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Vaccine coverage for 18-month-old children in Canada is often below the recommended level, which may be partially because of parental forgetfulness. SMS text message reminders have been shown to potentially improve childhood immunization uptake but have not been widely used in Alberta, Canada. In addition, it has been noted that language barriers may impede immunization service delivery but continue to remain unaddressed in many existing reminder and recall systems.
This study aimed to assess the effectiveness and acceptability of using SMS text messages containing a link to web-based immunization information in different languages to remind parents of their child’s 18-month immunization appointment.
The Childhood Immunization Reminder Project was a pilot intervention at 2 public health centers, one each in Lethbridge and Edmonton, Alberta, Canada. Two SMS text message reminders were sent to parents: a booking reminder 3 months before their child turned 18 months old and an appointment reminder 3 days before their scheduled appointment. Booking reminders included a link to the study website hosting immunization information in 9 languages. To evaluate intervention effectiveness, we compared the absolute attendance no-show rates before the intervention and after the intervention. The acceptability of the intervention was evaluated through web-based surveys completed by parents and public health center staff. Google Analytics was used to determine how often web-based immunization information was accessed, from where, and in which languages.
Following the intervention, the health center in Edmonton had a reduction of 6.4% (95% CI 3%-9.8%) in appointment no-shows, with no change at the Lethbridge Health Center (0.8%, 95% CI −1.4% to 3%). The acceptability surveys were completed by 222 parents (response rate: 23.9%) and 22 staff members. Almost all (>95%) respondents indicated that the reminders were helpful and provided useful suggestions for improvement. All surveyed parents (222/222, 100%) found it helpful to read web-based immunization information in their language of choice. Google Analytics data showed that immunization information was most often read in English (118/207, 57%), Punjabi (52/207, 25.1%), Arabic (13/207, 6.3%), Spanish (12/207, 5.8%), Italian (4/207, 1.9%), Chinese (4/207, 1.9%), French (2/207, 0.9%), Tagalog (1/207, 0.5%), and Vietnamese (1/207, 0.5%).
The study’s findings support the use of SMS text message reminders as a convenient and acceptable method to minimize parental forgetfulness and potentially reduce appointment no-shows. The diverse languages accessed in web-based immunization information suggest the need to provide appropriate translated immunization information. Further research is needed to evaluate the impact of SMS text message reminders on childhood immunization coverage in different settings.
Immunization is a safe and cost-effective intervention that substantially reduces childhood morbidity and mortality [
It is a well-recognized phenomenon that the uptake of infant vaccines exhibits a precipitous drop at the 18-month vaccine doses [
The literature has shown that parental forgetfulness of immunization appointments is a key barrier to 18-month vaccine uptake [
Previous research has shown that SMS text message reminders improve childhood immunization uptake [
Given that the effectiveness of public health interventions is context specific [
Alberta is a western Canadian province with approximately 4.4 million residents. The province is divided into 5 zones for the administration of health services by Alberta Health Services (AHS). Routine preschool immunization is delivered exclusively by nurses at public health centers (PHCs).
The Childhood Immunization Reminder Project (ChIRP) was a pilot intervention aimed at improving attendance at 18-month immunization appointments by sending SMS text message reminders to parents. ChIRP was implemented at two PHCs: (1) Mill Woods PHC in the Edmonton health zone, which serves an ethnically diverse population in a high-density urban city with a total population of 1.1 million [
Using an automated system (iceAlert), 2 SMS text message reminders were sent to each parent participating in the study. Messages were sent to the primary phone number on file provided by the parents during registration. Most were cell phone numbers, but voice message reminders were sent instead of SMS text messages if the phone number provided was a landline number. The first message was sent 3 months before the child turned 18 months (ie, when the child was 15 months old) to remind parents to book the 18-month appointment or to reschedule an existing appointment if needed. The reminders were sent monthly between May 2019 and May 2020 to all parents of children who turned 15 months old in that month and had a postal code within the service area of Mill Woods or Lethbridge PHCs. This reminder included a link to the study website hosting immunization information in 9 languages (English, French, Arabic, traditional Chinese, Italian, Punjabi, Spanish, Tagalog, and Vietnamese).
