Feasibility and acceptability of an electronic immunization registry in urban Bangladesh

Md Jawadul Haque; A K M Kamruzzaman; Rajendra Bohara; Chiranjit Das; Md Tarjumanul Haque Sanij; Abul Fazal Md Shahabuddin Khan; F A M Anjuman Ara Begum; Nazim Uzzaman

doi:10.1371/journal.pone.0352972

. 2026 Jul 2;21(7):e0352972. doi: 10.1371/journal.pone.0352972

Feasibility and acceptability of an electronic immunization registry in urban Bangladesh

Md Jawadul Haque ¹, A K M Kamruzzaman ², Rajendra Bohara ², Chiranjit Das ², Md Tarjumanul Haque Sanij ³, Abul Fazal Md Shahabuddin Khan ⁴, F A M Anjuman Ara Begum ⁵, Nazim Uzzaman ^1,^*

Editor: Samuel Kofi Tchum⁶

PMCID: PMC13327150 PMID: 42391166

Abstract

Introduction

Electronic Immunization Registries (EIRs) are increasingly being implemented in low- and middle-income countries (LMICs) to support immunization tracking and data management. In Bangladesh, an EIR was introduced in Rajshahi City Corporation (RCC) to strengthen routine immunization services. However, evidence on user perceptions and operational implementation in this context remains limited. We assessed perceptions related to the feasibility and acceptability of the EIR among caregivers and healthcare providers (HCPs) in an urban pilot setting.

Methods

We conducted a cross-sectional study between July and September 2024 in RCC, Bangladesh. Data were collected from caregivers of children receiving vaccinations and HCPs involved in immunization service delivery using a pretested semi-structured questionnaire. Perceptions of EIR-supported services were assessed using a 5-point Likert scale. Responses to open-ended questions were reviewed and summarized descriptively. This study was designed as a descriptive assessment and was not intended to evaluate the effectiveness or causal impact of the EIR system.

Results

A total of 321 participants were included, comprising 305 caregivers and 16 HCPs. Electronic registration was conducted primarily at the Expanded Program on Immunization centers (87%), with additional outreach through house-to-house visits. Reported vaccination uptake among children registered in the EIR system was high within the study sample. Caregivers and HCPs reported generally positive perceptions of EIR-supported services. Most respondents selected ‘satisfied’ or ‘highly satisfied’ responses across assessed items. HCPs also reported positive experiences, particularly in relation to record management and data accessibility, while noting operational challenges such as intermittent internet connectivity and device-related limitations.

Conclusions

The EIR was perceived as acceptable by caregivers and HCPs in this urban pilot setting. Further studies are needed to assess effectiveness, implementation challenges, and scalability across diverse settings.

Introduction

Immunization remains one of the most successful and cost-effective public health interventions globally, preventing an estimated 4.4 million deaths each year [1,2]. Despite these gains, coverage gaps persist, particularly in low- and middle-income countries (LMICs), where health system fragmentation, inadequate monitoring, and delayed reporting hinder timely vaccination [3,4]. The World Health Organization’s Immunization Agenda 2030 (IA2030) prioritizes strengthening data systems and digital health innovations to achieve equitable, timely, and complete coverage [5].

Bangladesh has made substantial progress in immunization since the launch of its Expanded Program on Immunization (EPI) in 1979, with coverage of key childhood vaccines reaching around 90% and marked reductions in vaccine-preventable diseases [6]. However, challenges remain in urban and peri-urban settings where rapid population growth, informal settlements, and migration complicate outreach and data tracking [7]. Coverage Evaluation Surveys 2023 revealed gaps between crude and valid vaccination coverage in Bangladesh, where children may receive vaccines but not according to the recommended schedule [8]. These gaps may be related to delayed vaccination, missed doses, and limitations in record-keeping and tracking systems.

Electronic Immunization Registries (EIRs) may support immunization programs by improving individual-level tracking, strengthening data availability, and enabling reminder systems [9–11]. Global experiences illustrate the benefits of transitioning from paper-based to digital systems: Vietnam’s National Immunization Information System has streamlined vaccine workflows and integrated SMS-based reminders [12]; the ‘Better Immunization Data’ initiative in Tanzania and Zambia demonstrated improved timeliness and data quality [13]; and Pakistan’s ‘Zindagi Mehfooz’ registry showed significant improvements in immunization tracking and engagement [14]. Similarly, evidence from Kenya, Brazil, and other LMICs highlights how digital registries enable targeted outreach, reduce dropout, and enhance planning [15].

In Bangladesh, WHO supported the introduction of an EIR in Rajshahi City Corporation (RCC) in 2019 to address gaps in immunization coverage and tracking [16]. This pilot system introduced unique identifiers, real-time reporting, and SMS reminders to enhance service delivery and improve data-driven decision-making [16]. Although EIRs have been introduced in selected settings in Bangladesh, available evidence is largely limited to programmatic descriptions of implementation. Empirical evidence on user-level perceptions, including feasibility and acceptability among caregivers and HCPs, remains limited. Understanding these aspects is important to inform how such systems function in routine service delivery. This study explored user perceptions and operational experiences related to the feasibility and acceptability of the EIR among caregivers and HCPs in RCC.

Materials and Methods

Study design and setting

A cross-sectional survey was conducted from July to September 2024 in RCC, Bangladesh. This study was designed as a descriptive assessment of perceptions related to the feasibility and acceptability of the EIR system among caregivers and HCPs. The study was not designed to evaluate effectiveness or causal impact of the EIR system. The assessment reflects user perceptions and reported operational experiences during the 2024 data collection period rather than the full implementation period since the EIR was introduced in 2019. The EIR system included unique digital identifiers for each child, real-time data entry using tablet devices, and automated SMS reminders to caregivers. Caregivers were recipients of EIR-supported services, while HCPs were the direct users of the digital platform.

Study participants

Adult caregivers residing in different wards of RCC who had children receiving routine immunization services, and HCPs involved in immunization service delivery, were eligible for inclusion in the study. The minimum required sample size for caregivers was initially estimated using the single-population proportion formula. In the absence of prior data on the feasibility or acceptability of EIRs in Bangladesh, the prevalence of caregivers lacking vaccination records (16%) [17] was used as an operationally relevant proxy indicator of baseline registration completeness. An initial estimate of approximately 207 caregivers was used to guide recruitment. Given the descriptive and operational nature of the study and the need to include participants with direct experience of the RCC EIR, purposive sampling was used to recruit caregivers attending EPI sessions. HCPs involved in EIR-supported immunization service delivery at the study site were approached for participation. As participants had already been exposed to EIR-supported services, the findings may reflect the perceptions of relatively engaged users and may overestimate satisfaction and perceived benefits.

Data collection

A semi-structured questionnaire containing both closed- and open-ended questions was used to collect information on demographics, registration timelines, satisfaction levels, and perceived benefits and challenges of using the EIR. The questionnaire was pretested among a small group of caregivers and HCPs to assess clarity, comprehension, and flow. Minor modifications were made prior to data collection. The questionnaire included sections tailored to caregivers and HCPs; caregiver items focused on experiences of EIR-supported services, while HCP items addressed system use, data entry processes, and operational challenges. A 5-point Likert scale was used to assess the perceptions related to EIR-supported services, with response options of not at all satisfied (1), dissatisfied (2), neutral (3), satisfied (4), and highly satisfied (5). These measures were used to assess perceptions related to the feasibility and acceptability of EIR-supported services, with satisfaction interpreted as one component of acceptability.

