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Conteúdo (article):

Vacina Sim: Development of Paired Mobile Applications as an Innovative Strategy to Improve Vaccine Adherence

Vacina Sim: desenvolvimento de aplicativos móveis pareados como estratégia inovadora para melhorar a adesão vacinal

Vacina Sim: desarrollo de aplicaciones móviles emparejadas como estrategia innovadora para mejorar la adherencia a la vacunación"

Ana Paula Ferreira Maciel, State University of Montes Claros, ana.maciel@unimontes.br, https://orcid.org/0000-0001-8056-4022
Rafael Almeida Soares, State University of Montes Claros, rafael.almeida.soares2012@gmail.com, https://orcid.org/0009-0006-5544-9798
Marcos Flávio Silveira Vasconcelos D\'Angelo, State University of Montes Claros, marcos.dangelo@unimontes.br, https://orcid.org/0000-0001-5754-3397
Dulce Aparecida Barbosa, Federal University of São Paulo, dulce.barbosa@unifesp.br, https://orcid.org/0000-0002-9912-4446
Jaqueline D\'Paula Ribeiro Vieira Torres, State University of Montes Claros, jaqueline.vieira@live.com, https://orcid.org/0000-0003-2383-2523
Claudia Mendes Campos Versiani, State University of Montes Claros, cmcversiani@gmail.com, https://orcid.org/0000-0001-5309-9022
Écila Campos Mota, Instituto Federal de Educação Ciência e Tecnologia do Norte de Minas Gerais, ecila.mota@ifnmg.edu.br, https://orcid.org/0000-0002-0283-6472
Carla Silvana de Oliveira e Silva, State University of Montes Claros, profcarlasosilva@gmail.com, https://orcid.org/0000-0002-0658-9990

Abstract
Objective: To describe the development of a prototype of paired mobile applications for community health workers and users as a strategy to increase vaccination adherence. Method: This is a methodological study of technological production using prototyping. The construction followed the human-centered design model, characterized by being a collaborative process focused on the person for the person. The development of the applications took place in four stages. Results: The technical-scientific content of the application was built according to the recommendations and information from the National Immunization Program of the Brazilian Ministry of Health. The goal of the prototype developed for community health agents is to assist in managing the vaccines of users assigned to their microareas. The user application aims to provide reliable information about vaccines and alert reminders for vaccination adherence. The paired applications help in actively seeking users with incomplete vaccinations and applying other timely interventions, such as health education and self-management for health seeking. Conclusion: The constructed model is an innovative strategy and a resilient way to achieve better vaccination coverage and prevent vaccine-preventable diseases.
Keywords: Mobile applications; Smartphone; Vaccines; Vaccination Coverage; Immunization.

Resumo
Objetivo: descrever o desenvolvimento de protótipo de aplicativos móveis pareados para agentes comunitários de saúde e usuários como estratégia para aumentar a adesão vacinal. Método: trata-se de um estudo metodológico de produção tecnológica do tipo prototipagem. A construção seguiu o modelo do design centrado no ser humano, caracterizando-se por ser um processo colaborativo focalizado na pessoa para a pessoa. O desenvolvimento dos aplicativos se deu em quatro etapas. Resultados: o conteúdo técnico-científico do aplicativo foi construído de acordo com as recomendações e informações do Programa Nacional de Imunização do Ministério da Saúde do Brasil. O objetivo do protótipo desenvolvido para os agentes comunitários de saúde é auxiliar na gestão das vacinas dos usuários adscritos em suas microáreas. O aplicativo do usuário tem por objetivo emitir informações confiáveis sobre vacinas e lembretes de alertas para adesão vacinal. Os aplicativos pareados auxiliam na busca ativa de usuários com incompletude vacinal e aplicação de outras intervenções oportunas, como educação em saúde e autogestão para busca de saúde. Conclusão: o modelo construído é uma estratégia inovadora, e uma forma resiliente no intento de melhores coberturas vacinais e prevenção de agravos imunopreviníveis.
Descritores: Aplicativos móveis; Smartphone; Vacinas; Cobertura vacinal; Imunização.