The second message was a reminder of the date and time of the booked 18-month appointment, which was sent 3 days before the scheduled visit. This reminder was initiated by AHS in December 2018, shortly before the start of ChIRP, and was, therefore, incorporated into the evaluation. This was an opt-out system (ie, parents received the message unless they asked not to).
Timeline of study intervention and evaluation periods. AHS: Alberta Health Services; PHC: public health center.
To evaluate the effectiveness of the intervention, we compared absolute no-show rates before (December 2017 to December 2018) and after (August 2019 to August 2020) the intervention in both PHCs using routinely collected administrative data from AHS. No-shows were defined as children who had missed their scheduled appointments, including those who rescheduled missed appointments. We identified all children with 18-month immunization appointments at the PHCs by using provincial patient identification numbers. Children were excluded from the analysis if their appointment was canceled or outside the preintervention or postintervention periods, they had not yet had their appointment, or were aged >24 months. No-show rates were determined by dividing the total number of no-shows by the total number of 18-month immunization appointments at each PHC. The no-show rates at the intervention sites were compared with PHCs with similar client demographics in the same health zone (ie, Northeast Edmonton PHC for Mill Woods and Medicine Hat PHC for Lethbridge) using a 2-sample proportion test. The analysis was performed using R (version 3.6.3; R Foundation for Statistical Computing) [
Parents and PHC staff evaluated the acceptability of the reminder intervention. The PHC staff recruited parents for the web-based survey evaluation during their child’s 12-month immunization appointment, starting in March (Lethbridge) or May 2019 (Edmonton) and continuing until February 2020. Interested parents received an information sheet and consent form (available in 9 languages) that collected their name, child’s name and date of birth, and mobile phone number. There were no eligibility restrictions in terms of age, gender, or other sociodemographic characteristics other than needing a mobile phone to receive the evaluation survey link. In consultation with PHC managers, a parallel survey was sent to all staff who worked at either participating PHC during the intervention period, including nurses and clerical staff. Informed consent was obtained from all the participants.
Participating parents were sent a text message containing a link to a web-based survey when their child was 19 months old, after the intended 18-month immunization appointment. Parent surveys were completed between September 2019 and October 2020. The PHC staff were sent the staff survey link via email at the end of the intervention period in December 2020 or January 2021. Survey data were collected and managed using REDCap (Research Electronic Data Capture; Vanderbilt University) tools hosted and supported by the Women and Children’s Health Research Institute at the University of Alberta [
Sociodemographic information collected from parents included residential location, whether they were born in Canada, language or languages read, education level, and annual household income. The PHC staff provided the PHC’s location and their job position. Parents were asked about the helpfulness of the reminders, when the reminders should be sent, what actions they took because of the reminders, and whether their child had attended the 18-month immunization appointment. The PHC staff evaluated the helpfulness and impact of the reminders, when and how many reminders should be sent, and which other routine vaccine programs (2-month, 4-month, 6-month, 12-month, preschool, and school-based) should be considered for reminders.
Both parents and PHC staff evaluated the helpfulness and impact of the web-based immunization information included in the reminder. Google Analytics [
This study was approved by the Health Research Ethics Board of the University of Alberta (study ID: Pro00085642).
Throughout the intervention period (May 2019 to May 2020), a total of 3307 booking reminders were successfully sent, including 2885 SMS text messages and 422 voice notifications. A small number of reminders (n=133) were not delivered. Data on the number of 3-day appointment reminders sent were not available because these reminders were sent zone-wide by AHS.
After removing those who had not yet had an appointment or had incomplete data, the Mill Woods PHC had 638 appointments for 18-month immunizations during the preintervention period. Of the 638 appointments, 116 (18.2%) were either no-show or initially no-show and then rebooked. During the postintervention period, there were 1508 appointments for 18-month immunizations, with 178 (11.8%) no-shows. Data from the Northeast Edmonton PHC are shown for comparison (
At Lethbridge PHC, there were 1657 appointments for 18-month immunization during the preintervention period, 186 (11.22%) of which were no-shows. During the postintervention period, there were 1653 appointments and 198 (11.97%) no-shows. Data from the Medicine Hat PHC are shown for comparison. There were no significant differences between preintervention and postintervention no-show rates in the other intervention (Lethbridge) and control site (Medicine Hat).
Absolute no-showa rates and change in rates before the intervention (December 2017 to December 2018) and after the intervention (August 2019 to August 2020).
