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Studies of undervaccinated children of minority/stateless populations have highlighted significant barriers at individual, community, and state levels. These include geography-related difficulties, poverty, and social norms/beliefs.
The objective of this study was to assess project outcomes regarding immunization coverage, as well as maternal attitudes and practices toward immunization.
The “StatelessVac” project was conducted in Thailand-Myanmar-Laos border areas using cell phone-based mechanisms to increase immunization coverage by incorporating phone-to-phone information sharing for both identification and prevention. With limitation of the study among vulnerable populations in low-resource settings, the pre/post assessments without comparison group were conducted. Immunization coverage was collected from routine monthly reports while behavior-change outcomes were from repeat surveys.
This study revealed potential benefits of the initiative for case identification; immunization coverage showed an improved trend. Prevention strategies were successfully integrated into the routine health care workflows of immunization activities at point-of-care. A behavior-change-communication package contributes significantly in raising both concern and awareness in relation to child care.
The mobile technology has proven to be an effective mechanism in improving a children’s immunization program among these hard-to-reach populations. Part of the intervention has now been revised for use at health centers across the country.
The figures for minority and stateless populations, besides the population of 64 million with citizen identification in Thailand, vary between different reports, depending on the definition of the populations of interest [
Geographically, hilltribe settlements in Thailand are scattered over 20 western and northern border provinces of the country; however, about 90% of them reside in nine upper northern provinces. The highest proportion of the hilltribe population lived in the Chiang Rai Province, Chiang Mai Province, Mae Hong Son Province, Tak Province, and Nan Province. According to the 1995 survey, there are six major distinctive ethnic groups, each of which can be identified by distinctive costumes and languages including: Karen, Hmong, Lahu, Akha, Mein or Yao, and Lisu [
Thailand has adopted the Expanded Programme on Immunisation (EPI) as a national policy since 1976 [
A review of the literature on the epidemiology of undervaccinated children in resource-limited settings [
The “StatelessVac” project was developed and implemented in Thailand-Myanmar-Laos border areas in the Chiang-Rai Province, using cell phone-based solutions with the specific purpose to provide an effective mechanism for achieving EPI coverage targets among ethnic hilltribe and stateless populations. Strategies included two system functionalities for phone-to-phone information sharing, for “identification
The areas for project implementation consisted of all villages under the responsibility of three governmental PHUs, covering Thai citizens and both registered and unregistered highland populations. Each village was populated with a mix of 6 main highland minorities: Karen, Hmong, Mein, Akha, Lahu, and Lisu, with one immigrant minority population of Yunnan Chinese. The distances from each village to its responsible PHU ranged from 1 to 17 kilometers, with a median of 7 kilometers.
It should be noted that in Thailand, the Ministry of Public Health has established and maintained 68 provincial hospitals, 759 district hospitals, and 28 referral (regional) hospitals, while providing 9761 primary health care services at the PHUs [
The StatelessVac project initiatives. (a) Project locations on highland; (b) picture and pronunciation for case identification; and (c) behavior change communication at health center and during routine home visit before schedule date.
In response to the call for proposal “Create Low-Cost Cell Phone-Based Solutions for Improved Uptake and Coverage of Childhood Vaccinations” by the Grand Challenges Explorations Round 7, the StatelessVac project was developed [
Mobile technology, particularly the use of smartphone systems, has already been employed as a vehicle for global health care innovation, in terms of facilitating behavior change and improving health care. The benefits of such innovations include: improved access to and quality of care, patient management, and health outcomes among underserved populations [
Some novel ideas for case identification include transmitting “picture” and “pronunciation” data using the phone-to-phone system from remote highland areas to lowland PHUs. Specific issues of complexity concerning the registration procedure include noncitizenship, lack of birth certificate, inconsistency of name, and unspecified residential location. Due to changes of a baby’s appearance throughout the 5 year immunization program, the picture of baby was used as a biometric data. With parental permission, pictures of each infant and its mother, taken via tablet prior to each vaccination visit, were securely transmitted to authorized health care personnel at the responsible PHU. Each hilltribe has its own dialect; most have spoken, but not written languages [
The case-identification strategy was developed and incorporated into tablet functionality. On a VHV’s tablet, after a baby was registered on the responsible PHU’s database, EPI scheduling was flagged monthly as due and/or overdue immunization(s) for each VHV’s routine home visit. Replacing monthly case management on papers between VHVs and PHU staff, the vaccination history of the infant/child was updated on each VHV’s tablet. Monthly information about EPI schedule, plus additional picture and pronunciation of each child’s name, was routinely transmitted and synchronized between VHV and responsible PHU’s tablet. On the set vaccination dates at the PHU each month, health care personnel employed pictures and pronunciation data obtained from the VHV’s tablets, by presenting the child’s picture on a television screen and calling out the child’s name in the ethnic language from the PHU’s tablet.