Data analysis

Quantitative data were analyzed using Statistical Package for the Social Sciences (SPSS), version 24.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including frequencies and percentages, were used to summarize participant characteristics, registration patterns, vaccination status, satisfaction responses, and reported challenges. The analysis was descriptive and aligned with the exploratory nature and objectives of the study. Responses on the Likert-scale items were analyzed individually and were not combined into a composite score. Responses to open-ended questions were reviewed and descriptively summarized to identify commonly reported issues and experiences.

Ethics

Ethical approval was obtained from the Institutional Review Board of Islami Bank Medical College (Ref: IBMC,R/IRB/2024/04/01). Written informed consent was obtained from all participants. All data were anonymized prior to analysis, and no personally identifiable information was included in the dataset used for this study.

Results

Demographics

A total of 321 participants were included in the study, comprising 305 caregivers and 16 HCPs. Among caregivers, most respondents were mothers (78%), followed by fathers (21%) and grandparents (1%). Among HCPs, vaccinators represented 56%, followed by vaccination supervisors (25%) and community health workers (19%).

Electronic registration and vaccination coverage

Electronic registration was conducted primarily at EPI centers (87%), with the remaining carried out during house-to-house visits, indicating that facility-based registration was the dominant approach, supported by outreach services. Reported vaccination uptake among children registered in the EIR system was high within the study sample (Table 1). These estimates reflect reported vaccination status among children registered in the EIR system and should not be interpreted as population-level vaccination coverage.

Table 1. Electronic immunization registration and vaccination coverage.

Indicator	Number	Target achieved^a
Electronic registration	305	100%
Registered within 45 days	268	88%
BCG vaccination	305	100%
Pentavalent 1–3	305	100%
MR‑1 vaccination	305	100%
MR‑2 vaccination	296	97%

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^aPercentages are calculated using the total number of respondents as the denominator.

Caregiver and HCP satisfaction

Caregiver responses reflected perceptions of EIR-supported service delivery rather than direct interaction with the digital registry system. Among caregivers, most respondents reported ‘satisfied’ or ‘highly satisfied’ responses across all assessed items, including ease of accessing EIR-supported services, usefulness of SMS reminders, preference for EIR over manual registration, and the perceived benefits of EIR (Table 2). The proportion reporting ‘satisfied’ responses ranged from 59% to 78%, while ‘highly satisfied’ responses ranged from 16% to 22% across items. No respondents selected the ‘dissatisfied’ or ‘not at all satisfied’ response categories.

Table 2. Caregiver perceptions of EIR-supported services.

Statements	Highly Satisfied n (%)^a	Satisfied n (%)	Neutral n (%)
Ease of accessing EIR^b-supported services	52 (17)	225 (74)	28 (9)
SMS reminders supporting timely child vaccination	50 (16)	191 (63)	64 (21)
Preference for using EIR over manual registration	52 (17)	181 (59)	72 (24)
Contribution of EIR to the EPI program	51 (17)	211 (69)	43 (14)
Provision of electronic vaccination certificates	66 (22)	239 (78)	0 (0)
Suitability of EIR for nationwide implementation	57 (19)	194 (63)	54 (18)

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a Percentages are calculated using the total number of respondents as the denominator. Satisfaction was assessed using a 5-point Likert scale: 1 = not at all satisfied, 2 = dissatisfied, 3 = neutral, 4 = satisfied, and 5 = highly satisfied.

b EIR = electronic immunization registry.

Among HCPs, responses also indicated generally positive perceptions across all assessed items, including the ease of handling the software, the simplicity of learning and managing the process, preference for EIR over manual registration, and the ease of accessing immunization records (Table 3). Most HCPs reported ‘highly satisfied’ responses, with smaller proportions selecting ‘satisfied’ or ‘neutral’. The proportion reporting ‘highly satisfied’ responses ranged from 75% to 88%. One response indicated ‘dissatisfied’ for the item related to ease of learning and managing the system, and no respondents selected the ‘not at all satisfied’ category. Given the small number of HCPs (n = 16), these findings should be interpreted as indicative of provider perceptions within this setting.

Table 3. Healthcare provider perceptions of EIR-supported services.

Statements	Highly Satisfied n (%)^a	Satisfied n (%)	Neutral n (%)	Dissatisfied n (%)
Ease of handling EIR^b software	12 (75)	4 (25)	0 (0)	0 (0)
EIR process is easy to learn and manage	13 (81)	1 (6)	1 (6)	1 (7)
Preference for EIR over manual registration	14 (88)	1 (6)	1 (6)	0 (0)
Ease of accessing immunization records using EIR	14 (87)	2 (13)	0 (0)	0 (0)
EIR is beneficial for immunization service delivery	12 (75)	4 (25)	0 (0)	0 (0)

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b EIR = electronic immunization registry

Perceived challenges and benefits

HCPs reported several operational and technical challenges, most commonly slow internet connectivity and device-related limitations. Despite these challenges, providers highlighted advantages such as easier access to immunization records, reduced reliance on paper-based record keeping, and improved timeliness of report sharing.

Discussion

Summary of the findings

Our study provides a descriptive assessment of user perceptions and reported operational experiences related to an EIR in an urban pilot setting in Bangladesh. The system was implemented within routine immunization service delivery, and both caregivers and HCPs reported generally positive perceptions and experiences. Caregivers described EIR-supported services as convenient, particularly in relation to receiving vaccination-related information and reminders, while HCPs highlighted advantages in record management and data accessibility. However, operational challenges, including intermittent internet connectivity and device-related issues, were also noted. These findings should be interpreted primarily as descriptive perceptions from an urban pilot implementation context rather than as evidence of effectiveness or system-level impact. Caregivers were not direct users of the EIR system, but recipients of services supported by it. Their responses therefore reflect perceptions of EIR-supported immunization services, such as reminders, certificates, and access to vaccination information, rather than direct interaction with the digital registry itself.

Strengths and limitations

This study provides early evidence on user perceptions and operational experiences related to EIR-supported immunization services in Bangladesh. By combining structured survey findings with descriptive summaries of open-ended responses, the study provides insights into usability, perceived benefits, and operational challenges associated with EIR-supported services. The inclusion of caregivers and HCPs allowed assessment of perspectives from service recipients and direct system users. The study also contributes context-specific insights on user perceptions and operational experiences of EIR-supported immunization services in Bangladesh, which may help inform future implementation and evaluation efforts.

This study has several limitations. First, the cross-sectional design provides a snapshot of user perceptions and does not allow assessment of sustainability, dropout reduction, equity impacts, or changes over time. Second, the absence of a comparison group means that observed outcomes such as reported vaccination coverage and registration timeliness cannot be attributed solely to the EIR system. Third, participants were purposively selected and had already been exposed to EIR-supported services, which may have overestimated satisfaction and perceived benefits. Fourth, satisfaction measures relied on self-report and may be affected by recall or social desirability bias. Fifth, the number of HCPs was small (n = 16), restricting the range of provider responses captured. Finally, the study was conducted in a single urban pilot setting, and findings may not be transferable to rural or resource-constrained areas where infrastructure, staffing, and connectivity differ substantially. Caregiver findings should also be interpreted as perceptions of service delivery influenced by the EIR rather than direct evaluation of the digital registry system. Future studies should include longitudinal or comparative designs, objective registry audits, richer qualitative exploration of HCP experiences, and assessment across diverse geographic settings.