Health zone | Preintervention rates | Postintervention rates | Change | |||||||||||||
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Rate, n (%) | 95% CI | Rate, n (%) | 95% CI | Rate, %b | 95% CI | ||||||||||
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Attended | 522 (81.8) | 78.8 to 84.8 | 1330 (88.2) | 86.6 to 89.8 | 6.4 | 3.0 to 9.8 | ||||||||
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No-show | 116 (18.2) | 15.2 to 21.2 | 178 (11.8) | 10.2 to 13.4 | −6.4 | −9.8 to −3.0 | ||||||||
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Attended | 388 (85.7) | 82.5 to 88.9 | 1105 (81.9) | 79.8 to 84.0 | −3.8 | −7.6 to 0.0 | ||||||||
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No-show | 65 (14.3) | 11.1 to 17.5 | 244 (18.1) | 16.0 to 20.2 | 3.8 | 0.0 to 7.6 | ||||||||
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Attended | 1471 (88.8) | 87.3 to 90.3 | 1455 (88) | 86.4 to 89.6 | −0.8 | −3.0 to 1.4 | ||||||||
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No-show | 186 (11.2) | 9.7 to 12.7 | 198 (12) | 6.0 to 13.6 | 0.8 | −1.4 to 3.0 | ||||||||
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Attended | 904 (89) | 87.1 to 90.9 | 824 (88.1) | 86.0 to 90.2 | −0.9 | −3.7 to 1.9 | ||||||||
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No-show | 112 (11) | 9.1 to 12.9 | 111 (11.9) | 5.4 to 14.0 | 0.9 | −1.9 to 3.7 |
aNo-show was defined as when a client failed to turn up for their scheduled appointment, including those who initially did not turn up for their scheduled appointment and later rebooked it.
bChange in rates calculated as the difference between postintervention and preintervention rates.
A total of 929 parents consented to participate in the evaluation survey (Mill Woods, n=484; Lethbridge, n=445), whereas 107 declined to participate (Mill Woods, n=24; Lethbridge, n=83). Of those who consented, 222 completed the parent survey (Mill Woods, n=105; Lethbridge, n=117) and 10 declined the survey after receiving it (Mill Woods, n=7; Lethbridge, n=3), with a response rate of 23.9% (222/929). Of those who responded, 93.7% (208/222) reported attending the 18-month visit, whereas 6.3% (14/222) reported missing it. A total of 22 PHC staff members completed the staff survey (Mill Woods, n=12; Lethbridge, n=10). The number who received the invitation was not available, as the PHC managers were responsible for forwarding the invitation to all staff who worked during the intervention period.
As seen in
Sociodemographic characteristics of parents (n=222) and public health center staff (n=22).
Variable | Respondents, n (%) | |||
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In or near Lethbridge | 115 (51.8) | |
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In or near Mill Woods (Edmonton) | 104 (46.8) | |
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Not specified | 3 (1.4) | |
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Yes | 16 (7.2) | |
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No | 197 (88.7) | |
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No response | 9 (4.1) | |
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English | 207 (93.2) | |
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Spanish | 4 (1.8) | |
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Punjabi | 2 (0.9) | |
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Chinese | 1 (0.5) | |
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Othersa | 7 (3.1) | |
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No response | 1 (0.5) | |
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University degree | 104 (46.8) | |
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College or other post–high-school academic certificate or diploma | 87 (39.2) | |
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High school | 21 (9.5) | |
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Lower than high school | 1 (0.5) | |
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Prefer not to answer or no response | 9 (4) | |
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<30,000 | 22 (9.9) | |
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30,000-59,999 | 36 (16.2) | |
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60,000-89,999 | 42 (18.9) | |
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>90,000 | 77 (34.7) | |
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Prefer not to answer | 33 (14.9) | |
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Do not know | 6 (2.7) | |
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No response | 6 (2.7) | |
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Mill Woods (Edmonton zone) | 12 (55) | |
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Lethbridge (south zone) | 10 (46) | |
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Nurse | 19 (86) | |
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Manager | 2 (9) | |
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Administrative support | 1 (5) |
aOther languages included Arabic, Dinka, Somali, Swedish, Ukrainian, Urdu, Yoruba, and not specified (all n=1).
bAt the time of study, CAD $1 was approximately equal to US $0.73.
