as we gear up to a world free of measles , rubella and congenital rubella syndrome ( world health organization 2012 ) , evidence - based communication planning must be an integral component of all elimination plans . importantly , communication plans must be effectively resourced to impart the necessary impact on immunization coverage . experience from the polio eradication programme has shown that there is a 1220% or more increase in the absolute level of immunization coverage when communication is included as a key component of immunization strengthening ( waisborda et al . even more important is that the channels and approaches used must be evidence - based , locally appropriate , interactive , community owned and reach all households before the vaccination days . africa in general and kenya in particular , has witnessed unprecedented expansion in the numbers and coverage of mobile phones , thus connecting millions of people that previously were unconnected . the massive availability of mobile phones creates new opportunities for disease prevention programmes and implementation ( dglise et al . secondly , kenya , as in many african countries , can not reach all households relying only on the traditional mass media approaches . the most recent demographic and health survey in kenya ( kenya national bureau of statistics ( knbs ) and icf macro 2010 ) showed that there has been a dramatic increase in ownership of telephones from 13% in 2003 to at least 62% in 200809 . during the same time period , changes in proportions of households owning television sets only increased from 18% to 28% with no change in ownership of radio that stayed at 74% . these changes in access to mobile telephones as a media platform are unprecedented and provided an opportunity to kenya red cross in integrating their use to support house - to - house canvassing visits . the innovation to use mobile phones was motivated by evidence on use of mobile phones that showed that short text messaging is a potentially powerful tool for complementing behaviour change communication because it is widely available , inexpensive and instant ( cole - lewis and kershaw 2010 ) . in this article , we document the innovative and additional activity of using house - to - house inter - personal communication visits conducted by red cross volunteers and documented by a web - enabled mobile phone application to create a real - time platform for linking household and immunization service providers . this additional intervention was specifically aimed at improving coverage in urban populations ( cutts 1991 ; cockcroft et al . the american red cross society in collaboration with kenya red cross funded a project that conducted a house - to - house canvassing for supplemental measles immunization days implemented from 3 to 7 november 2012 . by design , 1952 red cross volunteers were recruited , trained and deployed to conduct house - to - house canvassing and mobilization of communities 13 days before the supplemental immunization days . this additional social mobilization intervention was conducted in eight districts of nairobi and three districts of nyanza / western provinces . the red cross volunteers were selected from their respective communities to assure knowledge of households to be visited , community gatekeepers and most importantly acceptance . recruitment was based on the fundamental principles of the red cross / crescent movement , namely humanity , impartiality , neutrality , independence , voluntary service , unity and universality . however , only volunteers with android smart phones would be recruited to conduct the house - to - house canvassing . first day of training was facilitated by district trainers on communications for the supplemental measles immunization days ( including house - to - house inter - personal strategies / skills ) . the second day of training was facilitated by the kenya red cross trainers specifically on the use of the mobile phone application for documenting house - to - house visits . the process of training and house - to - house canvassing ( before and after the supplemental measles immunization days ) was supervised by the district medical officers of health directly or through the community health extension workers and their structures . three days before the supplemental measles immunization days , the trained red cross volunteers conducted house - to - house visits . for every household head or caregiver , the volunteer would provide a standardized package of messages specifying ( 1 ) the rationale of the campaigns , ( 2 ) the targeted age - group , ( 3 ) location of the nearest vaccination point , ( 4 ) what interventions the targeted children would receive and ( 5 ) expected reactions after the vaccinations . the volunteer would then open up an inter - personal communication session in which the household head / caregiver would seek clarifications or ask questions in the comfort of their compound / home . the dialogue would end with a volunteer seeking the consent of the family to bring the targeted children for a supplemental measles dose . basic contacts ( mobile phone number ) , number of children in the target age - range , sources of information on the supplemental measles immunization days and consent to bringing the eligible children for vaccination were captured on an epi - surveyor real - time entry screen installed on the volunteers mobile phone handset . kenya red cross volunteers developed the application with technical support from datadyne consultants hired and paid by the social mobilization project . safaricom hosted the web - access point for all volunteer collected data as part of their corporate social responsibility programme . the web application accessible to district , provincial and national levels would provide ( 1 ) sources of information flow that are not reaching the community targets , ( 2 ) basic demographics on the numbers to expect during the supplemental immunization days , ( 3 ) households ( and their contacts ) of families likely to refuse supplemental doses and ( 4 ) most importantly , frequency tables for reasons given by non - consenting households . during the supplemental measles immunization days , the red cross volunteers were under the supervision of the vaccination team leaders and their roles were to : ( 1 ) receive mothers and caregivers bringing children , ( 2 ) screening for age eligibility ( 959 months ) , ( 3 ) providing non - invasive interventions like vitamin a supplementation and ( 4 ) making reminder telephone calls or sending short text messages targeting households visited before the supplemental immunization days . when there were no children turning up for vaccinations , the volunteers would conduct reminder visits to the households in their catchment areas . at the end of each supplemental immunization day , the volunteers would relay the numbers of measles immunizations given at each vaccination point , using mobile phones to their district coaches for presentation and discussions at the daily progress review meetings . such daily immunization data provided catalytic information for re - engineering and re - design of the vaccination delivery strategies for subsequent days . at the end of the supplemental immunization days , all the red cross volunteers embarked on post - campaign house - to - house mop - up visits in which they performed the following tasks ( 1 ) cross - checked the immunization status of all children 959 months by history ( verbal report from mother ) or checking finger markings ( valid coverage ) , ( 2 ) documented the household sources of information on the supplemental measles immunization days , ( 3 ) collected / collated community events associated with the supplemental measles immunization days and ( 4 ) identified and referred all consenting but not immunized children to the nearest vaccinating health facility . all house - to - house visits conducted after the supplemental immunization days were also documented using the real - time mobile phone data collection tool installed on the phones of volunteers . a total of 164 643 households with 161 695 children were visited by mobile phone - enabled red cross volunteers 3 days before the 2012 supplemental measles immunization days in eight and three districts of nairobi and nyanza / western provinces , respectively . one to three days before the supplemental measles immunization days , 56% of the 164 643 households visited said that they had heard of the planned supplemental measles immunization days . of the households visited , 75% ( 123 161 ) said that they planned to bring their children for a measles supplemental immunization dose . in pre - campaign house - to - house visits , a total of 41 482 ( 25% ) households with 42 041 ( 26% ) of the targeted children had no plans to bring their children for the measles supplemental dose if they had not been reassured by the red cross volunteers . post - campaign house - to - house evaluations showed that the actual number of households with un - vaccinated children was 170 only . the major reasons cited for immunization refusal in pre- and post - campaign databases ( on a multiple answers question ) are illustrated in figure 1 below . figure 1reasons for  refusal to take a supplemental measles immunization dose in kenya , november 2012 . reasons for  refusal to take a supplemental measles immunization dose in kenya , november 2012 . daily immunizations as documented and remitted by the red cross volunteers at the immunization points using mobile phones were collated and shown as illustrated in figure 2 below : 
 figure 2daily monitoring of measles sias doses administered in selected districts of kenya , november 2012 . daily monitoring of measles sias doses administered in selected districts of kenya , november 2012 . after the campaign , phone - enabled red cross volunteers re - visited 175 617 households in which 180 493 children were counted . of the children found in the post - campaign house visits , 96% reported to have received a measles supplemental immunization dose , although only 92% had confirmation ( finger mark ) of vaccination . of the 17 627 households visited in post - campaign house - to - house visits , only 16 217 ( response rate of 92% ) were able to provide a source of information on the november measles campaign in kenya . table 3 outlines the frequency distribution of sources of information as provided in the post - campaign house - to - house survey . table 1pre - campaign house visits and consent to supplemental measles immunization dose by district of kenya ; november 2012districth / holds visitednumber of eligible children countedh / holds with information prior to the visitnumber of h / holds consenting to a supplemental measles immunization dose% h / hold consenting to supplemental measles immunizationbusia / nambale20 40036 546910614 31670dagoreti11 98393716178785566embakasi25 40620 06614 41616 39565kamukinji11 93787288196919077kasarani14 28312 2647303821858kisumu east22 17533 26213 46518 90485langata12 32810 823733511 14290makadara771260874219633282njiru13 06595547413843165starehe14 5919163926612 94389westlands10 76358316229943588total164 643161 69592 201123 16175 
 table 2post - campaign house visits and measles sias coverage verification by district of kenya ; november 2012districth / holds visitednumber of children countednumber of children reported vaccinatednumber of children found vaccinated and finger markedcoverage ( un weighted)crude ( % ) valid ( % ) busia / nambale20403646357334279894dagoreti10851067104610149895embakasi27572318222521099691kamukinji10731104109310279993kasarani1624108110499959792kisumu east22153362332832959998langata8686425525268682makadara1473124710239858279njiru15381226117711169691starehe21161636153814729490westlands8386646375989690total17 62717 99317 24116 5649692 