Interpretation in the light of published papers

The reported registration timeliness of 88% within 45 days is consistent with findings from several LMIC settings implementing EIR systems. Similar findings have been reported in Tanzania, Zambia, and Vietnam, where EIRs were associated with early registration and follow-up [18]. SMS reminders, adopted in multiple LMIC settings, further strengthen adherence to vaccination schedules by reducing missed appointments and improving completion rates [19–21]. The generally positive perceptions reported in this study are consistent with evidence from Kenya and Pakistan, where registries were associated with better user engagement and perceived service quality [14,22].

Despite these achievements, several challenges persist. Technological barriers, including intermittent internet access, and device limitations, were reported by providers. These findings are broadly consistent with reports from Zambia and Pakistan, where inadequate infrastructure occasionally limited EIR functionality [14,23]. Addressing these challenges will require sustained investment in digital infrastructure, offline-capable systems, and refresher training for frontline staff. These issues are particularly important if EIR implementation is extended beyond urban settings to rural or resource-constrained areas. Evidence from other LMIC settings suggests that EIRs may support improved data use, service delivery, and immunization program planning [23–24]. However, implementation challenges related to infrastructure, workforce capacity, and system integration remain important considerations. Experiences from other settings, including Vietnam, highlight the importance of phased implementation and coordination across stakeholders when scaling EIR systems [25].

As Bangladesh continues efforts to strengthen equitable and timely immunization coverage, EIRs may support strengthening service delivery and monitoring. However, nationwide implementation will require coordinated investment in improving internet connectivity and speed, capacity building, and integration with broader health information systems. Leveraging EIR data for microplanning, outreach, and resource allocation could further reduce missed opportunities for vaccination and improve health outcomes.

Conclusion

The EIR was perceived as acceptable by caregivers and HCPs in this urban pilot setting. However, the findings should be interpreted as descriptive evidence on user perceptions and operational experiences rather than evidence of effectiveness or scalability. Further studies are needed to assess implementation challenges, effectiveness, and scalability across diverse settings.

Supporting information

S1 Dataset. De-identified quantitative dataset underlying the findings of this study (Excel format).

(XLSX)

pone.0352972.s001.xlsx^{(57.3KB, xlsx)}

Acknowledgments

We thank the study participants for their contribution to this study.

Data Availability

All de-identified quantitative data underlying the findings of this study are provided within the paper and its Supporting Information files. Open-ended responses contributed to the descriptive findings reported in the manuscript but are not publicly shared because they may contain potentially identifiable information. Data access requests may be directed to the Institutional Review Board, Islami Bank Medical College, Rajshahi, Bangladesh (Ref: IBMC,R/IRB/2024/04/01; email: smbdbd22@gmail.com) or to Professor Md. Jawadul Haque, Rajshahi Medical University, Bangladesh (email: mjhaque61@gmail.com), subject to ethical and confidentiality considerations.

Funding Statement

MJH received support from the World Health Organization (WHO) Bangladesh under consultancy agreement number 203402311 for work related to this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0352972.r001

Decision Letter 0

Samuel Kofi Tchum

16 Feb 2026

-->PONE-D-25-67616-->-->Feasibility and acceptability of an electronic immunization registry in urban Bangladesh-->-->PLOS One

Dear Dr. Nazim Uzzaman,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Reviewer 1

Major Comments

Generalizability

The study is limited to a single urban pilot site (Rajshahi City Corporation). Findings may not reflect rural or resource-constrained areas. Please expand the discussion on how infrastructural differences (e.g., internet connectivity, staffing) might affect nationwide rollout.

Study Design

The cross-sectional design provides only a snapshot in time. Longitudinal or comparative studies would be needed to assess sustainability, dropout reduction, and equity impacts. Please acknowledge this limitation more explicitly.

Sampling Bias

Purposive sampling may have introduced bias, particularly if participants were more likely to be favorable toward the EIR. Clarification on participant selection criteria would strengthen the methodology.

Self-reported Satisfaction

Satisfaction measures rely on self-report, which may be subject to recall and social desirability bias. Please discuss this limitation in more depth and consider triangulating with objective usage data in future studies.

Absence of Control Group

Without comparison to paper-based registries, it is difficult to attribute improvements solely to the EIR. Acknowledging this limitation would improve transparency.

Technical Challenges

While slow internet and device malfunctions are noted, the discussion could be expanded to include potential solutions (e.g., offline-ready systems, infrastructure investment, refresher training). This would strengthen the scalability argument.

Data Availability

The statement “all relevant data are within the manuscript” may limit reproducibility. Consider depositing anonymized datasets in a public repository to align with open science practices.

Minor Comments

Clarity of Writing

Some sections of the discussion repeat global evidence without fully connecting back to the Bangladesh context. Strengthening the local interpretation would enhance impact.

Figures and Tables

Figures summarizing caregiver and HCP satisfaction could benefit from clearer legends and consistent formatting of percentages.

Methodological Detail

Please provide more information on questionnaire validation and how qualitative responses were coded.

Terminology Consistency

Ensure consistent use of abbreviations (e.g., EIR, EPI) throughout the manuscript.

Ethical and Publication Considerations

Ethical approval and informed consent are clearly stated; no concerns identified.

No evidence of dual publication or ethical violations.

Financial disclosure and competing interests are appropriately declared.

Overall Recommendation

This manuscript makes a meaningful contribution to the literature on digital health and immunization in LMICs. With revisions to strengthen methodological transparency, expand discussion of limitations, and improve data accessibility, the paper will be well-positioned for publication.

Reviewer 2

This manuscript presents a cross-sectional assessment of the feasibility and acceptability of an electronic immunization registry (EIR) in urban Bangladesh. The topic is relevant, the study appears technically sound, and the conclusions are generally supported by the data. However, several points require clarification.

Major points:

Funding statement: There is an inconsistency between the Funding and Acknowledgements sections. The authors should clarify whether WHO-IVD support was financial or in-kind and ensure consistency between these sections.

Data availability: For a survey-based study, PLOS data policy typically requires availability of the underlying de-identified dataset. The authors should clarify whether the raw survey data can be shared and update the Data Availability statement accordingly.

Minor points:

The description of the Likert scale is inconsistent (described as 5-point but defined from 0 to 5) and should be corrected.

Satisfaction outcomes are reported without explicit dissatisfied categories; the authors should clarify how these were handled and how overall satisfaction was calculated.

Minor typographical and formatting issues should be addressed.

Reviewer 3

Study design and causal interpretation

The cross-sectional design of the study limits the ability to attribute the observed high vaccination coverage and improved registration timeliness directly to the electronic immunization registry. Several statements in the Abstract, Results, and Conclusions sections appear to imply an impact of the EIR rather than focusing strictly on feasibility and acceptability. The conclusions should be reframed to clearly distinguish association from causation and to avoid over-claiming system effectiveness.

Sampling strategy and potential bias

Caregivers were selected using purposive sampling, and all participants were already engaged with the EIR system. This approach introduces selection bias and likely inflates estimates of satisfaction and vaccination coverage. The limitations section should be expanded to explicitly discuss how purposive sampling and the exclusion of non-users may have influenced the findings.