Resumen
Objetivo: Describir el desarrollo del prototipo de aplicaciones móviles emparejadas para agentes comunitarios de salud y usuarios como estrategia para aumentar la adherencia a la vacunación.
Método: Se trata de un estudio metodológico de producción tecnológica del tipo prototipado. La construcción siguió el modelo de diseño centrado en el ser humano, caracterizándose por ser un proceso colaborativo enfocado en la persona para la persona. El desarrollo de las aplicaciones se realizó en cuatro etapas. Resultados: El contenido técnico-científico de la aplicación fue construido de acuerdo con las recomendaciones e información del Programa Nacional de Inmunización del Ministerio de Salud de Brasil. El objetivo del prototipo desarrollado para los agentes comunitarios de salud es ayudar en la gestión de las vacunas de los usuarios adscritos a sus microáreas. La aplicación del usuario tiene como objetivo emitir información confiable sobre las vacunas y recordatorios de alertas para la adherencia a la vacunación. Las aplicaciones emparejadas ayudan en la búsqueda activa de usuarios con incompletitud de vacunación y en la aplicación de otras intervenciones oportunas, como la educación en salud y la autogestión para la búsqueda de salud. Conclusión: El modelo construido es una estrategia innovadora y una forma resiliente en el intento de mejorar las coberturas vacunales y la prevención de enfermedades prevenibles por vacunación.
Descriptores: Aplicaciones móviles; Teléfonos inteligentes; Vacunas; Cobertura vacunal; Inmunización.

INTRODUCTION
Vaccination is described as one of the best cost-effective actions for the prevention of vaccine-preventable diseases. However, the world has been experiencing a decrease in global vaccination coverage from 86% in 2019 to 81% in 2021, already signaling an improvement in 2022 (84%), but still with approximately 14.3 million children who have not received any vaccination—the so-called children with twelve zero(1-2).
The determinants of drops in vaccination coverage are complex and often translational and multifactorial, with variations between different geographical regions and types of immunobiologicals, influenced by aspects such as the population\'s health education and literacy, trust, complacency and convenience(3-4). This scenario led the World Health Organization (WHO), in 2019, to designate vaccine hesitancy—reluctance or refusal to vaccinate despite the availability of immunizers—as one of the 10 most important threats to global public health(3).
The Brazilian National Immunization Program (PNI), established in 1973, is a renowned program worldwide for its numerous breakthroughs in immunization in Brazil, but it has been following this global trend. The country has seen a decrease in vaccination coverage since 2016, with a slight improvement in 2022 and a downward trend in 2023(5).
In Brazil, although vaccines are distributed free of charge by the Unified Health System (SUS) and their use is encouraged by the Ministry of Health, several factors explain the drop in vaccination coverage in recent years, such as the absence or low perception of risk for diseases, the infodemic of fake-news about vaccines, lack of access to health information, difficulty in accessing vaccines, distrust of the efficacy and safety of vaccines, fear of adverse reactions, the population\'s lack of connection with vaccination actions, parents\' lack of time to go to health centers to vaccinate their children and the Covid-19 pandemic(1-2,6-8).
In this scenario, resilient strategies for resuming gains in public health for the prevention of vaccine-preventable diseases are gaining prominence. In the global context, in April 2021, the World Health Organization (WHO), the United Nations International Children\'s Emergency Fund (UNICEF), the Global Alliance for Vaccines and Immunization (GAVI), among other partners, launched the 2030 Immunization Agenda (IA2030), with the aim of recovering from the interruptions caused by the Covid-19 pandemic and achieving better vaccination coverage(1-2, 9).
The implementation of strategies to increase vaccination coverage can be directed at patients and their families, as well as at the health system and professionals. Interventions between the two groups need to be exchanged in order to improve vaccination coverage, covering conditions of structure and access to health units, greater technological support, training for professionals, health education for families and patients, active search for people with overdue doses, and even reminder systems. Thus, health technologies have been widely used as tools for educational strategies and as a reminder about immunizations, with positive impacts reported in studies(10-11).
In this sense, technology that assists health professionals and provides users with reliable information and reminders about vaccines can exchange better results in terms of optimizing vaccine adherence and improving vaccination coverage. To this end, this study aims to describe the development of a prototype of paired mobile applications for community health agents and users as a strategy to increase vaccine adherence.

