JMIR Publications

ABSTRACT

Background:

Zindagi Mehfooz (Safe Life) Electronic Immunization Registry (ZM-EIR) in Sindh Province, Pakistan is a comprehensive suite of digital health interventions that aims to improve equitable access, timeliness, and coverage of child immunizations through a smartphone-based application (app) for vaccinators, web-based dashboards for supervisors and managers, text message alerts and reminders for caregivers, and a call center. Since its inception in 2012 until August 2022, ZM has scaled across 30 districts of Sindh Province with phased introduction in other areas including the Federal Capital (Islamabad), Khyber Pakhtunkhwa province and Gilgit-Baltistan region and has been used by over 5,000 vaccinators at public and private immunization clinics to enroll over 7 million children.

Objective:

This paper summarizes findings from a mixed-methods study of ZM-EIR which assessed vaccinator use of ZM-EIR, provider and caregiver perceptions of ZM-EIR, temporal changes in immunization coverage and timeliness among children 12-23 months, equity, and cost-effectiveness.

Methods:

The mixed-methods study included a) Pre-post outcome evaluation using vaccine coverage from the Multiple Indicator Cluster Surveys (MICS) 2014 and 2019; b) In-depth interviews with caregivers, vaccinators, supervisors, and managers; c) Analysis of ZM-EIR system data, and d) costing analysis. Key outcomes of interest were receipt of individual antigens (BCG, Penta I-III, Measles), full immunization (all antigens), and zero dose children defined as a child aged 6 to 23 months that has not received the first dosage of DPT1/Penta. Incremental changes in coverage were input into the Lives Saved Tool (LiST) to model lives saved from 2017-2019.

Results:

ZM-EIR implementation in Sindh Province may have contributed to a 10-percentage point increase in the prevalence of fully immunized children (12-23 months), from 5% (95% CI) in 2014 (before implementation) to 15.1% (95% CI) in 2019. Increases in vaccine timeliness were observed for BCG (+8.3%), Penta I (+3.2%), and Measles II (+1.3) vaccines. The prevalence of zero-dose children declined from 38.7% in 2014 to 24.7% in 2019. Incremental changes in coverage are estimated to have saved over 3,000 lives at a cost per life saved of $1,362 USD per life saved. Stakeholder groups interviewed had favorable impressions of ZM-EIR. However, they highlighted the dual burden of reporting on paper and gender-related barriers of female caregivers not wanting to give their phone numbers to male vaccinators.

Conclusions:

ZM-EIR is a promising technology platform that may have contributed to improvements in immunization outcomes through systematic registration of children, alerts and reminders, and effective use of data from defaulter and zero-dose lists. Clinical Trial: The study received IRB approval from the IRD Review Board with number – IRD_IRB_2021_11_001 and is registered with ISRCTN #23078223.