Vaccination coverage results (100% coverage)

The reporting of 100% vaccination coverage for multiple antigens in an urban setting is unusual and requires careful contextualization. It is unclear whether the reported coverage reflects true population-level coverage or only coverage among children registered in the EIR system. The authors should clarify the denominators used, explicitly state that coverage estimates apply only to registered children, and temper interpretations accordingly.

Very small healthcare provider sample size

Only 16 healthcare providers were included in the study, yet results are presented in percentages and used to support relatively strong conclusions. This small sample size limits both statistical reliability and interpretive robustness. The manuscript should more explicitly acknowledge this limitation and avoid broad generalizations based on these data.

Data availability statement

The manuscript states that all relevant data are contained within the manuscript, yet the results appear to be derived from underlying survey datasets. This may not fully align with PLOS ONE data transparency requirements. The authors should clarify whether anonymized datasets can be shared as supplementary files or deposited in a public repository.

Minor reviewer comments (technical and editorial)

Likert scale description

The Likert scale is described in the Methods section as ranging from 0 to 5, while the tables appear to reflect a 1 to 5 scale. This discrepancy should be clarified and standardized throughout the manuscript.

Figures and tables

There are inconsistencies in figure numbering in the text, such as references to Figure 1 and Figure 3. These should be checked and corrected. In addition, figure captions should be improved to be fully self-explanatory without requiring reference to the main text.

Reviewer 4

Overall Assessment

This manuscript presents a cross-sectional evaluation of the feasibility and acceptability of an Electronic Immunization Registry (EIR) piloted in an urban setting in Bangladesh. The topic is timely and relevant, particularly in the context of digital health scale-up in low- and middle-income countries (LMICs) aligned with Immunization Agenda 2030. The study contributes descriptive evidence on user satisfaction, registration timeliness, and operational challenges from both caregivers and healthcare providers. While the findings are generally positive and policy-relevant, limitations in study design, sampling strategy, and inferential depth constrain the strength of conclusions regarding effectiveness and scalability. With substantive revisions to clarify methodology, contextualize findings, and temper conclusions, the manuscript could be suitable for publication.

Major Comments

Study design limits causal inference and claims of improvement

The cross-sectional design without a comparator (e.g., pre-EIR baseline or paper-based registry group) limits the ability to attribute high vaccination coverage, registration timeliness, or satisfaction directly to the EIR. Statements suggesting that the EIR “improved” coverage or service delivery should be reframed more cautiously to reflect association rather than impact.

Sampling strategy and representativeness require clearer justification

The use of purposive sampling to recruit “information-rich” caregivers and inclusion of all HCPs involved in the EIR introduces potential selection bias. The manuscript should more explicitly discuss how this approach may overestimate satisfaction and feasibility, and how findings may differ among less-engaged users or marginalized populations.

Interpretation of vaccination coverage results may be overstated

Reported vaccination coverage rates (100% for several antigens) are exceptionally high and may reflect programmatic selection rather than population-level performance. The manuscript should clarify whether these figures represent verified coverage within the EIR cohort only, and should avoid implying general population coverage improvements.

Limited analytical depth beyond descriptive statistics

The analysis is restricted to descriptive statistics, which is appropriate for feasibility assessment but limits insight into factors associated with satisfaction, delayed registration, or reported challenges. The authors should either justify this limitation explicitly or explore simple stratified analyses (e.g., caregiver demographics vs. satisfaction) if data permit.

Minor Comments

Clarify Likert scale description and reporting

The Likert scale is described as ranging from 0 to 5, but tables appear to reflect only categorical responses without explicit mention of scale anchors. Consistency and clarity in scale description would improve transparency.

Improve clarity in tables and figures

Tables 2 and 3 would benefit from clearer denominators and explicit reporting of missing or neutral responses. Figure captions should specify whether percentages are mutually exclusive or allow multiple responses.

Recommendation

The study is relevant and methodologically sound for a feasibility assessment, but substantial revisions are needed to address overinterpretation of results, clarify sampling limitations, and align conclusions more closely with the descriptive nature of the data.

Reviewer 5

This is very good research for the Bangladeshi population. This type of research should be performed. If this article publishes in national journal, then the effectiveness will be more for the national population. Thank you.

Reviewer 6

The authors are advised to visit the journal website for proper structuring of the article. The article is recommended to be accepted for publication if updated accordingly. The review is uploaded as an attachment.

Reviewer 7

The manuscript presents a technically sound feasibility study, with an appropriate study design and descriptive analyses that are aligned with the stated objectives. The data supports the conclusions regarding feasibility and acceptability of the EIR among caregivers and healthcare providers, and the authors appropriately acknowledge key methodological limitations. However, the manuscript would benefit from a clearer description of how caregivers interact with the EIR system, as caregivers appear to be largely passive recipients of EIR outputs rather than active users, which should be more clearly reflected in the interpretation of caregiver-related findings.

- Within the scope and aims of the study, the statistical analysis has been performed appropriately, but its rigor is limited by design and should be interpreted as descriptive rather than evaluative. The authors correctly use descriptive statistics (frequencies, percentages, means and standard deviations) to summarize feasibility, coverage, and satisfaction outcomes in a cross-sectional feasibility study, and no inappropriate inferential claims are made. However, the analysis remains basic, with no comparative or inferential testing, no assessment of associations, and no validation of measurement scales, which limits the ability to draw conclusions beyond descriptive feasibility and acceptability and should be explicitly reflected in the framing of results and conclusions.

- Overall, the manuscript is clearly structured, logically organized, and generally written in understandable standard English, and the main messages are easy to follow. The flow from introduction through methods, results, and discussion is coherent, and tables and figures are appropriately used to support the text.

However, the manuscript would benefit from careful language editing to address minor grammatical errors, awkward phrasing, repetition, and occasional inconsistencies in tense and word choice, particularly in the Introduction and Discussion sections. These issues do not obscure the scientific content but should be corrected at revision to improve clarity, precision, and readability in line with PLOS ONE requirements.

Reviewer 8

Dear Authors

Thank you for the efforts

Kindly find my comments below

ABSTRACT

Abstract language is that of operational report not scientific (eg 'high satisfaction', 'improved tracking')

the conclusion "demonstrates feasibility, acceptability, and scalability" cannot be made from your study because

1. Scalability was not studied

2. No cost analysis

3. No infrastructure assessment

4. No health system readiness evaluation

Methodology

1. Proxy indicator for feasibility and scalability (i.e prevalence of caregivers lacking vaccination records (16%)) may be weak conceptually.

2. Study is heavily centred on caregiver and provider satisfaction, 5-point Likert scale where 0 represented “not at all satisfied” and 5 represented “highly satisfied” That is actually a 6-point scale (0–5). This inconsistency portends measurement imprecision

3. The study lack details of qualitative data analysis

4.Ethics section incomplete - ethics reference number missing no mention of data confidentiality procedures

5. If purposive sampling was used as indicated in the discussion: Sample size calculation using Z²pq/d² may be invalid, representativeness is not statistically justified

Reviewer 9

This study is not methodologically corrected. Lack of proper sample size estimation, clarification of sample collection process and faulty analysis are present, which is a serious concern. I recommended a rejection for this manuscript.

see the attachment for details

Reviewer 10

It is mentioned that the EIR was piloted in 2019, but the study was conducted in 2024 which results in a 5 years gap. The manuscript did not clarify whether the assessment of feasibility and acceptability covers the whole implementation period or only recent performance.

