted bivariate analyses and created multivariable logistic regression models to assess differences in visit attendance between the intervention and control group. Model covariates were selected based on a significant (P<0.05) bivariate result and/or factors associated with compliance. Covariates included maternal age, education, and employment; child age and gender; and health facility setting (rural, semi-urban, or urban). Results are presented as adjusted odds ratios (aOR) and 95% confidence intervals (CI) and all reported P values are 2-sided with a 0.05 significance level. Analyses were conducted using SPSS version 19.0 (Armonk, NY: IBM Corp) software.
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