 table 3sources of information on measles sias from post - campaign house visit in kenya , november 2012where did you get the information on supplemental measles immunization days conducted from 3 to 7 november 2012?frequency of citation ( multiple responses)proportionate contribution ( % ) house visit12 09875megaphones624338radio528033health facility322920tv269817chw232014newspaper12107others210413 pre - campaign house visits and consent to supplemental measles immunization dose by district of kenya ; november 2012 post - campaign house visits and measles sias coverage verification by district of kenya ; sources of information on measles sias from post - campaign house visit in kenya , november 2012 of the 17 627 households visited in post - campaign house - to - house visits , only 16 217 ( response rate of 92% ) were able to provide a source of information on the november measles campaign in kenya . table 3 outlines the frequency distribution of sources of information as provided in the post - campaign house - to - house survey . table 1pre - campaign house visits and consent to supplemental measles immunization dose by district of kenya ; november 2012districth / holds visitednumber of eligible children countedh / holds with information prior to the visitnumber of h / holds consenting to a supplemental measles immunization dose% h / hold consenting to supplemental measles immunizationbusia / nambale20 40036 546910614 31670dagoreti11 98393716178785566embakasi25 40620 06614 41616 39565kamukinji11 93787288196919077kasarani14 28312 2647303821858kisumu east22 17533 26213 46518 90485langata12 32810 823733511 14290makadara771260874219633282njiru13 06595547413843165starehe14 5919163926612 94389westlands10 76358316229943588total164 643161 69592 201123 16175 
 table 2post - campaign house visits and measles sias coverage verification by district of kenya ; november 2012districth / holds visitednumber of children countednumber of children reported vaccinatednumber of children found vaccinated and finger markedcoverage ( un weighted)crude ( % ) valid ( % ) busia / nambale20403646357334279894dagoreti10851067104610149895embakasi27572318222521099691kamukinji10731104109310279993kasarani1624108110499959792kisumu east22153362332832959998langata8686425525268682makadara1473124710239858279njiru15381226117711169691starehe21161636153814729490westlands8386646375989690total17 62717 99317 24116 5649692 
 table 3sources of information on measles sias from post - campaign house visit in kenya , november 2012where did you get the information on supplemental measles immunization days conducted from 3 to 7 november 2012?frequency of citation ( multiple responses)proportionate contribution ( % ) house visit12 09875megaphones624338radio528033health facility322920tv269817chw232014newspaper12107others210413 pre - campaign house visits and consent to supplemental measles immunization dose by district of kenya ; november 2012 post - campaign house visits and measles sias coverage verification by district of kenya ; november 2012 sources of information on measles sias from post - campaign house visit in kenya , november 2012 mobile phone platforms were used to obtain real - time data on household perceptions , attitudes and concerns ( reasons for likely refusal to take a supplemental measles dose ) . the innovation to use mobile phones ( for household data collection / transmission , short text messages and phone calls ) was adapted based on reviewed evidence on providing reminders for attendance of health care appointments ( car et al . this was in addition to documented importance of mobile phones in promotion of physical activity in children and adolescents ( lau et al . 2011 ) , adherence to malaria treatment guidelines in kenya ( zurovac et al . 2011 ) , testing and treatment of tuberculosis ( tb ) , hiv and syphilis ( horvath et al . 2010 ; lester et al . 2010 ; person et al . 2011 ; pop - eleches et al . 2011 ) . information collected using mobile phones was in real - time uploaded to a web application that was designed based on the principles of epicollect ( aanensen et al . the characteristics of measles epidemiology in kenya ( unpublished surveillance reports ) justified extra and focused efforts directed to the three major cities of kenya in the november 2012 supplemental immunization days . in the three major cities of nairobi , nambale and kisumu , special and additional strategies ( house - to - house social mobilization by red cross volunteers supported by mobile phone applications ) were put in place , given their size and the potential roles in sustaining measles transmission . specifically , the high population density that is commonly associated with increased risk of measles transmission ( anderson and may 1990 ) . although measles transmission can be interrupted with lower immunization coverage levels in sparsely populated rural areas , the urban focus was needed to attain higher coverage rates needed for similar disease control effects ( cutts 1991 ; atkinson and cheyne 1994 ) . emphasis being mobile phone supported word - of - mouth communications by kenya red cross volunteers over and above the community health extension workers system , established by the ministry of public health and sanitation . data from the house - to - house visits that spread information by word - of - mouth and conducted dialogue at household level show that the large majority ( 75% ) of urban households in selected kenya cities would accept supplemental measles immunizations with or without additional information . the 25% likely refusals in these cities compare well with what is published on individual and contextual factors associated with low immunization coverage in sub - saharan africa ( wiysonge et al . although house - to - house canvassing strategy for social mobilization was conducted in previous supplemental immunization activities ( sias ) , no similar data had ever been collected and made available in kenya . this mobile phone application enabled a cross - sectional status of awareness on supplemental measles immunization days at least a day before the start date . as red cross volunteers spread information by word - of - mouth and held dialogue sessions on immunization at household level , they also collected data on sources of information , education and awareness . this data would then trigger the shifting