2. In line 125, 100% vaccination coverage was mentioned which seems implausibly high. It might be better to explain sample representativeness or verification methods.

3. Satisfaction was entirely based on self-reported data. It would be better to have objective verification such as vaccination card checks, registry audits or some kind of observation of the system use.

4. The manuscript did not mention any inter-rater reliability or data quality checks.

5. The statistical analysis only included descriptive statistics. It could benefit from bivariate analysis, comparing outcomes across different groups such as registered in the venue vs home visits.

Only descriptive statistics are presented. The study would benefit from:

6. "HCPs reported several technical and operational challenges during the EIR submission process, with the most common being slow internet connectivity (31%), and combined slow internet with tablet issues (37%) (Figure 3, Panel A). Tablet malfunctions were independently reported by 19%"---> the manuscript doesn't discuss anything about mitigation strategies, system downtime frequency, or workarounds used by providers.

7. The manuscript did not mention any description of the EIR system architecture, features, or data flow.

8. The discussion or result section did not mention details on how qualitative data were analyzed beyond "descriptive summary".

9. The manuscript does not mention anything about data privacy, security measures for the electronic registry, or how personally identifiable information is protected.

Reviewer 11

This is an interesting manuscript exploring the implementation of EIR to improve immunization coverage and monitoring in Bangladesh, as stated in the submitted manuscript. Overall, the research question is addressed using appropriate methods, and the results are properly presented. Nevertheless, a description of the current workflow and data flow of the immunization program in the studied health facilities would support better understanding of the context and the barriers and advantages presented. The reader cannot assess the current integration of the digital system if this information is not provided.

Abstract:

- Introduction: “We assessed the feasibility of the EIR to provide evidence and inform policymakers on strategies for scaling up digital immunization systems in Bangladesh.” I find this statement inaccurate and it does not represent the main focus of the paper, as informing policy makers was not part of the results of the paper. I recommend revising and focusing on the main focus of the research in the abstract methods section.

- “Coverage Evaluation Surveys 2023 revealed gaps 60 between crude and valid vaccination coverage, …” : specify the differences between the two and the specific gaps that were identified and can be supported by electronic immunization registries. This paragraph overall needs some revision to guide the reader to the specific evidence on the current gaps and the barriers and which of those can specifically be solved by scaling up electronic immunization registries, as I find the current description quite vague and general, and possibly misaligned with scope of the study.

- “Despite growing interest in scaling up EIRs nationwide, empirical evidence on their outcomes in Bangladesh remains limited.»: it is hard to understand this statement as there is no reference. Please revise and describe exactly what is that is already evident and what is still a gap of the current implementation. It is also hard to connect the provided information of the implementation with the feasibility that is being studies.

Introduction:

- “Bangladesh has made remarkable progress in immunization since the launch of its Expanded Program on Immunization (EPI) in 1979, achieving impressive reductions in vaccine-preventable diseases”: it would be more accurate to provide specific numbers to support these statements on progress.

Methods

- Data collection: the difference between the tool used for the caregivers and the one used for the care providers is not easy to understand with the description provided.

- Given the aim of the study it is difficult to understand why the study is mostly focused on caregivers (n=305 caregivers) instead of the main users of the immunization registry who are the health care providers (n=16). Also, why the data captured for the different cadres of health providers are not presented separately, given their clearly different interaction with the digital system.

Results:

- What do the following components mean for the caregivers: “easy of using the EIR system”; “contribution of EIR to the EPI program”; “suitability of EIR for nationwide implementation”. Given that caregivers are not users of the digital registry, but receivers of a service supported by the digital registry. What is the relevance of these component for the caregivers.

Discussion

- «Vaccination coverage remained high, and all eligible children were successfully registered.”: remained high compared to what. What did the authors expect to find?

- “…showed strong potential for broader scale-up.”: which results are supporting this statement? Also the barriers reported are not negligible.

- “The high caregiver satisfaction (91%) observed in our study is consistent with evidence…”: this is not reported in the results section. Also the authors have not assessed overall satisfaction.

- Overall I can observe an overinterpretation of the findings and related implications for the health system.

Reviewer 12

General comments:

This study is very important, as it seeks to provide evidence on the feasibility, acceptability, challenges and advantages of an EIR in Bangladesh. This can provide evidence for a national scale-up, and other LMICs can also benefit from this experience in Bangladesh.

That said, I believe the manuscript can benefit from some revisions in the focus and analysis of the results to make it more robust.

Specific Comments:

1. Consider revising your topic to reflect the content of the study. Most of the data reported in the manuscript speaks to caregiver and HCP satisfaction, not the feasibility of the EIR.

2. I recommend that the authors consider reporting this study in line with at least one of the WHO digital health evaluation frameworks. This will make it easier to compare with other studies in different settings in the LMICs.

3. I recommend that the authors clarify whether they are measuring the feasibility or satisfaction or both. Such clarity would help to focus on the substance of the study. Starting from the title of the study, through the results and discussions, ensure consistency.

4. Report the Cronbach's alpha (internal consistency) of the Likert scale here (Lines 101-103).

5. Conduct some advanced analytical statistics to compare the satisfaction between caregivers and HCPs (Line 106).

6. In line 107, you stated that you computed means and standard deviations. However, there are no means and SDs reported in your results. Include them for the satisfaction of caregivers and HCPs, respectively.

7. Insert the Ethics approval number here (111-112).

8. I would recommend that the authors conduct a more advanced analysis of the data, comparing the HCP satisfaction and Caregiver satisfaction. Use an " Independent t-test (caregivers vs providers)" or any other advanced statistical method.

9. After all these revisions, the discussion and conclusion have to be adapted to the results.

Reviewer 13

The paper is an interesting addition to the growing body of work on EIRs, but I suggest significant revisions before publication:

- the paper and findings should be framed specifically as around perceptions of EIR feasibility and acceptability to caregivers and health care workers as there is no comparative data presented to show that EIR implementation in the pilot district has improved timeliness, coverage or other metrics of EPI effectiveness.

- unclear why sampling size is relevant as only descriptive analysis with no comparison presented

- I would expect EIR feasibility and acceptance among HCWs, rather than caregivers, as HCWs are the ones primarily using the EIR. Yet number of HCWs in the sample is very small, also making it hard to draw valid conclusions on a quantitative basis

- Please present all data collected for each Likert category, even if number is 0 - e.g., some tables only 3/5 likert categories are included

- consider if (i) qualitative data to enhance understanding of HCW perceptions can be collected ; and / or (ii) data from other regions or time periods can be used to validate / assess metrics such as timeliness more objectively.

- Remove statements such as "all eligible children were successfully registered" if it cannot be clearly described how this was verified with data outside of the EIR.

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Reviewer #2: Yes

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Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

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Reviewer #10: Yes

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Reviewer #13: Partly

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: No

Reviewer #9: No

Reviewer #10: No

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Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #6: Yes

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Reviewer #8: Yes

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Reviewer #11: Yes

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Reviewer #13: Yes

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Reviewer #4: Yes

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Reviewer #1: Major Comments

Generalizability

Study Design

Sampling Bias

Self-reported Satisfaction

Absence of Control Group

Without comparison to paper-based registries, it is difficult to attribute improvements solely to the EIR. Acknowledging this limitation would improve transparency.

Technical Challenges

Data Availability

The statement “all relevant data are within the manuscript” may limit reproducibility. Consider depositing anonymized datasets in a public repository to align with open science practices.