Behavior change communication (BCC) and advocacy in the community is another preventive measure that was developed. Based on the United Nations Children’s Fund (UNICEF)’s guideline for communication strategy for a development program [
Expected project outcomes were changes in EPI coverage, and BCC determinants over time. EPI monthly coverage data, by child age and by different type of vaccine, were collected from quarterly reports from the three PHUs to the Ministry of Public Health, submitted from January 2011 to February 2012, and from March 2012 to March 2013, before and after project implementation. BCC outcomes are based on repeat surveys from the same respondents in relation to maternal knowledge, attitudes, and practices (KAP) toward EPI vaccination. As part of the formative project evaluation, surveys were collected at months 6 and 12 after BCC was first launched. The KAP survey content was based on messages delivered via the BCC package. With due consideration of limited literacy among minorities in remote settings, the KAP questionnaire was constructed with minimum critical issues and simplicity of format. The KAP survey composes of 6 items on knowledge, 5 items on attitude, and 6 items on practice. The survey items were developed by consensus among three content experts on immunization and one on hilltribes in the study area. The survey items were piloted and revised in the nearby villages of the study areas and with different ethnics groups participating in this study. The surveys were conducted using individual interview methods by trained, designated VHVs. The VHV interviewer either spoke Thai or translated the items according to the precoded script. The analysis of the data was simply descriptive statistics.
Access to EPI management systems and databases is strictly controlled, and only permitted for authorized health care personnel and village health volunteers in charge of case management. Information sharing on tablets as part of the phone-to-phone mechanism maintains all crucial features of data integrity and confidentiality, mirroring the routine paper-based processes at the local health care clinics, and during routine site/home visits.
Mothers and/or children who visited the health care clinics signed no written informed consent or assent form, or when meeting with health care personnel during site/home visits; all activities were routine work performed as part of standard health care practices. Data extracted for analysis were all secondary data and summary statistics, and were not identification (ID)-linked. The authors were granted permission to use extracted data for analysis from the authorized person at the Chiang-Rai Provincial Health Office. The study protocol was reviewed and approved by the Ethics Committee, Faculty of Tropical Medicine, Mahidol University.
During the study period, a total of 3649 highland children age < 6 years were registered in the three PHUs. Immunizations for tuberculosis (BCG) and hepatitis B (HepB) have been reported at 100%, according to the records that all children were immunized at the hospital at birth. Vaccine coverage for children age 1 year showed a slight improvement after project implementation. Overall immunizations for OPV and DTP increased from 91.7% (483/527) to 94.4% (408/432), while measles increased from 89.2% (470/527) to 89.6% (387/432) (
Among children age 2 years, overall coverage for OPV-DTP increased from 86.3% (391/453) to 86.6% (362/418), while JE increased from 83.9% (380/453) to 87.6% (366/418). However, the minimum-maximum range for monthly immunizations of OPV-DTP changed from 77% (24/31)-94% (31/33) to 60% (12/20)-96% (24/25), and for JE it was 67% (24/36)-93% (27/29) to 68% (21/31)-98% (43/44). Due to a change in the JE vaccine schedule for children age 3 years during the project implementation period, the overall coverage for JE decreased from 80.6% (348/432) to 75.4% (310/411), while the minimum-maximum range changed from 71% (20/28)-91% (20/22) to 68% (21/31)-88% (29/33). Among children age 4 years, the overall coverage for OPV and DTP increased from 73.2% (372/508) to 78.0% (348/446), and the minimum-maximum range for monthly immunizations changed from 54% (13/24)-87% (27/31) to 58% (21/36)-89% (17/19).