In total, 51.4% (114/222) of the parents surveyed reported receiving the 15-month booking reminder (
As shown in
As shown in
Evaluation of the 15-month booking reminder by parents who reported receiving the 15-month reminder (n=114) and public health center staff who completed the survey (n=22).
Variable | Response, n (%) | ||||
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Mill Woods | Lethbridge | Total | ||
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Yes | 57 (96.6) | 53 (96.4) | 110 (96.5) |
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No | 1 (1.7) | 1 (1.8) | 2 (1.8) |
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I do not know | 1 (1.7) | 1 (1.8) | 2 (1.7) |
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Booked appointment | 14 (24.6) | 14 (26.4) | 28 (25.5) |
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Changed appointment | 4 (7) | 2 (3.8) | 6 (5.5) |
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Did nothing | 37 (64.9) | 34 (64.2) | 71 (64.5) |
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Forgot to book or reschedule | 1 (1.8) | 2 (3.8) | 3 (2.7) |
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Other | 1 (1.8) | 1 (1.9) | 2 (1.8) |
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Reminded of the appointment | 55 (96.5) | 53 (100) | 108 (98.2) |
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Specified the name of the child | 15 (26.3) | 16 (30.2) | 31 (28.2) |
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Included phone number to call for booking | 18 (31.6) | 24 (45.3) | 42 (38.2) |
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Included vaccine information link | 5 (8.8) | 14 (26.4) | 19 (17.3) |
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When child is 15 months | 32 (30.5) | 31 (26.5) | 63 (28.4) |
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When child is 16 months | 25 (23.8) | 29 (24.8) | 54 (24.4) |
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When child is 17 months | 48 (45.7) | 66 (56.4) | 114 (51.4) |
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Other | 10 (9.5) | 5 (4.3) | 15 (6.8) |
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Yes | 12 (100) | 9 (90) | 21 (95.5) |
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No | 0 (0) | 1 (10) | 1 (4.5) |
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Not sure or do not know | 0 (0) | 0 (0) | 0 (0) |
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More clients came to their scheduled immunization than usual | 10 (83.3) | 8 (88.9) | 18 (85.7) |
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More clients canceled or rescheduled than usual | 1 (8.3) | 2 (22.2) | 3 (14.3) |
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Other | 2 (16.7) | 1 (11.1) | 3 (14.3) |
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No change | 0 (0) | 0 (0) | 0 (0) |
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When child is 15 months | 5 (41.7) | 2 (20) | 7 (31.8) |
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When child is 16 months | 4 (33.3) | 6 (60) | 10 (45.5) |
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When child is 17 months | 3 (25) | 0 (0) | 3 (13.7) |
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No need to send a booking or rescheduling reminder | 0 (0) | 1 (10) | 1 (4.5) |
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Other | 0 (0) | 1 (10) | 1 (4.5) |
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1 | 4 (33.3) | 3 (30) | 7 (31.8) |
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2 | 6 (50) | 6 (60) | 12 (54.5) |
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3 | 2 (16.7) | 1 (10) | 3 (13.7) |
aFor parents who responded that the 15-month reminder was helpful (Mill Woods: n=57; Lethbridge: n=53).
bRespondents could select more than one option.
cAnswered by all parents, not just those who received the 15-month reminder.
dFor staff who responded that the 15-month reminder was helpful.
Public health center staff (n=19) rankings of childhood vaccine programs for priority of scheduling or booking reminders (of those who answered yes to whether reminders will be helpful for other routine vaccine programs).
In total, 79.3% (176/222) of the surveyed parents reported receiving the 3-day appointment reminder (
Among the PHC staff, most (21/22, 96%) reported that the 3-day reminder was helpful (
Evaluation of the 3-day appointment reminder, among parents who reported receiving the 3-day reminder (n=176) and public health center staff who completed the survey (n=22).
