Does Exposure to Health Information through Mobile Phones Increase Immunisation Knowledge, Completeness and Timeliness in Rural India?

"Further efforts to use mobile-based communication to raise awareness about the benefits of immunisation, (ideally) supported by mass media communication, is even more crucial with the backdrop of COVID-19..."

While over 80% of Indians consider vaccines to be important, safe, and effective, low awareness and poor access have been identified as drivers of some hesitancy. Mobile health (mHealth) interventions have been used to provide health information on vaccines and to send alerts and reminders to improve immunisation timeliness. As part of a randomised controlled trial (RCT) to assess the impact of Kilkari, a maternal messaging programme, this study explored determinants of parental immunisation knowledge and immunisation practice (completeness and timeliness) for children 0-12 months of age in Madhya Pradesh (MP), India.

As detailed at Related Summaries, below, Kilkari is a direct-to-beneficiary mobile communication programmes that, since 2012, has reached over 10 million new and expectant mothers and their families with up to 72 weekly stage-based audio reproductive, maternal, newborn, and child health (RMNCH) information messages. Kilkari calls span from the 12th week of pregnancy up until the child's first birthday. Immunisation-related messages are provided over 11 calls, focusing on the benefits of vaccination and diseases prevented by it and reminding the parents to take the child for next vaccination. Week 32 example message: "I know you care for your child, and so you make sure he/she gets timely vaccinations, so that he/she is protected from life-threatening diseases. Your child is about to turn 2 and a half months old, which means that it's time for the next immunisation dose. Make sure you go for vaccination on the teekakaran diwas in your nearest health facility. Make sure you carry your MCP [mother-child protection] card along with you. If for some reason you forgot the last vaccination, make sure that your child receives that too..."

Study findings draw from data captured as part of the RCT in 4 districts (Rewa, Hoshangabad, Mandsaur, and Rajgarh) of MP, described in detail elsewhere. MP falls below national averages for most health indicators, including immunisations, and the gender gap in women versus household access to mobile phones was estimated to be 60% in rural areas and 44% in urban areas in 2015. Women 4-7 months pregnant with access to mobile phones were randomised to either a comparison arm of no calls or an intervention arm where they were eligible to receive Kilkari calls from the 18th week of pregnancy up until the child's first birthday.

The present analysis used the postpartum survey data from 4,423 postpartum women (87%, out of 5,095 enrolled in Kilkari) with a live birth during the index pregnancy and their husbands (3,781 men); the final sample included 3,230 children. Parental knowledge about immunisation and their child's receipt of vaccines, including timeliness and completeness, was assessed using self-reports and vaccination cards.

Overall, 20% of mobile numbers subscribed to Kilkari listened to 50% or more of the cumulative total of the 11 Kilkari immunisation calls in the intervention arm of the RCT. Declines in exposure across the RCT sample over the course of pregnancy were influenced by a range of factors, such as increases in call non-delivery rates.

Less than half of children had received the basic package of 8 vaccines (47%) and the comprehensive package of 19 vaccines (44%). For timeliness, while 84%-89% of the children received the birth vaccines on time, except for measles and rubella vaccine (MR1) (36%), timely administration of vaccines reduced as the child's age progressed.

Overall immunisation knowledge scores, out of a possible 11 points, averaged 3.64 (standard deviation (SD)=1.95) for men and 3.62 (SD=1.79) for women (a 33% of total score for both). Among the study population, 83% of women and 53% of men were aware that a child's first vaccination should be administered at birth. Most parents were aware that vaccination protects children from poliomyelitis (74% of mothers and 87% of fathers).

Ordered logistic regression models showed that higher immunisation knowledge was associated with higher exposure to Kilkari immunisation calls among men (odds ratio (OR)=1.23, 95% confidence interval (CI) 1.02 to 1.48) but not women. Factors associated with higher overall knowledge scores among women were: having more years of formal education, having a greater number of children, asking for immunisation information from a health worker, and receiving immunisation information from television or print (posters/newspapers/handouts). For both men and women, significant differences in knowledge scores were observed across districts.

Timely immunisation at birth was significantly associated with listening to 50% or more of the cumulative content of Kilkari immunisation calls, as well as higher women's knowledge scores. However, exposure to Kilkari had no association with overall full and timely immunisation for the basic or comprehensive immunisation package. The researchers suggest that these finding may be linked to the timing of Kilkari calls and parental listening patterns.

Reflecting on the findings, the researchers note that the finding that exposure to Kilkari increased men's but not women's immunisation knowledge may be linked to men's higher access to mobile phones in India. Qualitative research suggests that Kilkari calls made to mobile phones shared by spouses tend to be answered by husbands, not wives. About 25% of the women who were subscribed to the RCT reported they had access to a shared household phone. Even among phones owned by women that were not reportedly shared, husbands and other household members are likely to have answered and listened to a portion of the calls.

One of the most significant and positive determinants for both full and timely immunisation was the economic status of the household, echoing findings elsewhere. Thus, despite efforts such as Kilkari, gaps in complete and timely immunisation for infants persist in rural India.

In conclusion: "This analysis showcases the potential and the limitations of Kilkari. In a context with overall low parental knowledge about immunisation and poor child immunisation coverage, improvement demands expanded and intensified outreach coupled with health system strengthening. Parental engagement through a programme such as Kilkari can be an important component of a broader immunisation improvement strategy. Structured and focused approach needs to be adopted to reach socially and economically vulnerable in remote areas, specifically for immunisation practice."