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Sunday, February 16, 2014

Records for Life (Bill & Melinda Gates Foundation) - A project by Deepankar Bhattacharyya

Child Health Record - Project Background

The child health record serves at least five functions in the health system:

1. A unique identifier that is intimately connected to the child

2. A source of critical information for health workers about the child’s health and vaccination status, and what the child needs at each point of contact with the health system

3. A source of critical information for families, such as date of next visit for vaccination

4. A source of critical information for household surveys, which many countries and policymakers rely on to validate the vaccine coverage levels obtained from administrative data systems

5. An educational tool for families to learn more about health interventions

To enable these functions, child health records have to be available, accessible, and utilized by caregivers (e.g.parents), health providers, and surveyors. When a high percentage of the infant population has been issued a record, and families keep the record through the course of vaccination, we say that for that population, record prevalence is high. A high prevalence is fundamental to achieving the five functions of the child health record.

Unfortunately, child health records are frequently unavailable at the time of a household visit or when the child is brought to a health facility. Only 10 percent of countries with data have record prevalence rates higher than 90 percent—the foundation’s estimate of the minimum acceptable prevalence rate to feel confident that the health record is serving all five critical functions. This suggests the need for a strong effort across countries to ensure that the records are available and valued by family members. 

In addition to the issue of low prevalence, child health records are not always accurately filled out, or they may fail to provide adequate space to convey additional health information such as vaccinations received in supplementary immunization activities, e.g. vaccination campaigns. Over time, child health records will track more and more data, as countries increase the number of vaccines that they provide for children. As a result, accuracy is likely to decrease over time unless thoughtful design principles are applied to the records. Finally, looking forward, paper records may over time become obsolete due to implementation of a combination of the digitization of health information systems and other possible innovations such as biometric identification systems. At that point, the records will play an important role in the transition of information from a traditional, paper-based information system to a digital one. 

The Gates Foundation is partnering with WHO and UNICEF to assess what the global community has collectively learned about effective and ineffective child health records in 2013. We’ll be investigating root causes of records not being distributed, retained, and utilized. In addition, we will look to further understand the results of early studies that have shown programmatic impact due to redesigned records and incentives. For example, Usman et al. (2011) found that 66 percent of children in a Pakistan study received the full course of Diphtheria-tetanus-pertussis vaccine when child health records were redesigned (versus 39 percent in the control group). The redesign in this study had four simple elements: increasing the size of the record, making the record bright yellow, putting it in a plastic cover with a hanging string, and increasing the visual prominence of the “date of next vaccination” data element. We believe that these results could be replicated more broadly and yield an even greater impact by applying a suite of core principles of design to child health records, rather than a subset. 

Over the next few years, WHO will convene a group of experts to discuss the findings and start drafting a set of guidelines to help countries determine how to improve record accuracy, prevalence, and use. To inform the guidelines and bring an innovative lens to this problem, in 2013 the foundation is launching an international contest, open to anyone, to redesign current child health records. 

The language for this contest is English. This can be translated into other languages for different countries.

Submitted Proposal (November 2013)

The proposed solution comprises a health record book in 2 versions and a calendar along with a plastic cover that has a string which can be used to help carry the record book around the neck or shoulder. 

The record is a 6-page 2-fold document that has extra space for growth charts etc. as well as space for illustrations that help one to understand vaccinations. There is also a 4-page single fold version that has less space for newer vaccines and also does not have space for growth charts and vaccine education. The calendar is for 2 years, each of which is to be printed on either side. This calendar also has the vaccination schedule along with check boxes beside each vaccine dose that can be ticked by the care giver. 

The care giver should feel a sense of ownership and should be encouraged to personalise the health card (a place for a photograph of her child is provided). 

The calendar can be derived from the local way of tracking dates i.e. lunar and has a hole on top to enable it to be hung on the wall. It can also incorporate symbols and visuals that can relate specific dates to local festivals and rituals. There is usually someone in the neighbourhood who can read and this calendar will help initiate discussion and conversation about health and vaccination. The care giver can use the calendar independently of the card and is a way to remind everyone in the home of critical dates. The calendar is also a way to help reconstruct the record in the event of the health card getting lost or misplaced. The caregiver should be encouraged to note the due date given on the card on her calendar as well. She should also be encouraged to tick the boxes next to vaccine (see calendar) when she returns home after each vaccination session. This is designed in the same way as the vaccination schedule on the card which also has boxes that need to be ticked after each session, a task ideally carried out by the care giver along with the health provider. This kind of interaction would help the care giver understand vaccine administration and empower her to take the initiative in her child’s vaccination process.  

The record is placed in a plastic cover, it has a brightly coloured string that when extended to one side is long enough to enable the care giver to wear it around her neck or use it as a shoulder strap. This would make it easier for her to carry it along with her child. The cover will also protect the document from dirt and grime. 

A unique identifier that is intimately connected to the child 
The proposed solution has space for a photograph or any other mark that the care giver would like on the very first page. This helps both in identification as well as personalisation. It increases participation of the care giver and gives her a sense of ownership of the record.
It also has space for an ID no. that can be generated for each child and which then becomes associated with the child for all future contacts with the health system. Space for this ID no. is on the cover, the page for vaccination record and the calendar. The record book also has space for bio-metric identification marks and a mobile no. both of which help make the record unique.  
The calendar is an intrinsic part of the proposed solution and is uniquely connected to the child, it also carries the child’s date of birth and ID no. 

