How is your Memory? – Due Dates, Home-Based Records, and Vaccination

When/where/what time is your next doctor’s appointment, or meeting with a key investor or client, or a big soccer match or school exam? If the event is more than a month away, do you remember the date and time or do you write/save them in a calendar or elsewhere?

What would you do if you did not have that computer-like memory or an electronic or paper calendar?

Complete immunization and full protection from many leading killer or debilitating diseases require several vaccinations (often at recommended intervals – e.g. 4 weeks, 6 months, 2+ years – between doses of vaccines in a series, depending on the immunology and disease epidemiology).  For many of these vaccine-preventable diseases, infants are targeted for vaccination because: (a) they are most at risk due to not having natural antibodies to protect them from exposure to these severe viruses or bacteria or (b) their immune systems are rapidly developing and can, therefore, seroconvert (i.e. adapt to) the vaccines to ensure several years of protection or life-long immunity.

A mother holds her baby and the child’s up-to-date vaccination card during a routine immunization session at a health facility in Uttar Pradesh, India. Photo credit: Tasnim Partapuri

With medical technology developing, there are now more vaccines available, with varying calendars and recommended intervals that are difficult to remember. So, how do parents or clients remember these dates? How do you remember?

I have been using the example of my bi-annual dentist appointment. Thanks to parents who ingrained in me the importance of dental care (and because I am fortunate to have insurance and afford the co-payment), I have visited the dentist every 6 months for as long as I can remember. [Some of my earliest childhood memories are standing on a stool when my Dad brushed my baby teeth, and our family traveling together to the dentist’s office in the “bigger town” 30 minutes away.] At the end of each of my dental appointments, I make the next 6-month appointment. However, I have always had a spotty memory, so within a few days, I forget the date of that appointment. In the past, I wrote my next appointment in a paper calendar and kept the appointment card from my dentist, occasionally pulling it out of my wallet to refresh my memory. Now I have it scheduled on my electronic calendar (with phone and computer reminder alerts). Also, as backup, the dentist’s office calls and emails to remind me 48 hours beforehand. So, I have four opportunities for a reminder. Yet this past month (due to my heavy work travel schedule), I had to reschedule my appointment three times, with only a few days’ notice (and thanks to a flexible dental care provider).

What do parents do when they do not have mobile phones with electronic calendars, or SMS/text message reminders, or even a paper calendar?

Since the 1980s (and earlier in some countries), immunization programs have used paper-based vaccination cards in which the dates are written as reminders and tracking tools. However, in the last several years, these tools have not been emphasized or available or distributed due to lack of funding or other constraints, which we are also seeing in survey data. In some countries, we also see immunization dropout rates increasing (i.e. infants who start but do not complete the vaccination series) and a reliance on maternal recall as to which vaccines and doses were received (which can be inconsistent, like remembering due dates).

Of course, a top priority in immunization programs is that the vaccination services be available, accessible, affordable, acceptable, and affable to the clients. In addition to ensuring these, can a focus of attention by health workers, community mobilizers, and parents on the value, availability, reference and use of the cards – including the completion of data in them and the reminders for due dates – assist in addressing the challenges in improving coverage? This is something that the Bill & Melinda Gates Foundation and our JSI grant are considering. We have past experience with card design, use and reminders contributing to better communication between parents and health workers and potentially helping to reduce dropouts and improve coverage.

A mother holds her baby and the child’s up-to-date vaccination card during a routine immunization session at Kimilili District Hospital, Kenya. Photo credit: Lora Shimp, JSI.

I would have no record of my childhood vaccinations had my mother not kept my card with our awards, school report cards, etc. Also, just last week, I needed my paper vaccination card as proof of yellow fever vaccination to enter and exit Kinshasa airport. (This was one of the trips for which I had to reschedule my dentist appointment.  Incidentally, I have to periodically look at that card to remember when I had that 10-year yellow fever vaccination.)

Sometimes, simpler solutions like paper cards are more efficient and usable than technology – particularly where they are needed most and where mobile services, electricity, the internet, and computers are not reliably available. Also, often the paper cards – when their value is emphasized and understood – can “live on” longer than the ever-changing and limited archival storage of electronic systems. A combination of both can be very effective.

Side note: I thankfully had an “all is fine” appraisal from the dentist. Of course, I need to floss more (sound familiar to others?).  Now, over a week later, I have already forgotten the date of my next dentist appointment), so it’s helpful that I use my calendars and that the dentist’s office calls to remind me a few days beforehand.

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