Minor Comments

Clarity of Writing

Some sections of the discussion repeat global evidence without fully connecting back to the Bangladesh context. Strengthening the local interpretation would enhance impact.

Figures and Tables

Figures summarizing caregiver and HCP satisfaction could benefit from clearer legends and consistent formatting of percentages.

Methodological Detail

Please provide more information on questionnaire validation and how qualitative responses were coded.

Terminology Consistency

Ensure consistent use of abbreviations (e.g., EIR, EPI) throughout the manuscript.

Ethical and Publication Considerations

Ethical approval and informed consent are clearly stated; no concerns identified.

No evidence of dual publication or ethical violations.

Financial disclosure and competing interests are appropriately declared.

Overall Recommendation

Reviewer #2: This manuscript presents a cross-sectional assessment of the feasibility and acceptability of an electronic immunization registry (EIR) in urban Bangladesh. The topic is relevant, the study appears technically sound, and the conclusions are generally supported by the data. However, several points require clarification.

Major points:

Minor points:

The description of the Likert scale is inconsistent (described as 5-point but defined from 0 to 5) and should be corrected.

Satisfaction outcomes are reported without explicit dissatisfied categories; the authors should clarify how these were handled and how overall satisfaction was calculated.

Minor typographical and formatting issues should be addressed.

Reviewer #3: Study design and causal interpretation

Sampling strategy and potential bias

Vaccination coverage results (100% coverage)

Very small healthcare provider sample size

Data availability statement

Minor reviewer comments (technical and editorial)

Likert scale description

Figures and tables

Reviewer #4: Overall Assessment

Major Comments

Study design limits causal inference and claims of improvement

Sampling strategy and representativeness require clearer justification

Interpretation of vaccination coverage results may be overstated

Limited analytical depth beyond descriptive statistics

Minor Comments

Clarify Likert scale description and reporting

Improve clarity in tables and figures

Recommendation

Reviewer #5: This is very good research for the Bangladeshi population. This type of research should be performed. If this article publishes in national journal, then the effectiveness will be more for the national population. Thank you.

Reviewer #6: The authors are advised to visit the journal website for proper structuring of the article. The article is recommended to be accepted for publication if updated accordingly. The review is uploaded as an attachment.

Reviewer #7: - The manuscript presents a technically sound feasibility study, with an appropriate study design and descriptive analyses that are aligned with the stated objectives. The data supports the conclusions regarding feasibility and acceptability of the EIR among caregivers and healthcare providers, and the authors appropriately acknowledge key methodological limitations. However, the manuscript would benefit from a clearer description of how caregivers interact with the EIR system, as caregivers appear to be largely passive recipients of EIR outputs rather than active users, which should be more clearly reflected in the interpretation of caregiver-related findings.

Reviewer #8: Dear Authors

Thank you for the efforts

Kindly find my comments below

ABSTRACT

Abstract language is that of operational report not scientific (eg 'high satisfaction', 'improved tracking')

the conclusion "demonstrates feasibility, acceptability, and scalability" cannot be made from your study because

1. Scalability was not studied

2. No cost analysis

3. No infrastructure assessment

4. No health system readiness evaluation

Methodology

1. Proxy indicator for feasibility and scalability (i.e prevalence of caregivers lacking vaccination records (16%)) may be weak conceptually.

3. The study lack details of qualitative data analysis

4.Ethics section incomplete - ethics reference number missing no mention of data confidentiality procedures

5. If purposive sampling was used as indicated in the discussion: Sample size calculation using Z²pq/d² may be invalid, representativeness is not statistically justified

Reviewer #9: This study is not methodologically corrected. Lack of proper sample size estimation, clarification of sample collection process and faulty analysis are present, which is a serious concern. I recommended a rejection for this manuscript.

see the attachment for details

Reviewer #10: 1. It is mentioned that the EIR was piloted in 2019, but the study was conducted in 2024 which results in a 5 years gap. The manuscript did not clarify whether the assessment of feasibility and acceptability covers the whole implementation period or only recent performance.

2. In line 125, 100% vaccination coverage was mentioned which seems implausibly high. It might be better to explain sample representativeness or verification methods.

3. Satisfaction was entirely based on self-reported data. It would be better to have objective verification such as vaccination card checks, registry audits or some kind of observation of the system use.

4. The manuscript did not mention any inter-rater reliability or data quality checks.

5. The statistical analysis only included descriptive statistics. It could benefit from bivariate analysis, comparing outcomes across different groups such as registered in the venue vs home visits.

Only descriptive statistics are presented. The study would benefit from:

6. "HCPs reported several technical and operational challenges during the EIR submission process, with the most common being slow internet connectivity (31%), and combined slow internet with tablet issues (37%) (Figure 3, Panel A). Tablet malfunctions were independently reported by 19%"---> the manuscript doesn't discuss anything about mitigation strategies, system downtime frequency, or workarounds used by providers.

7. The manuscript did not mention any description of the EIR system architecture, features, or data flow.

8. The discussion or result section did not mention details on how qualitative data were analyzed beyond "descriptive summary".

9. The manuscript does not mention anything about data privacy, security measures for the electronic registry, or how personally identifiable information is protected.

Reviewer #11: This is an interesting manuscript exploring the implementation of EIR to improve immunization coverage and monitoring in Bangladesh, as stated in the submitted manuscript. Overall, the research question is addressed using appropriate methods, and the results are properly presented. Nevertheless, a description of the current workflow and data flow of the immunization program in the studied health facilities would support better understanding of the context and the barriers and advantages presented. The reader cannot assess the current integration of the digital system if this information is not provided.

Abstract:

Introduction:

Methods

- Data collection: the difference between the tool used for the caregivers and the one used for the care providers is not easy to understand with the description provided.

Results:

Discussion

- «Vaccination coverage remained high, and all eligible children were successfully registered.”: remained high compared to what. What did the authors expect to find?

- “…showed strong potential for broader scale-up.”: which results are supporting this statement? Also the barriers reported are not negligible.

- Overall I can observe an overinterpretation of the findings and related implications for the health system.

Reviewer #12: General comments:

That said, I believe the manuscript can benefit from some revisions in the focus and analysis of the results to make it more robust.

Specific Comments:

1. Consider revising your topic to reflect the content of the study. Most of the data reported in the manuscript speaks to caregiver and HCP satisfaction, not the feasibility of the EIR.

4. Report the Cronbach's alpha (internal consistency) of the Likert scale here (Lines 101-103).

5. Conduct some advanced analytical statistics to compare the satisfaction between caregivers and HCPs (Line 106).

7. Insert the Ethics approval number here (111-112).

9. After all these revisions, the discussion and conclusion have to be adapted to the results.

Reviewer #13: The paper is an interesting addition to the growing body of work on EIRs, but I suggest significant revisions before publication:

- unclear why sampling size is relevant as only descriptive analysis with no comparison presented

- Please present all data collected for each Likert category, even if number is 0 - e.g., some tables only 3/5 likert categories are included

- Remove statements such as "all eligible children were successfully registered" if it cannot be clearly described how this was verified with data outside of the EIR.

**********

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Reviewer #1: Yes: Sura Saad Abdullah

Reviewer #2: Yes: Abdullah Faisal Albukhari

Reviewer #3: Yes: Aisha Al-Khinji

Reviewer #4: No

Reviewer #5: No

Reviewer #6: Yes: Surajo Adamu Wada, PhD.