of communication strategies from information , education and awareness to wider but yet specific ecological complexities that influence household choices and capacity to choose . this shift in social mobilization was informed by the documented experiences from the polio eradication initiative that emphasizes use of data to guide actions in behaviour change communication ( taylor and shimp 2010 ) . in the house - to - house canvassing visits by red cross volunteers , emphasis would not be on a top - down information delivery approach but rather a hybrid strategy that combined informed activism supported by programme rationalization and key messages ( obregn and waisbord 2010 ) . comparing pre- and post - campaign reasons for refusal shows that targeted communication significantly reduced fear of injections , misconceptions , trust in herbs , fear of side effects and lack of time . lack of knowledge / forgetting and travel did not improve with house - to - house canvassing visit , underscoring the importance of good service delivery micro - planning in supplemental measles immunization days specifically and immunization in general ( shefer et al . 2012 ) . with daily immunization targets provided to all districts and provinces , we were able to document the slow start on day 1 and 2 ( saturday and sunday ) of the supplemental measles immunization days , when most vaccinations were expected and allowed the campaign managers to take timely corrective actions . major reasons for the slow start ( unpublished monitoring and daily review reports ) were heavy rains , parents expectation of house - to - house vaccination as had been the practice with supplemental polio immunization days , inadequacies in vaccination teams ( numbers and distribution ) and late start of sessions . armed with evidence of slow starts , innovations in the campaign delivery strategy and plan were put in place on day 3 and 4 ( monday / tuesday ) that included ( 1 ) the creation of additional teams ( by splitting vaccinators from the standard two , to one vaccinator ) , ( 2 ) creation of more temporary fixed points , ( 3 ) village - to - village vaccination services and ( 4 ) targeting early childhood development centers . this adaptive planning and management of supplemental measles immunization activities was always feasible but was more evidence based due to information available on real - time numbers of children immunized relayed by mobile phones on a daily basis . post - campaign house - to - house coverage verification data show that 9 out of 11 districts supported by kenya red cross attained 90% supplemental measles immunization coverage . even when 90% measles coverage was not attained , the changes in attained rates ( comparing 2009 and 2012 administrative data on follow - up campaigns ) were increased from 57% and 53% to 73% and 86% in langata and makadara districts , respectively . most importantly , the data show that despite several other confounding factors across board , the changes in coverage are more pronounced in districts that were introducing house - to - house strategy for the first time compared with those implementing the phone - documented house - to - house visits ( unpublished 2009 and 2012 administrative coverage reports ) for the second time . the major sources of information on the 2012 supplemental measles immunization days in kenya were documented as house visits , megaphones and radio in descending order . this data show that house - to - house visits can be very penetrative compared with traditional mass media approaches . the observed importance of interpersonal communication was confirmed by a survey in three coast region districts in which exit interviews with 104 mothers / caretakers of measles vaccine recipients showed that the major sources of information were health workers ( health facility at 24% ) , house visits by community health extension workers at 17% and radio at 14% . although radio and other mass media approaches to communication for immunization remain relevant , these results show that a house visit , by an independent and neutral but trusted community resource person like red cross volunteers contributes to an array of factors that parents need in decision making to vaccinate or not to vaccinate ( jackson et al . 2008 ) . the trust and confidence kenya red cross enjoys as a brand seemed to be more effective than all other sources of information , which is in line with what has been documented elsewhere ( brownlie and howson 2005 ; hobson - west 2007 ) . in conclusion , this article articulates the targeted use of a trusted , neutral and community - based support by red cross volunteers in attaining high measles coverage rates in selected urban populations of kenya . the use of house - to - house strategy supported by real - time documentation using mobile phones to conduct dialogue and seek consent to immunization is a shift from awareness , education and information giving approaches that have dominated planning and execution of sias for decades . second , documentation of house - to - house visits showed that this approach combined with giving information and education as well as seeking consent and creating a feedback loop between households and service delivery planners had a pronounced improvement in vaccination uptake . in turn , individualized and focused dialogue is documented to convince immunization sceptics while illustrating that good and adaptive operational micro - plans are an essential element to attainment of high vaccination coverage . last , we document that a house visit in which dialogue is held is more remembered and cited as a source of information on supplemental immunization . we recommend the use of household dialogue by trained house - to - house volunteers in promotion of immunization service utilization in future immunization promotional campaigns . where access to mobile communication technologies is high , it is also recommended that documentation of house visit findings be used to create a real time platform for adaptive communication strategy .