Increasing immunisation in Karachi, Pakistan: a feasibility and acceptability study of the vaccine indicator and reminder band community intervention

3ie evidence programme:  Innovations in Increasing Immunisation Evidence Programme
Author(s): Noor Sabah Rakhshani, Rehman Tahir, Farhan Ali, Mohammad Imran Khan
Institutional affiliation(s): Precision Development Research and Advocacy Consultants, Trust for Vaccines and Immunization
Grant-holding institution: Trust for Vaccines and Immunization
Main implementing agency: Trust for Vaccines and Immunization
Sex disaggregation: Yes
Gender analysis: Yes
Equity focus: No
Dataset: Available

Context

According to the Pakistan demographic and health survey 2012-13, while 85 per cent of the children in the country initiate routine immunisation, only 65 per cent receive the third dose of pentavalent vaccine. In the lowest socio-economic strata, 70 per cent initiate routine immunisation and only 29.9 per cent complete the cycle. Delayed vaccination initiation and dropout rates of almost 40 per cent in the low socio-economic strata is a major cause 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.

Intervention design

This study assessed 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 endpoint in four to six weeks.

Each infant enrolled in the study received three VIR bands: yellow, purple and aqua. The yellow bands were provided to infants arriving at the study health centres to receive their BCG vaccination. The band’s time-strip was calibrated to reach the endpoint 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 the purple bands, which were calibrated to indicate the time for the next immunisation visit. Lastly, aqua bands were provided to children returning for the second dose of pentavalent vaccine and were calibrated to remind caregivers to return in four weeks for the final dose of the vaccine. The intervention engaged various cadres of frontline health workers and midwives to enrol children in the study, who were given monetary compensations 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:

1. Gradual change in colour of the time-strip would serve as an active reminder for caregivers to vaccinate their children on time;
2. Vaccine services would be accessible and acceptable to the community; and
3. Engaging with communities would prompt conversations around immunisation.

Evaluation design and methodology

This was a mixed-methods study conducted in two peri-urban settlements in Karachi, Pakistan.

The study enrolled 497 infants who were followed for 18 weeks till they completed their three doses of pentavalent vaccine.

Qualitative methods were used at baseline to explore the communities’ knowledge, attitudes and practices related to immunisation. A social mapping exercise was also carried out prior to the implementation of the intervention to understand best possible sites to roll out the intervention.

A household survey was carried out at endline to assess the communities’ perception of vaccination following the implementation of the VIR intervention.

Primary evaluation questions

The study addressed the following questions:

1. What is the level of parental and community acceptance of the VIR band? 
2. What is the parental compliance with the VIR band?
3. What is the accuracy of the VIR band/time-strip indicator?
4. Is the VIR band an effective reminder to parents of the vaccine due date?

Primary findings

The study found that more than 90 per cent of the households surveyed were in favour of vaccination and about 70 per cent of these households reported that vaccination should be started soon after birth. While the overall vaccination coverage in the communities was found to be high, very few children actually received the pentavalent vaccine doses at the prescribed age. The team also found that some children missed the second dose of the Measles vaccine.

The authors found that the father’s decision is an important determinant of acceptance and uptake of the VIR band intervention. Interviews with mothers in one of the intervention communities revealed that they needed their husband’s permission to accept the VIR band. They also found that 54 per cent of the infants visiting vaccination centres for routine immunisation initiation were accompanied by the mother (34 per cent) or aunt (19 per cent). There was no statistically significant difference between male and female infant follow-up visits for receiving bands.

A major setback to the VIR band intervention was the high failure rate of the ‘time-strip’ indicator encased in the silicon moulding. Within the first eight weeks after enrolment, caregivers began reporting a defect in the time-strip indicator. The authors report that the time-strip functioned accurately in 42 per cent of the yellow bands, 33 per cent of the purple bands and 9 per cent of the aqua bands. This in turn, limited the study team’s ability to accurately measure the effectiveness of VIR bands in increasing timely uptake of pentavalent vaccine doses.

Implications

Given the low-cost of production, and the safety and durability of the VIR bands, the intervention was found to be highly acceptable among community members and received a lot of support from health officials. However, the implementation of the intervention did experience significant challenges, the most prominent one being technology failure. Even after repeated iterations to the design of the bands, the time-strip encased in the band malfunctioned due to faulty silicon moulding.

Despite these setbacks, the authors conclude that the VIR band, with minor iterations to its design, will function with close to 99 per cent accuracy and has the potential to be an effective reminder for caregivers in low-resource settings. Additionally, the team recommends further research assessing the effectiveness of the VIR band as it could provide an alternative to SMS reminders which are restricted to families that own mobile phones, or are likely to work only in settings with high mobile phone ownership.