Reviewer #7: No

Reviewer #8: No

Reviewer #9: No

Reviewer #10: Yes: Ishrat Binte Aftab

Reviewer #11: No

Reviewer #12: Yes: Austin Gideon Adobasom-Anane

Reviewer #13: Yes: Praveena Gunaratnam

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PLoS One. 2026 Jul 2;21(7):e0352972. doi: 10.1371/journal.pone.0352972.r002

Author response to Decision Letter 1

1 Jun 2026

16th May 2026

Dr Emily Chenette

Editor-in-Chief

PLOS ONE

Re: PONE-D-25-67616R1: Feasibility and acceptability of an electronic immunization registry in urban Bangladesh

Dear Dr Chenette,

Thank you for your interest in our paper and for enclosing the encouraging and helpful comments from your reviewers. We appreciate the time and effort taken by the reviewers and the editorial team to read our manuscript and provide constructive comments to improve it. We have pleasure in submitting our revised manuscript entitled “Feasibility and acceptability of an electronic immunization registry in urban Bangladesh” to be considered for publication in PLOS ONE.

For your convenience, we have reproduced the editor’s and reviewers’ comments verbatim, before detailing our response to each of the points made. Page and line numbers refer to the ‘Revised Manuscript with Track Changes’.

Academic Editor: Dr Samuel Kofi Tchum

Thank you for your encouraging words and for enclosing the helpful comments from your reviewers. We have responded to the reviewers’ comments in details below.

Reviewer #1

1. Generalizability: The study is limited to a single urban pilot site (Rajshahi City Corporation). Findings may not reflect rural or resource-constrained areas. Please expand the discussion on how infrastructural differences (e.g., internet connectivity, staffing) might affect nationwide rollout.

Thank you for this comment. We agree and have expanded the limitations and implementation discussion to emphasize that findings from a single urban pilot setting may not be transferable to rural or resource-constrained settings where infrastructure, staffing, and connectivity differ. We also added that nationwide implementation would require investment in internet connectivity, capacity building, and integration with broader health information systems (page 17, lines 322–328; page 19, lines 352–365; page 19, lines 375–382).

2. Study Design: The cross-sectional design provides only a snapshot in time. Longitudinal or comparative studies would be needed to assess sustainability, dropout reduction, and equity impacts. Please acknowledge this limitation more explicitly.

Thank you for this comment. We have now explicitly acknowledged this limitation. We also revised the Abstract, Methods, Discussion, and Conclusion to state that the study was not designed to evaluate effectiveness or causal impact (page 2, lines 31–40; page 7, lines 114–123; page 17, lines 313–328; page 20, lines 383–388).

3. Sampling Bias: Purposive sampling may have introduced bias, particularly if participants were more likely to be favorable toward the EIR. Clarification on participant selection criteria would strengthen the methodology.

Thank you. We agree that purposive sampling may have introduced selection bias, particularly because participants were recruited from individuals already exposed to EIR-supported services and may therefore have been more likely to report positive perceptions. We have revised the Methods section to more clearly describe the participant selection approach and rationale for using purposive sampling in this descriptive operational assessment. We have also expanded the limitations section to acknowledge that this approach may have overestimated satisfaction and perceived benefits among relatively engaged users (page 8, lines 125–142; page 17, lines 317–320).

4. Self-reported Satisfaction: Satisfaction measures rely on self-report, which may be subject to recall and social desirability bias. Please discuss this limitation in more depth and consider triangulating with objective usage data in future studies.

Thank you for this comment. We agree that self-reported satisfaction may be affected by recall and social desirability bias. We have expanded the limitations section to acknowledge this issue and have noted that future studies should include objective data sources, such as registry audits or direct observation of system use (page 17, lines 319–328).

5. Absence of Control Group: Without comparison to paper-based registries, it is difficult to attribute improvements solely to the EIR. Acknowledging this limitation would improve transparency.

Thank you for this comment. We agree that, without a comparator, observed outcomes cannot be attributed solely to the EIR. We have revised the manuscript to avoid causal language and clarify that the study provides descriptive findings (page 7, lines 114–123; page 17, lines 315–318; page 20, lines 384–388).

6. Technical Challenges: While slow internet and device malfunctions are noted, the discussion could be expanded to include potential solutions (e.g., offline-ready systems, infrastructure investment, refresher training). This would strengthen the scalability argument.

Thank you for this suggestion. We have now expanded the Discussion to include mitigation strategies, including digital infrastructure investment, offline-capable systems, and refresher training for frontline staff (page 19, lines 352–365).

7. Data Availability: The statement “all relevant data are within the manuscript” may limit reproducibility. Consider depositing anonymized datasets in a public repository to align with open science practices.

Thank you. We have now updated the Data availability statement to clarify that the de-identified dataset supporting the findings is provided as a supplementary file (page 21, lines 400–404).

8. Clarity of Writing: Some sections of the discussion repeat global evidence without fully connecting back to the Bangladesh context. Strengthening the local interpretation would enhance impact.

Thank you. We have revised the Discussion to reduce repetition of global evidence and to connect the findings to the Bangladesh implementation context, including infrastructure, workforce capacity, system integration, and phased implementation considerations (page 18, lines 342–351; page 19, lines 352–382).

9. Figures and Tables: Figures summarizing caregiver and HCP satisfaction could benefit from clearer legends and consistent formatting of percentages.

Thank you for this suggestion. Upon further consideration, we removed the figure because the number of HCPs was small, and percentage-based visualization could be misleading. The findings are now presented descriptively in the Results, and Tables 2 and 3 now include all five Likert response categories, including zero-response categories (page 12, lines 226–230; page 13, lines 247–259).

10. Methodological Detail: Please provide more information on questionnaire validation and how qualitative response s were coded.

Thank you. We have expanded the Methods section to describe questionnaire pretesting and clarified that open-ended responses were not subjected to formal qualitative coding but were reviewed and descriptively summarized to identify commonly reported issues and experiences (page 8, lines 143–157; page 9, lines 158–168).

11. Terminology Consistency: Ensure consistent use of abbreviations (e.g., EIR, EPI) throughout the manuscript.

Thank you. We have reviewed the manuscript and standardized abbreviations, including EIR, EPI, RCC, LMICs, and HCPs, throughout the manuscript.

12. Ethical and Publication Considerations: Ethical approval and informed consent are clearly stated; no concerns identified.

Thank you. We also have strengthened the Ethics section by adding the ethics approval reference number and data confidentiality procedures (page 9, lines 170–175).

13. No evidence of dual publication or ethical violations.

Thank you for confirming this.

14. Financial disclosure and competing interests are appropriately declared.

Thank you.

15. Overall Recommendation: This manuscript makes a meaningful contribution to the literature on digital health and immunization in LMICs. With revisions to strengthen methodological transparency, expand discussion of limitations, and improve data accessibility, the paper will be well-positioned for publication.

Thank you for this encouraging recommendation. We have revised the manuscript to strengthen methodological transparency, expand limitations, avoid causal overinterpretation, improve reporting of Likert-scale data, and update the Data availability statement.

Reviewer #2

16. This manuscript presents a cross-sectional assessment of the feasibility and acceptability of an electronic immunization registry (EIR) in urban Bangladesh. The topic is relevant, the study appears technically sound, and the conclusions are generally supported by the data. However, several points require clarification.

Thank you for your comment. We have addressed each clarification point below.

