Home-based records

A home-based, personal health record — from this point forward referred to as a home-based record (HBR) — is a medical document (more often physical rather than electronic) issued by a health authority (such as a national, provincial, state or district health department) on which an individual’s history of primary healthcare services (e.g., vaccinations) received (including a description of the service and the date of service) from all healthcare providers is recorded. In contrast to a facility-based record, the home-based record is maintained in the household by an individual or their caregiver (e.g., mother, father, grandparent, etc).

Within immunization service delivery, HBRs serve as an important information resource to enhance health professionals’ ability to make clinical decisions and prevent unnecessary repetition of vaccination, to empower patients/caregivers around immunization services, and to support public health monitoring. In the area of immunization performance monitoring, HBRs fill a gap where facility-based registers often fall short, such as for supporting outreach activities to vaccinate un-/under-immunized children and serving as a source of documented vaccination history in household coverage surveys. In population-based, household coverage surveys, evidence of vaccination history is ideally informed by documented evidence on HBRs maintained in the household or by caregiver recall, the latter being a source of information that is increasingly scrutinized as recommended immunization schedules become more complex.

HBRs are also important for documenting vaccination status for international travellers to countries requiring proof of vaccination against certain vaccine preventable diseases, such as yellow fever and, more recently in selected regions, polio. The Yellow Card, or Carte Jaune[1], is a home-based record issued by the World Health Organization to provide a standardized document for travelers. The document, recognized internationally when appropriately completed by authorized health professionals following receipt of immunization services, dates to the early 1950s and the adoption of the International Sanitary Regulations, now known as the International Health Regulations.

Finally, HBRs serve an important role in countries requiring proof of vaccination status for children prior to school entry. Schools provide a unique, widespread community-based environment for protecting children, their families and the general public from vaccine-preventable diseases and promoting health more broadly. Recent work has highlighted the delivery of immunization services through schools and provided strong evidence for vaccine delivery via schools as a mechanism for improving vaccine uptake.

What do home-based records look like?

Home-based records take many forms. They vary in complexity across, and sometimes within, countries. Recent reviews of HBRs from the immunization service delivery perspective have highlighted these differences and lack of content standardization (WHO review, Young et al 2014). Anecdotal evidence suggests that private and public health providers utilize different HBRs in some countries, but documentation of differences in HBR form between private and public settings or any challenges that may arise from such differences is scant. A brief description of differences identified in one area of India is provided by Professor Rane and colleagues.

In 1994 the World Health Organization produced the document Home-based maternal records, a document which provided guidance for development including content and design as well as notes for introduction into a health system. More recently in 2015, the World Health Organization produced the Practical Guide for the Design, Use and Promotion of Home-based Records in Immunization Programmes, which described design and content issues for multiple target audiences and highlighted specific design elements for countries to consider when adapting, revising or developing a home-based record keeping immunization front and centre.

The HBR form continues to evolve (see [2] for an electronic repository of HBRs). In many countries, the HBR evolved through the national immunization programme from a simple recording document, often the front and back of a small card, on which basic child demographic information (e.g., name, sex, date of birth) and vaccination services were documented. As the importance of early childhood nutrition and growth monitoring became a focus of child survival programmes in the 1980s, the vaccination-only card (NB: Young and colleagues (2014) proposed a taxonomy for HBRs based on form in their description of the evolution of the document as it was used in national immunization programmes that followed on the content shifts) evolved to include growth monitoring recording charts and basic health educational information. More recently, there has been a shift towards more comprehensive health booklets that combine the functions of a broad array of health service recording alongside expansive health education messaging. In Japan, such a comprehensive document has been utilized for more than 60 years following the introduction of the maternal and child health handbook by the Ministry of Welfare (currently known as the Ministry of Health, Labor and Welfare) in 1948. Through the Japanese International Cooperation Agency (JICA), the maternal and child health handbook has been adapted and implemented in other countries (see [3] for more information).

Some have expressed concern with the current shift towards lengthy, text heavy comprehensive health booklets --- particularly in communities where literacy levels are known to be low or in known mobile populations --- and encourage appropriate field testing with both caregivers and health workers prior to going to scale with such a design. Moreover, there is concern about the appropriate balance of the HBR serving as a recording tool for health service delivery and as a vehicle for delivering public health messaging.

The HBR must be durable enough to withstand regular use through the childhood years (at a minimum). Because HBRs may be exposed to a variety of harsh environments, both inside and outside the household, some countries (e.g., Fiji) have utilized innovative paper product materials that resist moisture, fire, pests, bacteria and tearing while also accepting ink (e.g., standard ball-point pen) and pencil marks without information being smudged or wiped off. In other countries, the HBR is housed in a protective plastic sleeve. Further work is needed to explore the marginal added costs associated with use of synthetic paper or protective sleeves.

Ontology of home-based records

Just as home-based records take many forms, there is no universal terminology for referring to these documents across countries. As such, it is important to maintain a dynamic, country-specific thesaurus of reference terms for HBRs.

In some places, the HBR is referred to by the following English terms:

• vaccination or immunization card
• vaccination or immunization record
• vaccination (history) or immunization (history) record
• child health book
• infant health book
• child health record
• well baby book

The following is a listing of the terms used in the respective local context (with English translation where available and necessary) for referring to a HBR. This is a dynamic, working list of terms, and it is hoped that the population of this listing will facilitate better communication around HBRs when interacting with immunization and child health programmes at the country level.

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