Source of critical information for health workers about the child’s health and vaccination status 
The proposed solution has well demarcated spaces for vaccination records both scheduled as well as unscheduled. It has space to record the child’s growth parameters at different scheduled visits as well as space for medical notes and suggestions. 

The record has the vaccination schedule on the back cover with check boxes next to each vaccine dose. When properly maintained this will show the vaccination status at a glance. 
The calendar at the care giver’s home can also be used to ascertain the child’s vaccination status even in the absence of the record book. This is possible because it also has the same vaccination schedule with check boxes next to each vaccine dose which the care giver fills in on reaching home after each administration of vaccine.
There is space for new information that may have been added for local conditions. 
The care giver actively participates in updating records and dates, thereby increasing her knowledge and information. This helps the health worker obtain critical information even if the health card goes missing or has not been carried on a particular day. 

Source of critical information for families, such as date of next visit for vaccination 
Place for dates of next visit due is on the back cover. Large boxes have been provided to note the due date with instructions to the health worker to cross out all previous dates. Care givers are also encouraged to note this due date in her calendar when she gets home. 
The vaccination schedule in the record book as well as in the calendar with their check boxes will also assist the care giver in remembering these dates especially since she is an active participant in noting them down. 
The health record of her child’s weight, growth and medical notes will help the care giver make informed decisions regarding her child.
The care giver is also reminded of the diseases the vaccines are protecting her child against. These are mentioned in the calendar as well and will hopefully become topics of conversation in the home since the calendar is likely to be hung on the wall.  
The interactive nature of the proposed solution is designed to increase awareness for everyone in the family through active participation, discussion and empowerment. 
The care giver notes down the date of next visit in her calendar, she ticks off the boxes against vaccine doses that have been administered, her calendar is her tool for action. 

Source of critical information for surveys, which many countries and policymakers rely on to validate coverage levels obtained from administrative data systems 
The vaccination record in the book has been designed to be quickly and easily filled as well as read. Dates and doses of vaccine administration can be seen at a glance. This page also has the child’s ID no. and date of birth. The surveyor could simply scan or photograph this page to obtain ready to digitise records. 
If the book is unavailable, the calendar in the home will provide information of vaccines administered and a record can be easily recreated. This is very useful if the health record book is lost or destroyed. 
The family is unlikely to misplace the calendar as well as the record book. 

An educational tool for families 
There is information at many levels in both the record book as well as in the calendar which will be triggers for conversation, discussion and learning. Diseases that are protected against are mentioned, vaccination administering modes are shown, growth charts and do’s and don’ts have their own space. 
Space has been left for educational illustrations although we have not made any of these. They need to be done in a style that is relevant to the culture of the community where the record will be used. 
The record has been designed to encourage participation and the care giver will check boxes and note dates in her calendar. Even if she is illiterate she is like to find others in the community to help her. She will thus feel empowered to make decisions that will help her protect the health of her child. 
The calendar hanging on the wall will start conversations and provide opportunities for raising awareness about health and vaccination issues apart from being a constant reminder of due dates. 

Ease of adding new information 
The vaccine record page has been designed in a way that makes it easy to add new vaccines and dose schedules. Even the 4 page version has space for 3 additional vaccines. 
The 6 page version demonstrates how this attribute can be used to increase space for 5 new vaccines without changing the basic design.
‘Out of schedule’ vaccination records also have been designed with this in mind, this is demonstrated in the 2 versions. 
There is space to add supplementary information that may be locally relevant. 

Digital transition: visualization of data 
The ID no., mobile phone no. and data entry in boxes provided in the design can become the foundation of a digital record environment. The dates in the vaccination record along with the check boxes on the vaccination schedule can trigger alerts for all stakeholders. The mobile phone can be used to remind care givers of due dates and venues. 
The vaccination record has been designed in a manner that enables entry to be made on a digital device. A printout or digital transfer of this record can be the care giver’s copy in the future. 

In the interim period, digital pens may be used by health workers to obtain a digital record of all data inputs in the vaccination record. This data can be manipulated in many ways to provide interpretations and visualisations that may offer unique insights and help in decision making. 
The design is such that only numbers have to be inputted i.e. date of vaccination and dose no. in little boxes. The chances of this being translated wrongly into digital spaces are slim. 
Care giver participation in updating records on her calendar paves the way to eventually her doing the same on digital devices. She updates her record and makes calendar entries and plans for her next visit. She is empowered. 

Digital transition: retroactive data entry 
The critical information is on the vaccination record page. This contains the child’s name, ID no. and date of birth along with date of administration of a dose of a particular vaccine or vaccines. 
This page has space for data input in little boxes. All numbers and letters will be entered in these boxes. The data inputted on each visit (date of vaccination and dose no.) are numerical. 
This can be easily scanned into a digital environment with OCR technologies with little chance of loss in accuracy.  

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The material in this post belongs either to the client or to Deepankar Bhattacharyya and is protected by copyrights and patents.

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Creative Commons License
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