The Impact of Information and Communication Technology on Immunisation and Immunisation Programmes in Low-income and Middle-income Countries: A Systematic Review and Meta-analysis

"By focusing on LMICs [low- and middle-income countries], this review addresses immunisation challenges within populations that often face systemic healthcare access barriers, thereby including marginalised groups in the assessment of digital health interventions."

Gavi, the Vaccine Alliance, advocates information and communication technology (ICT) adoption, leveraging the increasing mobile phone penetration in low- and middle-income countries (LMICs). This systematic review and meta-analysis summarises ICT effectiveness in improving vaccine delivery in LMICs.

Focusing on English-language, peer-reviewed studies published from January 2010 to August 2023, the study evaluated ICT interventions in immunisation programmes within LMICs, involving healthcare workers, caregivers, or health managers. It assessed ICT interventions like electronic health records, mHealth, and mobile apps, comparing their effect on immunisation services with traditional or non-ICT approaches.

Of 6,535 screened studies, 27 studies involving 354,979 children were included. Of the 27 studies, 15 were randomised controlled trials (RCTs), 7 were quasi-experimental, 4 used mixed methods, and one was an observational study. These studies were conducted in 17 LMICs, mainly in Africa (20 studies) and Asia (6 studies), with one in South America. ICT interventions predominantly involved digital reminders (19 studies), including automatic and manual short message system (SMS) and phone calls, primarily for vaccination appointment reminders and adverse events following immunisation (AEFI) alerts. Other interventions included electronic immunisation registries (EIR) (3 studies), software tools (3 studies), or other digital solutions (1 study) for vaccine stock and cold chain management.

All but one study demonstrated a positive impact of ICTs on immunisation coverage and timeliness, completeness and accuracy of records, number of AEFIs reported, vaccine stockouts, and cold chain expansion. For example, 19 (70%) focused on reminder-based interventions for scheduled vaccination appointments. Digital reminders generally improved immunisation coverage rates compared to control groups.

A meta-analysis demonstrated that reminders effectively improved coverage rate of the third dose of the pentavalent vaccine (odds ratio (OR) 2.32, 95% CI 1.34-4.03) and full immunisation at one year of age (OR 2.61, 95% CI 1.2-5.67) with significant degrees of heterogeneity, respectively I2 82% and I2 89%.

The risk of bias assessment identified 15 studies (55.6%) with a low risk of bias, 8 (29.6%) with a medium risk, and 4 (14.8%) with a high risk. Main concerns for bias in RCTs included unblinded outcome assessors and intervention providers.

The researchers note that none of the studies reviewed addressed concerns about data protection, which is likely to be a critical issue in the future. Nor did they mention the use of Digital Public Goods: products that meet standards to ensure open and free availability. Per the researchers, this lack points to a critical gap in research. They explore other research avenues, such as the need for investigation into how to effectively integrate advanced ICT solutions into immunisation programmes.

In short, this systematic review confirms the benefits of ICT in immunisation programmes by enhancing various stages of vaccine delivery. Specifically, reminders have been shown to enhance childhood immunisation coverage rates. However, the effectiveness of reminders may be limited in less advantaged groups, especially those without personal mobile phones or charging means. The success of reminders depends on caregivers' technological literacy and capacity to understand written messages. Hence, implementing electronic reminders or similar interventions could inadvertently exacerbate inequalities related to education and wealth, especially among groups or in areas where digital literacy levels are low.