Improving the Timeliness and Completeness of Childhood Vaccination through Color-coded Bracelets: A Pilot Study among Fulani Tribe Populations in Nigeria

"The main findings from this study are that a bracelet intervention appears to be feasible and well accepted in Fulani populations of Nigeria, and that there is preliminary evidence for this intervention for being effective."

About 60% of the population in Bauchi State, Nigeria, are Fulanis, a traditionally nomadic ethnic group with particularly low rates of vaccination coverage due to high mobility, low education levels, and cultural reasons. This controlled pilot intervention trial sought to: (i) investigate the feasibility of a colour-coded bracelet intervention amongst the ethnic Fulani population; (ii) assess and compare vaccination completeness and timeliness in the intervention and control populations; and (iii) study the feasibility and the effects of adding peer to peer mobilisers (PPM) for vaccination scale up.

All consenting mothers/caretakers attending the study health facilities with eligible newborns were recruited and followed up for 11 months. The control group received no bracelets (just the standard information provided to mothers/caretakers at routine immunisation services), whereas the children in the three intervention sites were provided with locally produced 5-colour-coded bracelets fixed together as a single but detachable unit. The caregivers were informed about the meaning of the bracelet colours regarding vaccine type(s), the susceptibility to a particular vaccine-preventable disease, or VPD (at each contact) in case of failure to meet up with scheduled appointment(s), and the timing of these vaccinations. Therefore, the study used these colour-coded bracelets as visible reminders for different contacts of vaccination due dates to enhance compliance with the immunisation schedules. Bracelets are common cultural adornments worn as part of normal dressing amongst the Fulanis in Nigeria and elsewhere. Bright colours were purposely selected based on the Fulanis affiliation to these colours and are common across most local markets. The sequencing of the colour order (from red to green) was meant to connote risk associated with lack of vaccination. As for exit bracelet, the researchers used two colours (pink for girls and black for boys).

To ensure uniformity of messaging at the intervention sites (bracelet group), a short audio recording in the two main languages (Fulani and Hausa) were played to each of the mothers/caregivers of children in the study during every vaccination visit to the health facilities. Upon every vaccination, the corresponding unit of the bracelet was cut off with a pair of scissors. At the 5th contact, a different design exit bracelet was issued to the child as a replacement gift to indicate his/her fully immunised status.

At the intervention sites (bracelet group), mothers were also voluntarily enrolled as PPM to motivate other women to bring their children for vaccination to promote uptake. The health worker in charge of vaccination provided key mobilisation messages as well as specific PPM cards to the enrolled PPM mother/caregiver. PPM messages emphasised the importance of getting as many as possible children vaccinated. The key messages from the PPM to the peer include: (i) vaccination of a child is a basic right; (ii) vaccination of as many children as possible also protects other children; (iii) I have been with my child to a given health facility for his/her vaccinations; (iv) if you go with your child to this health facility, please take the PPM card with you; (v) if you have further questions, feel free to ask the health worker, who will be willing to address your concerns.

In total, 435 children were studied. Vaccination completeness was higher in the intervention group compared to the control group at all contacts during follow-up. At the end of the study, 231/435 (53%) study children completed their vaccination schedule at 5th contact; 158/256 (62%) were from the intervention group compared to 73/179 (41%) from the control group, a highly significant difference(p=0.0001). Timeliness of vaccination was better in the intervention group compared to the control, which reached statistical significance at 2nd and 3rd vaccination contacts (p<0.05).

With regard to the PPM component, 68% of women volunteered as PPM and recruited 82 additional children for vaccination. The fact that PPM effects were much more pronounced in the rural as compared to the urban intervention areas of the study could be explained by the close and interconnected nature of the rural settings, having largely similar patterns of social behaviour and beliefs.

None of the mothers/caretakers who came back with their child to a study health facility refused vaccinations during follow-up. Bracelet retention rate (proportion of children whose bracelet was still intact after 5th contact) was 99% during the 11 month follow-up period.

In conclusion: "This study has demonstrated the feasibility of a composite intervention (bracelets & PPM) to increase the completeness and timeliness of childhood immunization and provided preliminary evidence for its efficacy amongst Fulani populations in Nigeria. Findings from this pilot study should be confirmed through a larger cluster randomized controlled trial."