Roundtable discussion about the reminder bracelet project

This is Melinda from Acasus and welcome to our new podcast session. Please welcome our guests who came up with a brilliant, innovative, creative solution for improving immunization coverage in Ethiopia using reminder bracelets. Please welcome Kirobel Begashaw, Tsion Tewodros and Guluma Berhanu.

Let’s start at the beginning! You know how they say a journey of a thousand miles begins with one first step.. so tell me, what was your first step, how did this whole amazing journey start? What’s the story behind it?

Kirobel: Great Quote! I guess it happened gradually and then suddenly. As part of our work, we conduct field visits to health facilities and one thing I quickly noticed was that many of the mothers in rural areas were illiterate. In fact data shows that only around 52% of people in Ethiopia are literate.

However, the health system in Ethiopia provides mothers with immunization reminder cards to assist them in knowing when they should come in for their next appointment. This immediately was a red flag to me because here we are working to improve immunization performance but we are not looking at things from the patient/consumer perspective. It led me to believe that this was a big reason why we see high defaulter rates in rural areas.

So after weeks and weeks of thinking about this, I realized on one of our field visits that many mothers in rural areas would wear cultural bracelets. Therein was the spark for the idea. The aha moment! That we could create ‘reminder bracelets’ which resemble the cultural ones and they could be used to assist mothers in knowing when to take their children to the health facility for immunization.

And with all journeys, you need a bit of luck, and it was just our luck that Acasus at the time was funding innovative ideas to pilot, so it was the perfect opportunity! 

So the team and I went about designing and developing the reminder bracelets, and the rest is history!

So simple and elegant. But as it is in case of any journey I can imagine there have been tremendous challenges along the way - let’s talk a little bit about the ones that were particularly memorable for one reason or another.

Tsion: So a funny but interesting challenge we encountered early on in the launch of the pilot happened in Afar. The reminder bracelets were so colorful and appealing that the mothers and even health workers wanted to keep them/not remove the beads after the sessions! This of course caused a dilemma as the reminder bracelets are designed in a way where each bead on the bracelet represents a vaccine and is supposed to be removed after each session.

Sadly, another big challenge we have faced is the ongoing conflict in northern Ethiopia which has led to the damage of more than half of the health facilities in Afar. This meant we had to postpone the launch of the pilot in Afar and evaluate where we could then launch the intervention to instead. 

It is sad how you all had to cope with such terrifying challenges along the way. But all the credit goes to you going forward even despite these events. When did you start seeing the first results? Were you satisfied with them?

Guluma: We first started to see results around October/November last year. It was really encouraging to see both strong quantitative and qualitative findings coming out of the pilot.

Due to the design of the intervention, it generally takes 20 or so weeks to see the impact the reminder bracelet is having on the mothers. This is because many of the child vaccinations happen in this timeframe and we can calculate a key indicator (Penta dropout rate) after obtaining this data.

However, to see the full impact of the reminder bracelets, it takes around 12 months as we wait for the child to complete all routine immunizations, and this then allows us to also calculate the second key indicator which is the Measles dropout rate.

To reach such results you must have a unique, focused, all-in kind of a team approach. Tell me a little bit about how you guys, as a team, went about in order to deliver such amazing goals?

Tsion: Yes, I remember when we first started designing the bracelet and implementing the pilot, everyone on the team at the time was so excited and keen to see how this would pan out. This meant we all wanted to be a part of the approach and see it succeed!

So what this meant initially was that we each focused on a separate part of the work i.e. designing the bracelet, discussing with regional offices, selecting pilot sites, getting feedback from health workers, managing the launch, etc.

Having a collaborative approach here really helped us in launching successfully but also in pivoting when the conflict began in Afar and disrupted our work there.

 It is so amazing to see how brilliant things one can create when feeling inspired to do so. How would you describe the main impact(s) of the project?

Kirobel: To date, I believe there have been a couple of impacts observed both from the data and the rhetorics.

Firstly, we have seen that from the mothers who have been given reminder bracelets, 9 in 10 children have been fully vaccinated. This is quite outstanding! And when we look at the administrative data, for both of our pilot sites, we have also seen a 29 ppt and 60 ppt improvement in the Penta 1-3 defaulter rates. Of course, this is amazing but cannot be fully attributed to the bracelets, as there are other things happening simultaneously such as health extension workers tracking down dropouts.

Secondly, a couple of anecdotes we have received so far from people involved.

• The bracelets together with the immunization cards, have helped us reduce drop-outs and improve immunization coverage and timeliness’ – Sister Marta, Gadamsa Health Center
• The mothers love the bracelets. They say it has provided a simple to use and easy to understand way of tracking and reminder of their child’s due vaccines. It is quite stylish too, adding to its popularity in the community’ – Sister Rahel, Dire Health Center

Hats off to all of you, really. It must feel really rewarding receiving that feedback. Having had this amount of work and dedication behind you, how do you see the current status of the project? What are the main things to focus on right now?

Kirobel: I feel the intervention is going great and now at a critical juncture. We are looking to finalize the results of the pilot at the two initial sites over the next 1-2 months.

Once we do that, we will be looking at how we can expand the pilot to other areas in Ethiopia (so far we have only tested it in Oromia region). We will of course need to obtain funding and backing so that will be a main focus too, however, it has been great to see that Gavi and the Ministry of Health are fond of the project and really behind us seeing this through.

I really feel we are solving a large bottleneck which is impacting immunization performance in Ethiopia and that this intervention will also help in areas which are relaunching health services post conflict.

How do you anticipate 2022 would go in terms of future plans for this project?

Guluma: We are

• Looking to finalize the pilot at the current sites
• Looking to expand to other sites in different regions
• Obtain funding to do so

I always ask everyone on the podcast series about their favourite memory of working with Acasus but this time let me ask you guys about your favourite stories regarding this project?

Kirobel: My favourite memory of the project to date would have to be when we went to the field to record the short documentary on all of this. It was amazing to see an idea come to fruition and just see all the mothers wearing the bracelet holding their babies. And then hearing the impact of it through the interviews we had with the mothers. Very fulfilling!

Tsion:I  guess my favourite memory would be going to deliver the bracelets in our pilot health centers in Afar, it was great to see the response of the staff when they saw the bracelet and how excited they were to implement this tool to minimize dropouts in their catchment area.

Guluma: Conducting a field trip to capture the progress and showing decision-makers about the impact of the study makes the pilot study more interesting and favourite for me. I always gain new insight from the project.

I guess all of those are the kinds of memories that you will take on and remember for the rest of your lives. Thank you so much for sharing these! I was so looking forward to this conversation with you all and I have to say it was worth the wait. I really believe your creativity, enthusiasm and belief in such a great cause will inspire many others to dare to think more freely and innovatively about solutions to long-lasting issues. Thank you all again and I wish you the best of luck for the challenges to come.

Thank you all for tuning in, we will be back with another roundtable soon enough. Follow us on social media to make sure you do not miss any new content.

Until then, take care and be safe. Bye!

Tune in to the original podcast here.