METHOD
This is a methodological study for a prototyping-type technological production aimed at building a mobile application, using scientific rigor. It was based on the technical-scientific guidelines on available vaccines from the Brazilian Ministry of Health\'s PNI (12).
Software development followed the principles of human-centered design (HCD), a methodological approach that systematizes the process of creating products, services and systems, as well as solving complex challenges that emerge as a response to a particular human need, and is characterized by being a collaborative process focused on the person for the person(13). The International Standard (ISO) broadens this definition, highlighting that HCD not only improves the effectiveness and efficiency of procedures, but also promotes human well-being, user satisfaction, accessibility and sustainability(14). Furthermore, the approach promises to drive innovation in the development of user-oriented solutions with the aim of ensuring maximum user satisfaction(15).
The study was carried out in partnership with a professor and a student from a postgraduate program in Health Sciences (both nurses), professors from the Undergraduate Nursing Technician Course and a supervisor and student from a postgraduate program in Computational Modeling and Systems.
To develop the content of the apps, six nursing professionals with knowledge of vaccines were involved (four professionals with experience in vaccine rooms and in the Family Health Strategy and two other professors from undergraduate and postgraduate health courses) and two information technology professionals (a professor and advisor from an undergraduate course in Information Systems and another professional studying for a master\'s degree in the Computational Modeling and Systems Program). The work was carried out in a transdisciplinary way in order to properly cover the content and to develop the technology so that the devices could be better applied.
The apps were developed in four stages: the first was a survey of the real need to create a technology to assist vaccination processes; the second was strategic meetings between nurses and information systems professionals to choose the approaches to be followed in developing the app; the third stage was implementation, and the fourth stage was the evaluation of use by volunteers on different device models (Chart 1).
In the first stage, active listening was carried out in groups by category, so that they could report on the main needs for improvement related to the vaccination process.
The interviewees were: 5 community health agents, 5 users and 2 nurses working in the Family Health Strategy. In this context, “users” refers to people who are part of the specific PNI groups and/or their legal guardians.
For community health agents and nurses, the main demand was the need to improve the task of monitoring the vaccination status of users under the responsibility of community health agents, since the format used to carry out this activity is manual, with records on forms.
The current format for monitoring vaccines administered to users under the responsibility of community health agents, as reported by these professionals, has several limitations. This process is considered labor-intensive, time-consuming, favors the occurrence of errors, which hinders active search within the appropriate timeframes, and is unsustainable due to the high consumption of graphic materials.
On the other hand, among users of vaccination services, several difficulties related to vaccination adherence were identified, especially the lack of recall of vaccination history, especially for childhood vaccinations. These difficulties led to the design of functionalities designed to facilitate both the control and reminder of vaccinations, benefiting both health professionals and users. Based on this diagnosis, the creation of a technology—a mobile application—was considered to be a practical and effective solution for improving vaccination monitoring and increasing adherence to vaccination campaigns, with a view to increasing vaccination coverage and promoting public health.
In the second stage, to ensure that the application meets the principles of HCD, three strategic meetings were held with professionals from the health and information technology areas, ensuring that the development was geared towards the real needs of community health workers and users. Each meeting played a key role in defining and refining the functionalities of the application under development, allowing the specificities of the vaccination context to be fully considered and integrated into the project.
At the first meeting, the general needs and essential functionalities of the application under development were discussed. This meeting was fundamental in outlining the scope of the project, identifying the main difficulties faced by community health agents in monitoring immunizations. Based on these discussions, it was decided to create two separate applications: one aimed at community health workers (figure 1) and the other at users (figure 2). This division allowed each application to be designed to more effectively meet the particular demands and challenges of each group, optimizing access to functionalities and organizing information to maximize usability, taking into account the specific needs of each profile.
Dividing the functions into two applications proved to be a strategic decision, since community health agents need specific tools for registering and monitoring users, while users benefit from notifications about overdue vaccinations and information about the vaccination schedule. This organizational model allowed for the creation of customized interfaces and user flows, suited to the context of each group, promoting an intuitive and efficient user experience for both.
At the second meeting, it was decided that the app for community health agents should include features such as user registration, making it possible to send a link to the app to users via email or WhatsApp. This feature helps with quick and efficient registration, making it easier for users to sign up to the app. To register, the community health agent will have to enter the user\'s details into the app, such as: full name, date of birth, address, email and/or WhatsApp. Once the community health worker has registered, the user will receive an invitation and a link to access the app in their email and/or WhatsApp.
Also at this meeting, the team focused on the essential functionalities for the applications. In the case of the application for use by community health agents, the specific needs related to monitoring and following up on vaccinations were detailed. Thus, the application was designed to include a detailed record of the vaccines administered, enabling precise and always up-to-date control of each user\'s immunization history. For the users\' app, functionalities have been defined such as sending notifications to alert them of vaccinations that are overdue or scheduled for the next seven days, as well as the option to locate nearby vaccination posts and consult their vaccination history. This history provides complete information on the user\'s immunization, including dates, types of vaccines and reliable data on specific vaccines, as well as possible adverse events.
This stage was essential to ensure that the project met the functional requirements and provided an organized and efficient experience for both groups. Defining these functionalities helped to anticipate the system\'s practical impact on the routine of community health agents and users, providing tools that would facilitate engagement with the vaccination schedule and increase ongoing adherence to vaccination.
At the third meeting, the focus was on the accessibility and compatibility of the apps, with the aim of reaching as many users as possible. The decision to develop the apps for the Android and iOS operating systems was made to promote accessibility and ensure that both were usable, regardless of the type of device. To do this, the decision was made to use the Flutter Software Development Kit (SDK), which allows cross-platform development with a single code base and offers flexibility for customizing the interface using customizable widgets.
Flutter, maintained by Google, offers a robust set of tools that are compatible with Android and iOS, making it easy to develop modern, customizable interfaces. This choice saved time and resources during development, as well as ensuring the quality of the visual experience for users of different devices.
In choosing the approaches, a client-server architecture was adopted, which is essential for the synchronization and secure storage of information between the community health agents\' and users\' applications. This architecture allows both applications to access a centralized database, ensuring that vaccination updates are reflected in real time and avoiding data redundancies and inconsistencies. Communication between the applications and the database was made possible by an Application Programming Interface (API) developed in Node.js (version 18.16.1), chosen for its ability to efficiently manage Hypertext Transfer Protocol (HTTP) requests and offer fast and stable communication.
The use of a client-server architecture based on a Structured Query Language (SQL) database also provides a robust data structure that enables fast queries and guarantees data security and integrity. All connections are protected with SSL (Secure Socket Layer), and additional security measures, such as authentication and access control, ensure that only community health agents, in the course of their duties, can access user information.
During development, in the third stage, an incremental methodology was used, which allows for the progressive implementation of functionalities and continuous adjustments based on feedback from users and community health agents. This approach allowed essential functionalities to be delivered in the early stages, facilitating early testing and validation of the system. Aside from that, during the process, feedback contributed to improving the system, with suggestions that were incorporated to better adapt to the needs of community health agents and users.
Simultaneously with the development of the API, the team progressed with the development of the community health agents\' application using Flutter, version 3.13.1, and the Dart language (version 3.1.0). In addition to the functionalities originally proposed, some significant additions were incorporated into the applications, extending their usefulness and providing a comprehensive set of features.
In the fourth and final stage of development, both applications were subjected to usability tests on different devices. The tests took place in two phases, with the first evaluation carried out by two nurses with experience in the Family Health Strategy, as well as two community health agents and two potential users. The choice of nurses for the initial evaluation was based on their expertise and relevance as specialists in content analysis related to the area of interest. After this evaluation, feedback and suggestions for adjustments were provided and implemented, resulting in the final version of the apps. The usability assessment considered the following aspects: ease of use, loading time, suitability for screen resolution, frequency of use and relevance of data.
The final version of the apps was then tested by six community health agents and four users over a period of two months, using different device models on the Android and iOS platforms. Upon completion of each evaluation phase, all the data entered into the testing processes was deleted, guaranteeing the privacy and confidentiality of the information.
For data processing, the system was designed in compliance with the General Data Protection Law (LGPD), guaranteeing the security and privacy of user information. Data collection with access by users and community health agents to the apps is done transparently, with explicit consent for the use of location data and other personal information, which is stored securely and protected by end-to-end encryption. In addition, the apps allow community health agents to access, correct and delete data as needed, complying with the principle of data minimization.
The creation process began in August 2023 and the apps were completed in November of the same year.
The development of the apps is part of the umbrella research project entitled: “Implementation of the National Health Surveillance Policy and the National Immunization Program in the population of the municipality of Montes Claros/MG” and was approved by the Human Research Ethics Committee of the State University of Montes Claros, under opinion no. 6.234.026.