Variable | Response, n (%) | |||||||
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Mill Woods | Lethbridge | Total | |||||
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Yes | 89 (98.9) | 86 (100) | 175 (99.4) | |||
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No | 1 (1.1) | 0 (0) | 1 (0.6) | |||
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Changed appointment | 7 (7.8) | 5 (5.8) | 12 (6.8) | |||
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Did nothing | 82 (91.1) | 79 (91.9) | 161 (91.4) | |||
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Other | 1 (1.1) | 2 (2.3) | 3 (1.7) | |||
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On the same day as the appointment | 9 (8.6) | 9 (7.7) | 18 (8.1) | |||
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1 day before the appointment | 23 (21.9) | 30 (25.6) | 53 (23.9) | |||
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2 days before the appointment | 16 (15.2) | 23 (19.7) | 39 (17.6) | |||
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3 days before the appointment | 53 (50.5) | 60 (51.3) | 113 (50.9) | |||
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1 week before the appointment | 36 (34.3) | 49 (41.9) | 85 (38.3) | |||
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2 weeks before the appointment | 8 (7.6) | 3 (2.6) | 11 (5.0) | |||
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1 month before the appointment | 10 (9.5) | 7 (6.0) | 17 (7.7) | |||
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Other | 0 (0) | 2 (1.7) | 2 (0.9) | |||
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Yes | 99 (94.3) | 109 (93.2) | 208 (93.6) | |||
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No | 6 (5.7) | 8 (6.8) | 14 (6.3) | |||
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Yes | 11 (91.7) | 10 (100) | 21 (95.5) | |||
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No | 0 (0) | 0 (0) | 0 (0) | |||
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Not sure or I do not know | 1 (8.3) | 0 (0) | 1 (4.5) | |||
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1 week before the visit | 0 (0) | 2 (20) | 2 (9.1) | |||
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3 days before the visit | 7 (58.3) | 5 (50) | 12 (54.6) | |||
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2 days before the visit | 2 (16.7) | 1 (10) | 3 (13.6) | |||
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1 day before the visit | 3 (25) | 0 (0) | 3 (13.6) | |||
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Other | 0 (0) | 1 (10) | 1 (4.6) | |||
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1 | 6 (50) | 7 (70) | 13 (59.1) | |||
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2 | 4 (33.3) | 2 (20) | 6 (27.3) | |||
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3 | 2 (16.7) | 1 (10) | 3 (13.6) |
aAnswered by all parents, not just those who received the 3-day reminder.
bOne respondent did not specify their other response, and the other respondent specified that no reminders should be sent.
Approximately half (51/114, 44.7%) of the parents who received the 15-month reminder reported reading the web-based immunization information (
As shown in
Evaluation of immunization information sheet use, among parents who reported receiving the 15-month reminder (n=114) and public health center staff (n=19).
Variable | Response, n (%) | |||||||
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Mill Woods | Lethbridge | Total | |||||
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Yes | 31 (52.5) | 20 (36.4) | 51 (44.7) | |||
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No | 28 (47.5) | 35 (63.6) | 63 (55.3) | |||
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English | 29 (93.5) | 18 (90) | 47 (92.2) | |||
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Punjabi | 6 (19.4) | 1 (5) | 7 (13.7) | |||
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Tagalog | 2 (6.5) | 0 (0) | 2 (3.9) | |||
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Spanish | 0 (0) | 2 (10) | 2 (3.9) | |||
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French | 1 (3.2) | 0 (0) | 1 (2) | |||
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Yes | 31 (100) | 20 (100) | 51 (100) | |||
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No | 0 (0) | 0 (0) | 0 (0) | |||
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Yes | 30 (96.8) | 20 (100) | 50 (98) | |||
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No | 1 (3.2) | 0 (0) | 1 (2) | |||
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Already knew the information | 11 (39.3) | 17 (48.6) | 28 (44.4) | |||
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Did not see a link to information in reminder | 5 (17.9) | 1 (2.9) | 6 (9.5) | |||
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Too long | 2 (7.1) | 2 (5.7) | 4 (6.3) | |||
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Forgot | 2 (7.1) | 1 (2.9) | 3 (4.8) | |||
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Not enough time | 0 (0) | 3 (8.6) | 3 (4.8) | |||
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Language of choice not available | 1 (3.6) | 1 (2.9) | 2 (3.2) | |||
