SMS Reminders for Missed Immunization Appointments

8/12/2019 SMS Reminders for Missed Immunization Appointments

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Using SMS Reminders to Red

Missed Immunizations

Jordan Schermerhorn

10 August 2014


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Overview

Part 1: SMS Reminders

Background

Procedure

Results

Part 2: Patient Interviews

Part 3: Identifying Vulnerable Patients Methods

Results

Future Plans & Recommendations


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SMS Reminders

Part 1


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Background | SMS Reminders

Goals: Easy way to remind patients about appointments they m

Reduce time nurses spend calling defaulters

Sends SMS to immunization and vitamin A defaulter

Vitamin A: lots of defaulters, but too many wrong numbe

Immunizations: fewer defaulters, more right numbers

Began in June 2013, Taybeh Health Center

Problems with defaulter list corrected in June 2014


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Setting | SMS Reminders

Taybeh Health Center

Average 23 defaulters eachweek

~100 births each month


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Procedure | SMS Reminders

1. Set Criteria:

Missed appointment

No scheduled future appointment

2. Receive spreadsheet from e-Health

Once per week for immunizations

3. Check & clean numbers

4. Send messages using Clickatell


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Results: Return to Care | SMS Reminders

114 patients received messages total 85 received messages before August 6

66 of these 85 have returned to care (77%)

Days Late

(before SMS)

Days until new appointment

(after SMS)

Median 16 1.5

Mean 23 6


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Results: Return to Care | SMS Reminders


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Results: Message Status | SMS Reminder

Out of 114 phone numbers

Functional 89 78.1%

Out of service or landline 15 13.2%

Missing digit in e-Health 4 3.5%

Wrong number in e-Health At least 2 1.8%

Transfer to other clinic At least 4 3.5%


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Vaccine Type | Who received SMS remin

0

10

20

30

40

IPV, OPV, DPT

- Dose 1

IPV, OPV, DPT

- Dose 2

IPV, OPV, DPT

- Dose 3

Measles &

OPV 4

MMR 1 MM

boo

* 12 patients missed >1 appointment

Month of life:

Vaccine Type:

1 2 3 9 12


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Gender | Who received SMS reminders

114 patients

43% male 57% fema

Would expect 50/50


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Gender | Who received SMS reminders

For MMR2, gender difference is statistically significant (p = 0

0

10

20

30

40

IPV, OPV,

DPT - Dose 1

IPV, OPV,

DPT - Dose 2

IPV, OPV,

DPT - Dose 3

Measles &

OPV 4

MMR 1 MMR 2 &

boosters


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Results: Time Cost| SMS Reminders

Simulate defaulter calls Called 25 patients to request interviews; called 3 times if no

Total time: 94 minutes

Time to send SMS: 15 minutes/week

Time spent: 1 hr, 15 minutes (5 weeks)

Total time saved: 5 hours, 35 minutes of calling t

Total cost: $6.84 or 4.04 JOD


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Challenges | SMS Reminders

3 local cell providers

Zain expires most quickly, Orange lasts longest

UNRWA patients have:

Orange 2%

Umniah 34%

Zain 64%


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Challenges | SMS reminders

Expired numbers

Multiple phones per family

Problems with numbers listed in e-Health Missing digits

Extra digits

Landlines

Some patients go to private clinicsand show up asdefaulters in e-Health

Nonsense data in e-Health (ex. patient missed appoibefore he was born)


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Patient Interviews

Part 2


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Patient Interviews | Part 2

Goal: get patient feedback on SMS

14 interviews with mothers at Taybeh who

Missed an immunization appointment

Received SMS reminder

Questions about:

Missed appointments

SMS reminders

Scheduling


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Patient Interviews | Conclusions

Everyone has at least 2 phones (some 3, 4, 5) People are usually happy with MCH programs at Tay

People like the SMS alerts

They want reminders before appointments, not afte

12 before, 1 after, 1 did not want Some people think wait times are long (9:30 am 1


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Patient Interviews | Forgetting Appointm

I do not look at the handbook once a week, but I try to not mappointments. The nurses will talk to me if I miss an appointmIm late. If you come at a time that is not your appointment, ttell you to go home and then reschedule you and ask you to cthat new time.

When my appointments are at 9:30 I cant be there at that stime in Ramadan. I have a kid in high school. My kids dont haon me. The things that happen in the morning get moved to tafternoon.


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Patient Interviews | SMS reminders

I was very surprised by it! It is very good, honestly. It is so mueasier.

SMS are good, phone is good, but whats better is when theyhusband a SMS and then called him after when we forgot aga


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Patient Interviews | Interesting Quotes

When the neighborhood doesnt have running water, I feel liclinic is unusually crowded. It gets crazy. The health center alwwater so people come here instead.

My husbands family, they are [sabaawiyeh?]. I feel like they aneglectful of their children, I dont know whymy father-in-lahe had a daughter and he didnt want to take her to the immu

didnt want to take her to the doctor, because she is a girl.

The family health team is a wonderful system. They implemerecent times and its fantastic.


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Identifying Vulnerable Patie

Part 3


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Background | Vulnerable Patients

Mothers said they preferred messages before That costs more money

IF we send messages before, WHO should we r

Goal: identify patients at high risk of defaultiimmunizations


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Methods | Vulnerable Patients

Cohort analysis

June birth & July births

BCG vaccine only so far

Given in groups

Late if received BCG after the first group >1 wafter birth

Data obtained from e-Health


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Methods | Vulnerable Patients

Child gender

Maternal education

Child birth order

Ramadan or no Ramadan


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Results: Ramadan | Vulnerable Patients

99 due during Ramadan, 65 due during not Ramadan

3.40x more likely to be > 1 week late (p < 0.0001)

Average Days Late Late > 1 week Total

Ramadan 8.3 57 99

Not Ramadan 3.1 11 65


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Results: Education | Vulnerable Patients

No education: 1.75 RR of >1 week late (n=14, p=0.0

University: may work, have difficulty choosing exact


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Results: Gender | Vulnerable Patients

Gender Median Delay # >1 week % Total

Female 4 33 38.8 85

Male 4 31 41.3 75

No statistically significant difference (p = 0.76)


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Results: Birth Order | Vulnerable Patient

Born 1 or 2: 29% late > 1 week

Born > 2: 51% late > 1 week

Risk Ratio 1.71, p < 0.01

# Older Siblings Median Delay # >1 wk % Total

0 4 13 32 41

1 3 11 28 40

2 7 18 64 28

3 7 12 46 26

4 8.5 6 60 10

5 0 0 0 6

6 0 1 0 5

7 7 2 100 2

8 7 1 100 1


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Future Plans

Send letter to clerks about updating phone numbers

Continue monitoring of patients who received SMSreminders for 6 months

Continue monitoring all patients in June cohort to sechanges by vaccine type and dose


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Recommendations

Send SMS reminders to all patients scheduled for

immunizations during Ramadan before appointment

Consider sending pre-appointment reminders to vulpatients

Mothers with no education or primary-school education Girls who need MMR Dose 2

Babies with 2 or more older siblings


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Recommendations

Maybe send SMS about prenatal nutrition

Check box in e-Health for patients who want SMS (c

Build system that integrates reminders automatically

Health I cant do this, but could facilitate partnership

Medic Mobile


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Questions?

Thanks to everyone at UNRWA HQ and Taybeh Health C

Funding: Duke University

Statistical analysis: STATA software

[email protected] me for raw data, interview transcripts, etc!

SMS Reminders for Missed Immunization Appointments

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