RESULTS
The applications, which had already been finalized, were submitted for initial evaluation by volunteers using different models of devices. To assess the applicability of the devices, initial tests were carried out with two nurses working in the Family Health Strategy (one of whom lives in the area), two community health agents and two potential users.
After their feedback, the following adjustments were suggested: the need to include a login in the app for community health agents with a username and password for restricted access; a request for automatic calculation of the user\'s age with each access made by the community health agent, to make it easier to see the current age; in the app for users, inclusion of the possibility of access with more than one login for the same user, taking into account situations of users who are parents/guardians of more than one child.
In the application for community health agents, a report generation function has been included. This feature allows agents to obtain valuable information about vaccinations carried out in a given time interval. Another feature added to the community health agent application is a report that identifies users according to age and the possible vaccine that should be received according to the PNI calendar. This report includes detailed information such as the date on which the vaccine should be administered and the user\'s address. It should be emphasized that the appointment should be made in the vaccination room by a qualified professional, and that the role of the community health agent is to actively search for the vaccine, guided by the PNI calendar, where they should check the appointment made in the document recording the vaccines received (vaccination booklet) by the user. In addition, the report highlights the vaccines that are overdue, providing a clear view of the users who need to have their vaccination cards checked, through timely active search.
In the application for users, multiple login functionality was implemented, allowing guardians to keep track of the vaccination schedule of more than one person. This functionality was adjusted based on user suggestions, reinforcing the project\'s commitment to adapting to users\' real needs.
These additions to the apps demonstrate a commitment to the efficiency and usefulness of the system, allowing health workers to generate crucial reports for managing and monitoring vaccination activities. Furthermore, by providing users with specific information on the vaccines that need to be taken and the dates of administration, the app raises awareness of vaccination adherence, contributing to better vaccination coverage.
One of the most innovative features is the geolocation feature, which makes it easy to find the nearest vaccination rooms in real time. The app identifies the user\'s position and displays a list of nearby vaccination posts/rooms, organized by distance and with useful information such as opening hours. This feature helps to reduce access barriers and speeds up the movement of patients to vaccination sites.
Once the suggested corrections had been made, the software in its final phase was submitted to the online stores for storing and distributing mobile software: app stores.
An evaluation was proposed to users of the final version of the applications. The aim was to assess the usability of the program in terms of ease of use, loading time, suitability for screen resolution, frequency of use and relevance of data. Six community health agents and four users tested the apps for two months, after which they were asked about the items evaluated and expressed a satisfactory experience. To evaluate the apps\' features, initial hypothetical tests were carried out which proved to be positive for the proposed objectives. In this evaluation, the community health agents and users were very satisfied with the software and gave positive evaluations to the items evaluated, with no initial reservations. In addition, the community health agents indicated that the applications would be extremely valuable for optimizing their activities in terms of managing the vaccines of the users under their responsibility.