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Felt information was unnecessary, as had already decided to get child immunized | 2 (7.1) | 0 (0) | 2 (3.2) | |||
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Felt doctors or nurses would provide the information | 2 (7.1) | 0 (0) | 2 (3.2) | |||
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Had no concerns with immunization | 0 (0) | 2 (5.7) | 2 (3.2) | |||
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Difficult to understand | 0 (0) | 1 (2.9) | 1 (1.6) | |||
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Font too small on device screen | 0 (0) | 1 (2.9) | 1 (1.6) | |||
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Did not specify | 3 (10.7) | 8 (22.9) | 11 (17.5) | |||
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I did not notice any change | 6 (50) | 1 (10) | 7 (36.8) | |||
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More clients read the information sheets than usual | 4 (33.3) | 2 (20) | 6 (31.6) | |||
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Not sure or I do not know | 2 (16.7) | 2 (20) | 4 (21.1) | |||
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Other | 0 (0) | 2 (20) | 2 (10.5) | |||
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I did not notice any change | 6 (50) | 2 (20) | 8 (42.1) | |||
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I noticed more clients engaging in the conversation than usual | 4 (33.3) | 0 (0) | 4 (21.1) | |||
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Not sure or I do not know | 2 (16.7) | 5 (50) | 7 (36.8) | |||
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I do not think it changed anything | 5 (41.7) | 1 (10) | 6 (31.2) | |||
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I noticed more clients asking questions about vaccines than usual | 5 (41.7) | 1 (10) | 6 (31.2) | |||
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Not sure or I do not know | 2 (16.7) | 5 (50) | 7 (36.8) | |||
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Provide the link to the website in the appointment reminder text (ie, the 3-day reminder) | 9 (75) | 8 (80) | 17 (77.3) | |||
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Promote the website using posters or handouts in the health center | 9 (75) | 7 (70) | 16 (72.7) | |||
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Have printed copies of the information sheets (in various languages) available at the health center | 6 (50) | 6 (60) | 12 (54.5) | |||
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Other | 0 (0) | 1 (10) | 1 (4.5) |
aFor parents who reported reading web-based immunization information (Mill Woods: n=31, Lethbridge: n=20).
bRespondents could select more than one option.
cOther potential language options included Arabic, Chinese, Italian, and Vietnamese; however, these options were not selected by any parent.
dFor parents who reported that they did not read web-based immunization information (Mill Woods: n=28, Lethbridge: n=35).
ePHC: public health center.
fQuestion asked to all public health center staff (n=22).
According to Google Analytics, ChIRP web-based immunization information pages received 207 unique visits during the intervention period. Immunization information was most often read in English (118/207, 57%), followed by Punjabi (52/207, 25.1%), Arabic (13/207, 6.3%), Spanish (12/207, 5.8%), Italian (4/207, 1.9%), Chinese (4/207, 1.9%), French (2/207, 1%), Tagalog (1/207, 0.5%), and Vietnamese (1/207, 0.5%).
This pilot intervention aimed to assess the effectiveness and acceptability of SMS text message reminders for preschool immunization appointments. Consistent with previous literature [
There was a decline in absolute no-show rates at Mill Woods PHC, which corresponds with other studies [
Overall, parents reported high acceptability of the 15-month and 3-day message reminders, with almost all stating that they were helpful. Literature has shown that parents often prefer SMS text message reminders over mail or email because of the convenience and timeliness [
Most of the surveyed PHC staff stated that SMS text message reminders were helpful, indicating provider support for the intervention. This reflects the readiness to engage parents in positive discussions about childhood immunizations and encourage them to subscribe to reminder services [
Parents and PHC staff agreed that the best time to send appointment reminders was 3 days before the appointment but had different preferences for the booking (15-month) reminder, with staff preferring the reminder to be sent earlier. This difference in preferences is likely because of staff needing to schedule in advance to accommodate many immunization appointments, whereas parents may not be thinking about the 18-month appointment until their child is 17 months old or may forget the appointment if the reminder is sent too early. Interestingly, the staff at Mill Woods PHC preferred the reminder to be sent earlier than the Lethbridge staff. This may reflect differences in the size of the 2 PHCs; Mill Woods serves a larger urban area and thus requires parents to book in advance, whereas Lethbridge serves a smaller urban population within a rural zone and may accommodate appointments on shorter notice.
