Supporting CHWs as Vaccine Educators: Impact of a Digital Training and Chatbot Intervention on Vaccination in Kenya

Supporting Community Health Workers as Vaccine Educators: Assessing the Impact of a Digital Health Training and Patient-facing Chatbot Intervention on Vaccination Rates in Kenya

This study seeks to understand how to support community health workers (CHWs) to improve routine vaccination rates in high-need areas by testing a two-part intervention. The first part of the intervention is a digital training provided to CHWs, which includes videos and job aids on vaccine education to support patient communication. The second part of the intervention is a patient-facing chatbot that CHWs can share with their patients. The chatbot is designed to answer patient questions about routine immunization. The intervention will be implemented in two sub-counties in Migori County Kenya (Awendo and Nyatike) that Lwala Community Health Alliance has identified as high need with respect to vaccine education. We hypothesize that the intervention will increase knowledge about routine immunization among CHWs and patients, increase vaccine acceptance, intent-to-vaccinate, and vaccination rates among patients in the treatment group.

Study Overview

• Status: Active, not recruiting
• Conditions: Vaccine Hesitancy; Vaccine Refusal; Vaccine Knowledge
• Intervention / Treatment: Behavioral: Digital Vaccine Education Training & Patient-facing Chatbot Tool; Behavioral: Standard Training

Detailed Description

Background:

Immunization programs in Sub-Saharan Africa have made progress in recent decades, yet coverage remains low overall for some childhood vaccines. Immunization is one of the most powerful and cost effective public health interventions. In addition to saving lives, vaccination can greatly reduce the burden of illness and disability from vaccine preventable diseases, and contribute to improving child health and welfare, as well as reducing hospitalization costs. Yet, globally, mistrust in childhood vaccinations increased during the COVID-19 pandemic. Vaccine hesitancy in Kenya is driven by multiple interrelated and interconnected factors, including mistrust in health systems and vaccine misinformation which has grown during the global COVID-19 pandemic.

Community Health Workers (CHWs) are vital to global vaccination efforts, both in the distribution and logistical support, but also in promoting vaccine acceptance. Now more than ever, CHWs face barriers as vaccine educators including the proliferation of misinformation, lack of reliable, up-to-date information, and limited training in effective communication.

Aim:

Researchers at Stanford University's Center for Health Education and the Lwala Community Health Alliance are partnering to investigate how to better support CHWs to improve routine vaccination rates in high-need areas by testing a two-part intervention. The first part of the intervention is a digital training provided to CHWs, which includes videos and job aids on vaccine education. The second part of the intervention is a patient-facing chatbot that is designed to provide patients with key information about routine immunizations with the intent of increasing patient knowledge about vaccines, vaccine acceptance, and vaccination rates.

Methods:

To test the effectiveness of training and equipping CHWs with the digital training and chatbot tool, study researchers will conduct a cluster randomized trial in the two focal subcounties in Migori County (Awendo and Nyatike) that the Lwala Community Health Alliance has identified as high need with respect to vaccine education. Lwala survey data suggest that between 20-25 percent of children under 5 years have not received routine immunizations in these two sub-counties. Early anecdotal data has shown that there are additional barriers and vaccine hesitancy concerns with the rollout of the new malaria vaccine.

CHWs in the focal subcounties are organized into regional administrative units known as Community Health Units (CHUs). Training is provided at regularly scheduled CHU meetings attended by CHWs on a regular basis. The research team will randomize CHUs (Awendo/ 31 CHUs and Nyatike/ 48 CHUs) into a treatment arm in which CHWs receive the training and chatbot tool and a control arm in which CHWs receive neither. The CHWs will be blinded to treatment assignment and informed that they are taking part in a study to understand the CHW experiences and their communication with patients. Randomization will be stratified by geographic units (wards) and whether a health facility is available in the ward.

The participants in the treatment group will receive the intervention at the start of the study, while the participants in the control group will receive upon conclusion of the study, which will allow for the comparison of knowledge, beliefs and vaccination rates with a group that is controlled for bias introduced by time. The duration of the study for participants will be roughly four months, which will allow CHWs ample time to introduce the chatbot to eligible patients and provide patients with time to use the chatbot to inform their vaccine decision making.

Intervention:

The intervention is being developed by the Stanford Center for Health Education Digital Medic Initiative in collaboration with Lwala Community Health Alliance. The first part of the intervention is a digital training provided to CHWs, which includes videos and job aids on vaccine education to support patient communication. The second part of the intervention is a patient-facing chatbot designed to provide key information about routine immunization that CHWs can share with their patients through the social media and messenger application, WhatsApp.

The Stanford team has led the production of the video content, job aids, and chatbot design. The Lwala team has partnered in intervention design and development at all stages including script writing, piloting, and checking for relevance and resonance of educational content. The video content addresses reasons to vaccinate, vaccine misperceptions, side effects, and other barriers to improve childhood vaccination uptake. The video content is complemented by a set of infographic job aids for CHWs to share with their patients to encourage childhood immunization uptake. Content will be available in English and Dholuo.