DISCUSSION
This is the first software prototype in Portuguese built to pair mobile applications for health professionals (CHWs) and users to exchange information about vaccines. The use of this technology allows CHWs and users to share management and co-responsibility for vaccine administration, as proposed by the PNI. The simultaneous pairing of information between the applications also provides a sustainable and timely way for CHWs to actively search for updates to the vaccination schedule, which allows for the organization of work and favors resilient performance in the face of low vaccination coverage. The information available on the app also facilitates access to scientific content in accessible language on vaccines, contributing to a quality and contemporary health education process.
Mobile devices and their features are already part of the population\'s routine and offer agile solutions for everyday life, and are tools with a high potential for use in the areas of health, education and comprehensive care. In the area of health, especially nursing, they can be valuable tools for optimizing health promotion and prevention processes, such as immunization, with impactful solutions from the point of view of public policy and sustainability.
In the context of vaccines and the use of apps as a strategy for improving vaccine adherence, a systematic review that evaluated twenty-five mobile apps that included information on vaccines, options for scheduling appointments at vaccination units and alerts for overdue doses, concluded that all the apps contributed to increasing vaccination coverage (16).
Moreover, the involvement and management of patients with overdue vaccine doses through screening and active patient search has also been shown to be a positive action for improving vaccination coverage(17). At the same time, to help health professionals, the implementation of support systems, using computer resources, was also considered a strategy with a positive impact(18-19).
In addition, the use of means that promote the provision of accurate vaccine information in communities and health facilities should be integrated into all childhood vaccination programs in low- and middle-income countries; accompanied by robust monitoring of the impact and use of data for action(20).
In a systematic review that evaluated effective interventions to increase routine childhood vaccination coverage, it was concluded that actions such as improving human resources (such as health teams with adequate resources to expand immunization services) and the use of technologies (such as information systems that incorporate direct reminders to parents) are considered effective in increasing routine childhood immunization adherence (20).
The limitations of this study include the lack of validation of the apps using instruments that can assess their quality. In order to evaluate the effects of the apps, we suggest quantitative and prospective studies to assess the impact on vaccine adherence results after their implementation, steps that will be completed at another point in the umbrella study.

CONCLUSION
The mobile application prototype model developed in pairs for community health agents and users is an innovative proposal and a strategic resilience tool for health promotion practices and the prevention of vaccine-preventable diseases. The implementation of mobile technologies in the field of health and their application as resolutive practices to achieve better vaccination coverage result in positive impacts for public health.

This work was funded by the Minas Gerais State Research Foundation (FAPEMIG) [APQ-04777-24]. We would like to thank FAPEMIG for the essential financial support for this research.

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