The web-based immunization information in different languages was also positively received by parents. According to the Google Analytics data, many participants accessed the information in other languages. There is increasing awareness that language barriers impede immunization service delivery, but they continue to remain unaddressed in many existing reminder and recall systems [
Notably, the Google Analytics data showed a different picture of website activity than the parent survey. Specifically, Google Analytics showed more visits to the website (n=207) compared with the number of survey participants who reported accessing the information (n=51). As the link to the website was sent to all parents receiving the intervention, it is possible that nonsurvey participants accessed the information. In addition, Google Analytics showed more diversity in the languages accessed on the website (ie, more non-English users) compared with the parent survey. This may reflect the fact that English-speaking participants may have been more likely to complete the survey than participants whose first language was not English. The diverse languages accessed by parents suggest the need to provide appropriately translated immunization information.
Using SMS text message reminders for immunization appointments may be a convenient and cost-effective way of reducing appointment no-shows. The acceptability of the intervention by parents and PHC staff means that there is potential for SMS text message reminders to be implemented for other immunization programs, particularly 2-month and 12-month immunizations, as well as in other provinces. Future research should consider the use of experimental studies to evaluate the impact of SMS text message reminders on immunization coverage following widespread implementation.
To maximize the effectiveness of an SMS text message reminder system, it is important to make it appealing to both parents and PHC staff. For example, parents preferred later booking reminders than staff; therefore, perhaps sending both early and later reminders might be a useful compromise.
A strength of this study is the diverse perspectives obtained from both parents and PHC staff at 2 different sites in Alberta: one large urban site and one small urban site in a rural area. We were also able to assess the change in no-show rates at both clinics, using data over an extended time (ie, 1 year for both baseline and intervention), and in comparison with a control site for each. The limitations of this study include a low parent survey response rate (222/929, 23.9%), which may be because of the 7-month gap between recruitment and when links to the evaluation survey were sent out. It is possible that parents who responded to the survey differed from nonrespondents. For example, as the survey was conducted in English, non-English speakers were likely to be underrepresented. In addition, a lower proportion of survey respondents did not attend their child’s 18-month immunization appointment compared with the calculated no-show rates at the 2 clinics, which means that our survey likely underrepresented no-shows. However, it is encouraging that the survey respondents had diverse sociodemographic characteristics, such as income. The number of surveyed PHC staff was also low, which may be explained by the increased strain on health care providers during the COVID-19 pandemic [
This study found that parents and staff at the 2 PHCs were highly accepting of the SMS text message reminder system implemented to address the drop in coverage for 18-month immunizations. The intervention reduced the number of missed appointments at the urban intervention site. Findings support the use of SMS text message reminders as a convenient and acceptable method to minimize parental forgetfulness and potentially reduce appointment no-shows.
Alberta Health Services
Childhood Immunization Reminder Project
diphtheria-tetanus-acellular pertussis-polio-Haemophilus influenzae type b
measles-mumps-rubella-varicella
public health center
Research Electronic Data Capture
This project was a partnership project between Alberta Health, Alberta Health Services, and the Applied Immunization research team at the University of Alberta. This project was funded by the Public Health Agency of Canada through an Immunization Partnership Fund grant. The authors would like to thank Celine O’Brien and Derrick Cleaver from the Alberta Health Communicable Disease and Immunization team; Elaine Sartison, Carlene Beek, and Chrystal Ference from the Alberta Health Services Edmonton Public Health Program team; Faridat Etoroma, Zenia Deol, Sjaane Heikoop, Stephanie McNabb, Britany Tyssen, and Anna Marshall from the public health center leadership and staff in Mill Woods and Lethbridge. Finally, the authors would like to acknowledge their late coauthor Dr Larry Svenson, whose wisdom, humor, and support were critical to the success of this project. This work was generously funded by the Immunization Partnership Fund through the Public Health Agency of Canada.
All authors attest that they met the International Committee of Medical Journal Editors criteria for authorship. SEM was involved in conceptualization, funding acquisition, investigation, formal analysis, writing (review and editing), and supervision. EM was involved in formal analysis and writing (original draft, review, and editing). HS was involved in formal analysis and writing (original draft, review, and editing). AA was involved in conceptualization, investigation, project administration, formal analysis, and writing (review and editing). AFW was involved in analytical design, statistical analysis, and writing (review and editing). All other authors assisted with conceptualization, methodology, and writing (review and editing).
KA is a cofounder and the chief operating officer of CANImmunize Inc. All other authors declare no conflicts of interest.