Overall immunization coverage before and after project implementation. (BCG= Bacillus Calmette-Guérin vaccine, DTP= diphtheria-tetanus-pertussis vaccine, JE= Japanese encephalitis vaccine, HepB= Hepatitis B vaccine, and OPV= oral polio vaccine).
Monthly immunization rates by children ages. (BCG= Bacillus Calmette-Guérin vaccine, DTP= diphtheria-tetanus-pertussis vaccine, JE= Japanese encephalitis vaccine, HepB= Hepatitis B vaccine, and OPV= oral polio vaccine).
Repeat KAP surveys were carried out among the 7 highland minority groups, and composed of: 32.5% (104/320) Akha, 25.3% (81/320) Lahu, 15.6% (50/320) Hmong, 11.3% (36/320) Mein, and other groups (
Knowledge scores, measured at months 6 and 12 after the BCC was launched, appeared to increase, but without statistical significance. The percentages of those who scored > 50% correct about a particular disease changed from 82.2% (263/320) to 88.8% (284/320) (
Characteristics of respondents in repeated KAP survey.
Characteristics | n | Percentage |
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Akha | 104 | 32.5 |
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Lahu | 81 | 25.3 |
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Lisu | 7 | 2.2 |
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Karen | 1 | 0.3 |
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Hmong | 50 | 15.6 |
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Mien | 36 | 11.3 |
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Other | 36 | 11.3 |
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Missing | 5 | 1.5 |
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≤ 20 years | 24 | 7.5 |
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21-30 years | 148 | 46.3 |
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31-40 years | 106 | 33.1 |
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≥ 41 | 42 | 13.1 |
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Thai ID card | 247 | 77.2 |
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Hilltribe status card | 40 | 12.5 |
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Other cards | 3 | 0.9 |
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Stateless status | 24 | 7.5 |
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Missing | 6 | 1.9 |
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1-2 | 177 | 55.3 |
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3-5 | 131 | 40.9 |
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≥ 6 | 9 | 2.8 |
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Missing | 3 | 1.0 |
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1 | 188 | 58.8 |
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2 | 100 | 31.3 |
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3 | 11 | 3.4 |
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Missing | 21 | 6.5 |
KAP of mothers at months 6 and 12 after implementation of behavior change communication package.
KAP survey | Month 6 (N=320) | Month 12 (N=320) |
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n | percentage | n | percentage | |||
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≥ 80% (5-6 score) | 17 | 5.3 | 12 | 3.8 | .134 |
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≥ 50% (3-4 score) | 246 | 76.9 | 272 | 85.0 |
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< 50% (1-2 score) | 50 | 15.6 | 30 | 9.3 |
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None (0 score) | 1 | 0.3 | 0 | 0.0 |
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Missing | 6 | 1.9 | 6 | 1.9 |
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≥ 80% (4-5 items) | 259 | 80.9 | 270 | 84.4 | .004 |
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≥ 50% (3 items) | 40 | 12.6 | 17 | 5.3 |
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< 50% (1-2 items) | 19 | 5.9 | 24 | 7.5 |
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Missing | 2 | 0.6 | 9 | 2.8 |
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≥ 80% (5-6 items) | 90 | 28.1 | 141 | 44.1 | < .001 |
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≥ 50% (3-4 items) | 195 | 61.0 | 138 | 43.1 |
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< 50% (1-2 items) | 35 | 10.9 | 23 | 7.2 |
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Missing | 0 | 0.0 | 18 | 5.6 |
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The technical challenge of applying information sharing between tablets of VHVs and health care personnel staff in remote areas was manageable. The telephone signals in the highland project implementation villages varied, but all data could be transmitted when a telephone signal was available, while other routine activities and data collection during each home visit were conducted offline. This proved that the innovation could be useful in hard-to-reach populations. Other research also suggests this kind of innovation can yield timely information for improving case management, delivering much higher quality, validity, and reliability [
In 2011, Thai nationwide statistics indicated that vaccine coverage rates were > 90%: 99% for BCG, DTP, and OPV; and 98% for measles and HepB [
As suggested in the literature, nonimmunization or lower immunization rates could be partly attributable to the complexity of individual, community, and legal factors involved. The most common explanations about this outcome concern competing priorities in child immunization, working longer hours due to poverty, and being socially and legally alienated [
Differences in culture and beliefs in relation to the health care-seeking behaviors of hilltribe peoples represent an ongoing challenge. The BCC animations with selectable languages have been implemented and accepted by all stakeholders. As part of the development of a selectable language BCC, the script translation into 7 ethnic languages was quite a challenge. While many common and technical words are equivalent to Thai or English, sometimes no words had precisely the same meaning. Moreover, some words have different spellings and pronunciations, even within the same tribe. However, posttesting translations and back-translations and piloting their use among several tribal groups achieved a solution.
