Improving vaccination initiation and completion via vaccine indicator and reminder bands: a formative study in Nigeria
3ie evidence programme: Innovations in Increasing Immunisation Evidence Programme
Author(s): Chisom Obi-Jeff, Ebubechi Nwaononiwu, Nahum Nuhu, Kelechi Irechukwu, Suleiman Mahmud, Tobi Bamiduro, Chike, Nwangwu, Jamila Ibiye Bello-Malabu, Noor Sabah Rakhshani, Chizoba Wonodi
Institutional affiliation(s): Direct Consulting and Logistics Limited, Health Strategy and Delivery Foundation, Precision Development Research and Advocacy, Independent researcher from Johns Hopkins International Vaccine Access Center
Grant-holding institution: Health Strategy and Delivery Foundation
Main implementing agency: Health Strategy and Delivery Foundation; and Direct Consulting and Logistics Limited
Sex disaggregation: No
Gender analysis: No
Equity focus: No
According to the World Health Organisation, Nigeria accounts for approximately 28 per cent of global child mortality due to vaccine-preventable diseases. In 2016, the coverage for the third dose of pentavalent and full immunisation were 33 per cent and 23 per cent, respectively. While there has been a significant improvement in delivery of Nigeria’s routine immunisation programme, delayed vaccination and low overall coverage are still major causes for concern. This study explores the feasibility and acceptability of using anklets worn by children as a visual reminder for caregivers, to encourage timely initiation and completion of routine immunisation.
This study evaluated the feasibility and acceptability of the Vaccine Indicator Reminder (VIR) bands. Encased in a silicon mould, the band comprised a time-strip indicator and a one-time locking button. The time-strip indicator consisted of a white membrane and a dye blister; pressing the blister activated the band, which caused a red-coloured dye to be released along the membrane. The progression of the ink on the membrane was calibrated to reach the end-point in four to six weeks.
Each infant enrolled in the study received three VIR bands: yellow, purple and green. The yellow bands were provided to infants upon receiving their Bacillus Calmette-Guérin vaccination (either at birth or in the first two weeks of life). The band’s time-strip was calibrated to reach the end-point in six weeks, which corresponded to the due date for the first dose of the pentavalent vaccine. The infants who returned for the pentavalent vaccine at six weeks received purple bands, which were calibrated to indicate the time for the second dose of pentavalent vaccine. When children returned for the second dose, they received green bands, which were calibrated to remind caregivers to return in four weeks for the final dose of pentavalent. The intervention engaged health workers and traditional birth attendants (TBAs) to enrol children in the study. The TBAs also received monetary compensation for the delivery of services.
The study hypothesised that the VIR band will serve as a visual reminder for caregivers to vaccinate their children on time and complete the pentavalent vaccinations.
This hypothesis was based on three key assumptions:
- Community will accept the VIR band;
- Gradual change in the colour of the time-strip would serve as an active reminder for caregivers to vaccinate their children on time; and
- Health workers and TBAs would be able to utilise the VIR bands to trigger conversations around immunisation in the community.
Evaluation design and methodology
This was a mixed-methods study conducted in three wards of Bunza Local Government Area in Kebbi State, Nigeria.
The study enrolled 503 infants who were followed for 18 – 22 weeks, till they completed their three doses of pentavalent vaccine.
Quantitative methods comprised a household survey which was conducted at baseline. Exit interviews were conducted during endline with caregivers of children who returned for the third dose of pentavalent vaccine.
Qualitative methods, including focus group discussions and in-depth interviews, were used at baseline and endline to explore the communities’ knowledge, attitudes and practices related to immunisation.
Primary evaluation questions
This study answers the following questions:
- Will parents/caregivers and the community accept the VIR band?
- Will parents/caregivers retain the bands on their infants’ ankles for the duration of the study?
- Is it feasible for health providers to incorporate the use of the VIR band as part of routine immunisation services?
- Will healthcare workers follow the protocol for the appropriate use of the VIR band?
The authors reported that although vaccination knowledge and intention to vaccinate were high at 91 and 100 per cent respectively, and there were no stated socio-cultural impediments to vaccine uptake, motivation to vaccinate was still low. At endline, only nine per cent of enrolled children had received their third dose of pentavalent vaccine by 18 weeks. The most commonly cited reasons for under-vaccination largely pertained to caregiver complacency.
Of 503 children enrolled in the study, 155 returned for the third dose of pentavalent vaccination. Exit interviews with the caregivers of these children found that 97 per cent of them perceived VIR bands to be an effective vaccination reminder.
In-depth interviews with the caregivers, health workers and community leaders revealed that the overall acceptability of the VIR intervention was high and it was perceived as an incentive by several caregivers. However, there were some general concerns and hesitancy about the band design; primarily, caregivers found the concept of ankle bands strange and would have preferred wrist bands. Additionally, the red-coloured dye in the time-strip indicator was also found to be concerning as it had led some caregivers to erroneously conclude that the band was sucking the infant’s blood.
A major setback to the VIR band intervention was the high failure rate of the time-strip indicator, which led to delays in vaccinating many enrolled children. In addition, the limited availability of VIR bands due to import restrictions may have reduced immunisation uptake among caregivers who perceived it as an incentive. This, in turn, limited the study team’s ability to accurately measure the effectiveness of VIR bands.
Given the study findings, the authors conclude that successful uptake of interventions such as the VIR band, is contingent upon well-planned sensitisation and mobilisation strategies. The research team found that using existing trusted community structures, especially community leaders and TBAs, helped them address knowledge gaps and encourage uptake of the intervention.
Despite this successful engagement, the authors acknowledge that the VIR band technology itself had limited success. The authors recommend further research to assess the effectiveness of the VIR band as a reminder and an incentive to caregivers.