A Smartphone App to Increase Immunizations in the Pediatric Solid Organ Transplant Population: Development and Initial Usability Study

Abstract

Background Vaccine-preventable infections result in significant morbidity, mortality, and costs in pediatric transplant recipients. However, at the time of transplant, less than 20% of children are up-to-date for age-appropriate immunizations that could prevent these diseases. Smartphone apps have the potential to increase immunization rates through their ability to provide vaccine education, send vaccine reminders, and facilitate communication between parents and a multidisciplinary medical group. Objective The aim of this study was to describe the development of a smartphone app, Immunize PediatricTransplant, to promote pretransplant immunization and to report on app functionality and usability when applied to the target population. Methods We used a mixed methods study design guided by the Mobile Health Agile Development and Evaluation Lifecycle. We first completed a formative research including semistructured interviews with transplant stakeholders (12 primary care physicians, 40 parents or guardians of transplant recipients, 11 transplant nurse coordinators, and 19 transplant subspecialists) to explore the acceptability of an immunization app to be used in the pretransplant period. Based on these findings, CANImmunize Inc developed the Immunize PediatricTransplant app. We next held 2 focus group discussions with 5-6 transplant stakeholders/group (n=11; 5 parents of transplant recipients, 2 primary care physicians, 2 transplant nurse coordinators, and 2 transplant subspecialists) to receive feedback on the app. After the app modifications were made, alpha testing was conducted on the functional prototype. We then implemented beta testing with 12 stakeholders (6 parents of transplant recipients, 2 primary care doctors, 2 transplant nurse coordinators, and 2 transplant subspecialists) to refine the app through an iterative process. Finally, the stakeholders completed the user version of the Mobile Application Rating Scale (uMARS) to assess the functionality and quality of the app. Results A new Android- and Apple-compatible app, Immunize PediatricTransplant, was developed to improve immunization delivery in the pretransplant period. The app contains information about vaccine use in the pretransplant period, houses a complete immunization record for each child, includes a communication tool for parents and care providers, and sends automated reminders to parents and care providers when immunizations are due. During usability testing, the stakeholders were able to enter a mock vaccine record containing 16 vaccines in an average of 8.1 minutes (SD 1.8) with 87% accuracy. The stakeholders rated engagement, functionality, aesthetics, and information quality of the app as 4.2/5, 4.5/5, 4.6/5, and 4.8/5, respectively. All participants reported that they would recommend this app to families and care teams with a child awaiting solid organ transplant. Conclusions Through a systematic, user-centered, agile, iterative approach, the Immunize PediatricTransplant app was developed to improve immunization delivery in the pretransplant period. The app tested well with end users. Further testing and agile development among patients awaiting transplant are needed to understand real-world acceptability and effectiveness in improving immunization rates in children awaiting transplant.

Vaccine-Preventable Infections Among Solid Organ Transplant Recipients in Switzerland

“…In our analysis, VPIs occurred more frequently among SOT recipients than in the general population. This finding highlights the importance of ongoing efforts to decrease the incidence of these potentially preventable infections, including attempts to increase vaccine uptake in transplant recipients and to improve the immunogenicity of vaccines in immunocompromised patients …”

A scoping review of pediatric transplant education

“…Eighteen articles describing 17 educational interventions were identified through the literature search. These studies were conducted in the United States (n = 11), 16,27,28,[30][31][32]35,36,40,41,43 Canada (n = 2), 38,42 Germany (n = 2), 34 and England (n = 1) 37 or multi-setting (United…”

“…Sample sizes ranged from 7 to 137 participants. The study design included randomized controlled trials (RCT) (n = 2), 29,33 pre-post design (n = 5), 16,28,30,31,35 feasibility, acceptability or usability (n = 2), 27,40 experimental design with a control group (n = 2), 32,34 descriptive assessments (n = 3), 37,41,43 and mixed method types (n = 4). 36,38,39,42 (Table 1).…”

“…One study described a pretransplant educational intervention, 27 and two were aimed at educating patients and their caregivers throughout the transplant process. 42,43 The target audience for most educational programs were both patients and their caregivers (n = 9) 16,28,29,31,32,37,38,40,41 however, some studies described interventions whose educacomponent was relevant to only caregivers/family members (n = 3), 27,36,43 , or patients (n = 6). 30,[33][34][35]39,42 Children and teenagers were the most frequently included patient populations.…”

“…Patients described by the study were most likely to be recipients of a kidney transplant (n = 6) 28,30,32-34,37 followed by liver (n = 2) 41,43 and heart transplants (n = 2). 16,38 Several studies described educational interventions applicable to multiple organ types (n = 5) 27,35,36,40,42 or all pediatric solid organ transplant recipients and their caregivers (n = 3). 29,31,39 Most educational interventions provided information on medications and medication self-management to improve knowledge and/or adherence 28,30,32,33,35,40,41 (n = 7).…”