In analyzing the postlaunch success of BCC in the community, the KAP survey revealed that the mothers had good knowledge, a positive attitude, and employed proper practices at completion of the 6 month survey, and demonstrated even higher levels at the 12 month follow-up. In this study, even though knowledge of diseases under the EPI scheme measured at 2 time points were not statistically significant; the overall percentage of correct answers was higher at 12 months. As shown by studies of factors associated with completing immunization in vulnerable populations, the primary goal of EPI activities and interventions should be strengthening communication and raising awareness in the community; inadequate knowledge regarding the objectives and importance of immunization demonstrably leads to low vaccine coverage [
To meet the challenge of attaining their maternal and child health Millennium Development Goals, the WHO and UNICEF have recommended countries to implement a central strategy of immunizing hard-to-reach infants and other age groups by focusing more on work carried out at district level [
Example of edutainment animation on expanded programme on immunization (EPI) in each dialect languages.
Google application of the BCC package in Thai version.
Google application of the BCC package in English version.
Google application of the BCC package in Myanmar version.
Google application of the BCC package in Akha version.
Google application of the BCC package in Yunnan Chinese version.
Google application of the BCC package in Hmong version.
Google application of the BCC package in Karen version.
Google application of the BCC package in Lahu version.
Google application of the BCC package in Lisu version.
Google application of the BCC package in Yao version.
antenatal care
behavior change communication
Bacillus Calmette-Guérin vaccine
diphtheria-tetanus-pertussis vaccine
Expanded Programme on Immunisation
Hepatitis B vaccine
identification
Japanese encephalitis vaccine
knowledge, attitudes, and practices
oral polio vaccine
primary health unit
United Nations Children’s Fund
village health volunteers
World Health Organization
The StatelessVac project was awarded from the Bill & Melinda Gates Foundation through the Grand Challenges Explorations initiative. We would like to thank the Foundation for funding and supporting us throughout the duration of the project. We would like to acknowledge all health care personnel and village health volunteers at the 3 subdistrict health promoting hospitals (at Wawi, Rak Pan Din, and Phaya Prai) for their vision and attitude and for their efforts in project implementation, especially their devotion to providing effective mother and child care; also the information technology and data management teams at BIOPHICS for their contributions in system development. Special thanks to Paul Adams and Gary Hutton of the Office of Research Services, Faculty of Tropical Medicine, Mahidol University, for editing the language of the manuscript.
JK designed and planned the study, drafted the first version of the paper, submitted the paper, and approved the final version. TA, KJ, and SL assisted in designing and planning the study, collected data, monitored activities at study sites, wrote the submitted paper, and approved the final version. AK, SS, AS, and PW designed and programed the application module and approved the final version. JK is the chief executive officer of the Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS) at the Faculty of Tropical Medicine, Mahidol University. TA is a faculty member at School of Health Science, Mae Fah Luang University, Chiang Rai Province. SL is the chief of informatics, and AK is the chief of logistics and operation at BIOPHICS. KJ is a graduate student at the Department of Tropical Hygiene and a member of the public health staff at BIOPHICS. SS, AS, and PW are system analysts and programmers at BIOPHICS.
The StatelessVac project was awarded via Grand Challenges Explorations (Round 7-Grant Number OPP1046158) by the Bill & Melinda Gates Foundation. This project has been receiving in-kind support from the Faculty of Tropical Medicine, Mahidol University, Bangkok, and the School of Health Science, Mae Fah Luang University, Chiang Rai Province, Thailand. Faculty members of both universities have been actively involved in planning and implementing the project at the study locations.