Increasing Immunisation in Karachi, Pakistan: A Feasibility and Acceptability Study of the Vaccine Indicator and Reminder Band Community Intervention

"Improving RI timeliness and completion needs a targeted approach coupling a robust social behavior change communication strategy harnessing all the available health producing resources and coupled with an active reminder like the VIR band to provide visual cues to action."

Delayed vaccination initiation and dropout rates of almost 40% in Pakistan's low socio-economic strata are a major concern. Funded by the International Initiative for Impact Evaluation (3ie), 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 (RI).

In brief, the Vaccine Indicator Reminder (VIR) band (see also Related Summaries, below) comprises a time-strip indicator and a one-time locking button encased in a silicon mould. The time-strip indicator consists of a white membrane and a dye blister; pressing the blister activates the band, which causes a red coloured dye to be released along the membrane. The progression of the ink on the membrane is calibrated to reach the endpoint in 4-6 weeks, hopefully serving as a visual reminder for caregivers to vaccinate their children on time and complete the pentavalent vaccinations.

Each infant enrolled in the study received 3 VIR bands: yellow, purple, and aqua. The yellow bands were provided to infants arriving at the study health centres to receive their Bacillus Calmette-Guérin (BCG) vaccine. The band's time-strip was calibrated to reach the endpoint in 6 weeks, which corresponded to the due date for the first dose of the pentavalent vaccine. The infants who returned for the pentavalent vaccine at 6 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 4 weeks for the final dose of the vaccine.

Three cadres of community health workers - namely, the Lady Health Workers (LHWs) employed by the Government of Sindh (GoS), female community volunteers (FCVs) hired by the United Nations Children's Fund (UNICEF), and traditional birth attendants (TBAs) - were engaged and provided incentives for counseling and referring parents for timely initiation of RI. They were not directly involved in distributing VIR band or vaccines to infants but received monetary compensation for every child they referred.

This was a mixed-methods study conducted in 2 peri-urban settlements of Sachal Goth (village) and Pehalwan Goth of District East, in Karachi, Pakistan. The study enrolled 497 infants, who were followed for 18 weeks until they completed their 3 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. At endline, a household survey was conducted to assess the communities' perceptions.

The study found that more than 90% of the households surveyed were in favour of vaccination, and about 70% of these households reported that vaccination should be started soon after birth. There was an almost 100% acceptance of the VIR band and more than 86% retention of the VIR band at each subsequent vaccination visit. However, very few children actually received the pentavalent vaccine doses at the prescribed age. Among the cohort, 61.9% of the infants completed the third dose (Penta-3). Among those who completed the RI schedule up to Penta-3, the proportion of those returning late for immunisation (i.e., beyond 7 days of the date of the prescribed follow-up visit) was observed to be 28.6% for first follow-up, 56.4% for second follow-up, and 76.0% for the third follow-up visits.

The researchers 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 they needed their husband's permission to accept the VIR band. In that context, it was a challenge for the VIR band team to engage with male community members during the usual working hours of 9 a.m. - 5 p.m.; the operating hours of all the public vaccination centres (9 a.m. - 2 p.m.) also posed a challenge for reaching the men and disseminating the key VIR band messages to them. Thus, the VIR band male team members often had to stay after 5 p.m. to meet with community influencers and decision makers in the realm of child health.

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 8 weeks after enrolment, caregivers began reporting a defect; the time-strip functioned accurately in only 42% of the yellow bands, 33% of the purple bands, and 9% 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.

Despite these and other challenges outlined in the report, the VIR band reportedly received support and encouragement from community stakeholders, LHWs, the FCV programme manager, and health policymakers. "The key lesson learned was to continually engage with all stakeholders identified in the SEEP [Stakeholder Engagement and Evidence uptake Plan] document and share results at every stage and different forums. Continued sharing of results at diverse platforms and engagement with non-health stakeholders is also key to being recognized. The VIR band presence on social media is maintained on its 'Facebook' page which is regularly visited, liked and shared within the contacts and list shared. The VIR band intervention has been appreciated not only by health planners but also highlighted on the Radio, TV and print media."

The researchers also advise that rapid social mapping to identify all health resources available to the community and service providers coming into direct contact with newborn children and their parents/caregivers should be part of the VIR band intervention going forward. Social mapping exercises are already being conducted by UNICEF during Supplementary Immunisation Activities (SIAs) for polio and measles. The most time-consuming component of the social mapping exercise in the VIR band study was the household line listing and identification of children under 2 years of age. UNICEF could be approached to share data of social mapping of communities covered by their programme. The VIR band team could then focus on identifying each and every cadre of healthcare provider working in the community and mapping all health-producing resources available to the community, which can support community engagement.

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

More specifically, whether the VIR band can alone alter parental attitudes and behaviour needs to be evaluated, the researchers suggest, through studies comparing different social and behaviour change communication (SBCC) strategies addressing all levels of the socio-ecological sphere. Parental knowledge of vaccine-preventable diseases, RI schedules, and barriers to action for its timely completion need to be assessed in the context of other low- and middle-income countries.