An Assessment of the Effectiveness of an Electronic Wristband in Improving Routine Immunization Timeliness and Reducing Drop-out

"The caregivers who are the key drivers of immunization timeliness reported WIA to be helpful and expressed a desire to recommend it to others."

Infants and children cannot decide whether and when they get vaccinated. Thus, the significant role caregivers play in immunisation uptake and timeliness cannot be overemphasised. The need to mobilise caregivers to improve immunisation uptake, coverage. and timeliness has been established in previous studies. As an adjunct to the conventional paper-based immunisation cards that have been generally deployed across Nigeria, this group of researchers designed and deployed a simple electronic, silicone-based wristband that flashes a light to remind caregivers of their immunisation sessions. This study assessed the effectiveness and user-friendliness of Wristband for Immunization Alert (WIA) as a reminder device for caregivers to improve immunisation uptake and reduce drop-outs in Kano state, Northwestern Nigeria.

A process flow of project implementation was developed in collaboration with relevant stakeholders in line with Nigeria's goal of improving immunisation coverage and data quality through electronic data capture and reminder systems. The intervention reviewed similar projects that have been implemented in Nigeria (Alma Sana band deployed in Nassarawa state, Vaccine Indicator Reminder band in Kebbi state, and Bracelet for Immunization deployed in Bauchi state). Lessons from the project implementation as well as best practices informed the design and implementation of the project plan.

WIA is an electronic, water-resistant wristband device made from an unreactive silicone material, and it has a lifespan of 12 months from the day it is activated. WIA is worn by the caregiver and is programmed to flash a dim-red light before the child's immunisation to the day of the immunisation. In line with the human-centred design approach, the WIA device was pretested on a smaller population of caregivers in one primary healthcare facility in a rural local government area (LGA) in Kano state.

Eight health facilities, selected from two LGAs in Kano state, were clustered in a two-arm study involving an intervention group and a control group. Only the caregivers (757) from the intervention group received WIA as an immunisation reminder device. Immunisation timeliness data were then collected from the control and intervention groups for the period of intervention and analysed using Microsoft Excel and IBM SPSS version 21.

A cohort analysis of caregivers who received WIA at their second visit showed an increase in immunisation timeliness from 10% at the second visit to 86% at the third visit and maintained at 66% for the fifth visit. A difference-in-difference analysis of the effect of WIA on immunisation timeliness from baseline to endline in the control and intervention groups showed a positive 30% increase in immunisation timeliness associated with the introduction of WIA.

Findings from 12 key informant interviews (KIIs) with health workers at the pilot facilities showed that all of them demonstrated a full understanding of the purpose of the wristband and how to reset the wristband when the caregivers return for subsequent vaccinations. Findings from 51 KIIs with caregivers engaged at the pilot facilities showed that all of them (100%) demonstrated a good understanding of the purpose of the wristband, as they could articulate in their own words how the wristband functions and their expectations of it to signal when immunisation is due. There was also no occurrence of discontinuation of use of the WIA device after the first visit, indicating 100% acceptance of the wristbands by the caregivers. "The acceptance and continued use of the WIA device by the caregivers in this study is an important validation of the wristband in the context of value reorientation, especially in the Northwestern part of Nigeria where religious and cultural beliefs tend to checkmate technological innovations."

In conclusion: "The WIA device aided the timeliness of immunization and reduced the immunization drop-out rate among the intervention group compared with the control group. Given that immunization timeliness and drop-outs are reported issues of concern in Northwestern Nigeria, the use of the WIA device that has been shown by this study as a solution is a recommended intervention."