17. Funding statement: There is an inconsistency between the Funding and Acknowledgements sections. The authors should clarify whether WHO-IVD support was financial or in-kind and ensure consistency between these sections.

Thank you for this comment. In response to the journal’s technical check following the revised submission, funding-related text has now been removed from the manuscript file, including the Funding, Competing Interests, and Acknowledgements sections. The Acknowledgements section in the revised manuscript now reads: “We thank the study participants for their contribution to this study.”

18. Data availability: For a survey-based study, PLOS data policy typically requires availability of the underlying de-identified dataset. The authors should clarify whether the raw survey data can be shared and update the Data Availability statement accordingly.

Thank you. We have updated the Data availability statement to indicate that the de-identified dataset is available as a supplementary file (page 21, lines 400–404)

19. The description of the Likert scale is inconsistent (described as 5-point but defined from 0 to 5) and should be corrected.

Thank you for identifying this error. We have now corrected the Likert-scale description throughout the manuscript. The scale is now consistently described as a 5-point scale ranging from 1 to 5 (page 8, lines 151–157; page 12, lines 227–230; page 14, lines 249–252).

20. Satisfaction outcomes are reported without explicit dissatisfied categories; the authors should clarify how these were handled and how overall satisfaction was calculated.

Thank you for this comment. We have revised Tables 2 and 3 to display all five Likert categories, including categories with zero responses. We also clarified that Likert items were analyzed individually and were not combined into a composite or overall satisfaction score (page 9, lines 159–168; page 12, lines 226–230; page 13–14, lines 247–252).

21. Minor typographical and formatting issues should be addressed.

Thank you. We have reviewed the manuscript and corrected typographical, grammatical, and formatting issues.

Reviewer #3

22. Study design and causal interpretation: The cross-sectional design of the study limits the ability to attribute the observed high vaccination coverage and improved registration timeliness directly to the electronic immunization registry. Several statements in the Abstract, Results, and Conclusions sections appear to imply an impact of the EIR rather than focusing strictly on feasibility and acceptability. The conclusions should be reframed to clearly distinguish association from causation and to avoid over-claiming system effectiveness.

Thank you. We agree and have revised the Abstract, Methods, Results, Discussion, and Conclusion to remove causal language and to frame the findings as descriptive perceptions and reported operational experiences rather than evidence of effectiveness or system-level impact (page 2–3, lines 31–58; page 7, lines 114–123; page 15–16, lines 277–295; page 20, lines 383–388).

23. Sampling strategy and potential bias: Caregivers were selected using purposive sampling, and all participants were already engaged with the EIR system. This approach introduces selection bias and likely inflates estimates of satisfaction and vaccination coverage. The limitations section should be expanded to explicitly discuss how purposive sampling and the exclusion of non-users may have influenced the findings.

Thank you. We have now clarified the purposive sampling strategy in the Methods and explicitly acknowledged selection bias in the limitations (page 8, lines 136–142; page 17, lines 317–320)

24. Vaccination coverage results (100% coverage): The reporting of 100% vaccination coverage for multiple antigens in an urban setting is unusual and requires careful contextualization. It is unclear whether the reported coverage reflects true population-level coverage or only coverage among children registered in the EIR system. The authors should clarify the denominators used, explicitly state that coverage estimates apply only to registered children, and temper interpretations accordingly.

We appreciate your concern and agree that the coverage results require careful contextualization. We have now clarified that these estimates reflect reported vaccination status among children registered in the EIR system and should not be interpreted as population-level vaccination coverage. We also have revised the Results and Discussion to avoid population-level interpretation (page 10, lines 183–190; page 11, lines 194–203).

25. Very small healthcare provider sample size: Only 16 healthcare providers were included in the study, yet results are presented in percentages and used to support relatively strong conclusions. This small sample size limits both statistical reliability and interpretive robustness. The manuscript should more explicitly acknowledge this limitation and avoid broad generalizations based on these data.

Thank you. We agree and now explicitly state that the HCP sample was small and that findings should be interpreted as indicative of provider perceptions within this setting. We have also removed broad claims based on HCP percentages (page 13, lines 231–242; page 17, lines 321–322)

26. Data availability statement: The manuscript states that all relevant data are contained within the manuscript, yet the results appear to be derived from underlying survey datasets. This may not fully align with PLOS ONE data transparency requirements. The authors should clarify whether anonymized datasets can be shared as supplementary files or deposited in a public repository.

Thank you. We have revised the Data availability statement to indicate that the de-identified dataset is available as a supplementary file (page 21, lines 400–404)

27. Likert scale description: The Likert scale is described in the Methods section as ranging from 0 to 5, while the tables appear to reflect a 1 to 5 scale. This discrepancy should be clarified and standardized throughout the manuscript.

Thank you for identifying this error. We have now corrected the Methods and table footnotes to describe the 5-point Likert scale consistently as 1 to 5 (page 8, lines 151–157; page 12, lines 227–230; page 14, lines 249–252).

28. Figures and tables: There are inconsistencies in figure numbering in the text, such as references to Figure 1 and Figure 3. These should be checked and corrected. In addition, figure captions should be improved to be fully self-explanatory without requiring reference to the main text.

Thank you for this suggestion. We have checked figure numbering and removed the figure from the manuscript, as it added limited analytical value and could be misleading given the small number of HCPs. The relevant findings are now presented descriptively in the Results section (page 14, lines 254–259).

Reviewer #4

29. Overall Assessment: This manuscript presents a cross-sectional evaluation of the feasibility and acceptability of an Electronic Immunization Registry (EIR) piloted in an urban setting in Bangladesh. The topic is timely and relevant, particularly in the context of digital health scale-up in low- and middle-income countries (LMICs) aligned with Immunization Agenda 2030. The study contributes descripti

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PLoS One. doi: 10.1371/journal.pone.0352972.r003

Decision Letter 1

Samuel Kofi Tchum

18 Jun 2026

Feasibility and acceptability of an electronic immunization registry in urban Bangladesh

PONE-D-25-67616R1

Dear Dr. Uzzaman,

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PLoS One. doi: 10.1371/journal.pone.0352972.r004

Acceptance letter

Samuel Kofi Tchum

PONE-D-25-67616R1

PLOS One

Dear Dr. Uzzaman,

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Dataset. De-identified quantitative dataset underlying the findings of this study (Excel format).

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Data Availability Statement

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PERMALINK

Feasibility and acceptability of an electronic immunization registry in urban Bangladesh

Md Jawadul Haque

A K M Kamruzzaman

Rajendra Bohara

Chiranjit Das

Md Tarjumanul Haque Sanij

Abul Fazal Md Shahabuddin Khan

F A M Anjuman Ara Begum

Nazim Uzzaman

Roles

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Materials and Methods

Study design and setting

Study participants

Data collection

Data analysis

Ethics

Results

Demographics

Electronic registration and vaccination coverage

Table 1. Electronic immunization registration and vaccination coverage.

Caregiver and HCP satisfaction

Table 2. Caregiver perceptions of EIR-supported services.

Table 3. Healthcare provider perceptions of EIR-supported services.

Perceived challenges and benefits

Discussion

Summary of the findings

Strengths and limitations

Interpretation in the light of published papers

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Samuel Kofi Tchum

Roles

Author response to Decision Letter 1

Decision Letter 1

Samuel Kofi Tchum

Roles

Acceptance letter

Samuel Kofi Tchum

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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