Data collection:

Treatment and control CHWs will complete a baseline and endline survey administered at the same time. The baseline survey will include demographic questions and questions about CHWs' work experience including their perceptions of vaccine safety and effectiveness and preparedness to educate patients about complex health topics including childhood immunization. The endline survey will include a knowledge assessment drawn from the training content, as well as measures of CHW vaccine acceptance and preparedness to educate patients about childhood immunization. A subsample of patients will be surveyed at endline from both the treatment and control groups. The patient survey will include demographic questions and questions about patients' knowledge and beliefs about childhood immunization, intent-to-vaccinate and vaccination status among household members.

Data Analysis:

The primary analysis will be based on intention-to-treat at the CHU unit. The analysis will include randomization strata fixed effects and control for baseline covariates to improve precision of estimates.

• Study Type: Interventional
• Enrollment (Estimated): 795
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Jamie S Johnston, PhD; Phone Number: 6507248074; Email: jamiejs@stanford.edu
• Study Contact Backup: Name: Victoria Ward, MD; Phone Number: 6507248074; Email: vward@stanford.edu

Study Locations

• Kenya
  • Rongo, Kenya
    • Lwala Community Health Alliance

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• CHWs identified by Lwala Community Health Alliance in study area
• Patients with children in the household of eligible age for routine immunization

Exclusion Criteria:

- Patients without children in the household of eligible age for routine immunization

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Treatment; Community health workers (CHWs) will receive the intervention training videos, job aids and chatbot tool to share with patients via WhatsApp in addition to standard CHW training provided by Lwala Community Health Alliance.	Behavioral: Digital Vaccine Education Training & Patient-facing Chatbot Tool; The first part of the intervention is a digital training provided to CHWs, which includes videos and job aids on vaccine education to support patient communication. The second part of the intervention is a patient-facing chatbot designed to provide key information about routine immunization that CHWs can share with their patients through the social media and messenger application, WhatsApp.; Behavioral: Standard Training; All CHWs in the study will receive the standard CHW training that is provided on an ongoing basis by Lwala Community Health Alliance.
Active Comparator: Control; Participants in the control group will receive standard community health worker (CHW) training provided by Lwala Community Health Alliance.	Behavioral: Standard Training; All CHWs in the study will receive the standard CHW training that is provided on an ongoing basis by Lwala Community Health Alliance.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
CHW vaccine knowledge	Knowledge about routine childhood vaccines based on a set of 15 knowledge questions draw directly from the digital training	Collected after roughly 1 month of exposure to the training content
CHW vaccine beliefs	Set of 5 Likert scale questions about beliefs about routine childhood vaccines regarding 1) the safety of childhood vaccines, 2) the effectiveness of childhood vaccines, 3) whether children should receive the new Malaria vaccine, 4) whether children receive too many vaccines, and 5) whether vaccination is compatible with one's personal beliefs.	Collected after roughly 1 month of exposure to the training content
CHW vaccine education preparedness	Set of 5 Likert scale questions about preparedness to educate patients about routine childhood vaccines including 1) preparedness to answer patient questions, 2) preparedness to explain complex health topics including immunization to patients, 3) adequate access to information about vaccines and the diseases they prevent, 4) preparedness to explain the need for so many childhood vaccines, and 5) preparedness to alleviate patients' fears about vaccination.	Collected after roughly 1 month of exposure to the training content
Patient vaccine knowledge	Knowledge about routine childhood vaccines based on a set of 15 knowledge questions draw directly from the digital training	Collected roughly 4-6 months from CHW first exposure to the training content
Patient vaccine beliefs	Set of 5 Likert scale questions about beliefs about routine childhood vaccines regarding 1) the safety of childhood vaccines, 2) the effectiveness of childhood vaccines, 3) whether children should receive the new Malaria vaccine, 4) whether children receive too many vaccines, and 5) whether vaccination is compatible with one's personal beliefs.	Collected roughly 4-6 months from CHW first exposure to the training content
Patient vaccination uptake	Vaccination uptake among patients of treatment CHWs measured by CHW records, patient self reports, and administrative health records (where available)	Collected roughly 6 months from CHW first exposure to the training content

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
CHW perceptions of patient vaccine beliefs	Set of 6 Likert scale questions posted to CHWs about the beliefs of their patients including whether their patients 1) believe vaccines are safe, 2) believe vaccines are important, 3) know when you bring children to clinic to receive vaccinations, 4) believe that all doses are important for children to receive, 5) are fearful of adverse vaccine side effects, and 6) are fearful of long-term impact of vaccines on their children.	Collected after roughly 1 month of exposure to the training content

Collaborators and Investigators

• Sponsor: Stanford University

Study record dates

Study Major Dates

• Study Start (Actual): January 16, 2024
• Primary Completion (Actual): March 1, 2024
• Study Completion (Estimated): August 1, 2024

Study Registration Dates

• First Submitted: January 24, 2024
• First Submitted That Met QC Criteria: January 24, 2024
• First Posted (Actual): February 1, 2024

Study Record Updates

• Last Update Posted (Actual): April 16, 2024
• Last Update Submitted That Met QC Criteria: April 15, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Other Study ID Numbers: 69793

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No