Acceptability and perceived facilitators and barriers to the usability of biometric registration among infants and children in Manhiça district, Mozambique: A qualitative study

  • PLoS ONE, Volume 16, No. 12 December, Year 2021

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Study Justification:
This study aimed to assess the acceptability and perceived facilitators and barriers to the usability of a biometric registration prototype among infants and children in the Manhiça district of Mozambique. The study was conducted in response to the problem of many infants and children in low- and middle-income countries remaining unregistered in civil registration and healthcare records, which limits their access to essential services, including healthcare. The use of a novel biometric registration prototype using smartphones and tablets was tested as a potential solution to this problem.
Highlights:
– The biometric registration prototype was widely accepted among healthcare providers and caregivers.
– Participants were aware of the benefits of the biometric registration prototype, including its potential to solve the inefficiency of paper-based registration and its perception as a “healthcare norm.”
– Perceived barriers to the implementation of the biometric registration prototype included myths and taboos, lack of information, lack of time, lack of father’s consent, and potential workload among healthcare providers.
– The study emphasized the need to address these perceived barriers and involve children’s fathers and other relevant family members in the biometric registration process.
Recommendations:
– Address the perceived barriers to the implementation of the biometric registration prototype, such as through targeted education and awareness campaigns.
– Involve children’s fathers and other relevant family members in the process of biometric registration to ensure their consent and participation.
– Develop strategies to manage potential workload issues among healthcare providers during the implementation of the biometric registration system.
Key Role Players:
– Healthcare providers: They play a crucial role in implementing and using the biometric registration system. Their involvement is necessary for successful adoption and acceptance.
– Caregivers: They are responsible for registering infants and children and providing consent. Their understanding and acceptance of the biometric registration system are essential.
– Data collectors: They are involved in the implementation of the biometric registration pilot project and provide valuable insights into its usability and effectiveness.
– Research coordinator: Oversees the data collection process and ensures the quality and accuracy of the study.
Cost Items for Planning Recommendations:
– Education and awareness campaigns: Budget for materials, training sessions, and community engagement activities to address the lack of information and myths and taboos surrounding biometric registration.
– Technology infrastructure: Budget for smartphones, tablets, and other necessary devices for capturing and storing biometric data.
– Training and capacity building: Budget for training healthcare providers and data collectors on the use of the biometric registration system and its implementation.
– Monitoring and evaluation: Budget for ongoing monitoring and evaluation of the biometric registration system to assess its effectiveness and address any challenges that arise.
Please note that the provided cost items are examples and not actual costs. The actual budget items may vary depending on the specific context and requirements of the implementation.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong as it presents the findings of a qualitative study that assessed the acceptability and perceived barriers and facilitators to the usability of a biometric registration prototype in Mozambique. The study used a qualitative design consisting of interviews and focus group discussions with healthcare providers, caregivers, and data collectors. The data were thematically analyzed, and the results showed wide acceptability of the biometric registration prototype among healthcare providers and caregivers. The abstract provides a clear overview of the study design, methods, and key findings. However, to improve the evidence, the abstract could include more specific details about the sample size, demographics of the participants, and the specific themes that emerged from the data analysis.

In low-and middle-income countries, many infants and children remain unregistered in both civil registration and healthcare records, limiting their access to essential rights-based services, including healthcare. A novel biometric registration prototype, applying a non-touch platform using smart phones and tablets to capture physical characteristics of infants and children for electronic registration, was tested in rural Mozambique. This study assessed acceptability and perceived barriers and facilitators to the usability of this biometric registration prototype in Manhiça district, southern Mozambique. The study followed a qualitative design consisting of 5 semi-structured interviews with healthcare providers, 7 focus group discussions with caregivers of infants aged between 0 and 5 years old, and 2 focus group discussions with data collectors involved in the implementation of the biometric registration pilot project. Data were thematically analysed. The results of this study show that there is wide acceptability of the biometric registration prototype among healthcare providers and caregivers. Participants were aware of the benefits of the biometric registration prototype. The perceived benefits included that the biometric registration prototype would solve the inefficiency of paper-based registration, and the perception of biometric registration as “healthcare norm”. Perceived potential barriers to the implementation of the biometric registration prototype included: myths and taboos, lack of information, lack of time, lack of father’s consent, and potential workload among healthcare providers. In conclusion, the biometric prototype was widely accepted due to its perceived usefulness. However, there is a need to address the perceived barriers, and involvement of children’s fathers and/or other relevant family members in the process of biometric registration.

This qualitative study is part of a broader cross-sectional observational research in the study biometric data collection in Mozambique infants and children: evaluation of an infant and child biometric prototype to accurately assess unique identity in southern Mozambique. The qualitative research was conducted in the districts of Manhiça and Bilene-Macia, located in the southern region of Mozambique. Manhiça district, 80 km north of the capital Maputo, is located in the northwest of Maputo province, and spans to 2,373 square kilometres. It borders Magude district in the north, Gaza province in the northeast, Marracuene district in the south and Moamba district in the west [25]. Approximately 208,466 inhabitants lived in this district in 2017 [26]. There are 12 health centres and two hospitals, including the district hospital [26]. The Manhiça Health Research Centre (Centro de Investigação em saúde da Manhiça) (CISM), located in Manhiça district, has been running a demographic surveillance system in an area defined as Manhiça health and demographic surveillance site (Manhiça HDSS) since the year 1996 [27]. This research centre carries out among other activities, research on malaria, tuberculosis, diarrhoea, HIV and reproductive and maternal and child health [28], to improve population health through testing disease control interventions [27]. Some outcomes of the research findings produced by CISM have directly impacted the health of Manhiça’s population both at local and national level [27,29]. The majority of Manhiça’s population is rural, mostly engaged in small businesses or subsistence farming, or are labour in sugar cane plantations and sugar refining companies, and other small agriculture companies. The residents speak mainly Xichangana and Xitsonga. Some inhabitants also speak Portuguese, the official language nationwide. The predominant religion is Christian (dominated Zionists and Protestants) [25]. Bilene-Macia district has 2,157 square kilometres, and is located in Gaza province, south-western Mozambique. It borders with Chokwé district in the north, Xai-Xai district in the east, Magude district of Maputo province in the west and Indian Ocean in the south [25,30]. About 150,554 inhabitants lived in Bilene-Macia district in 2017 [26]. The district has 9 health centres [31]. The population of this district is mainly rural, and practice subsistence farming, small businesses, fishing, and some work in small agriculture companies and tourism industry [25,32]. The local inhabitants speak Xichangana, and some of them also speak Portuguese. The predominant religion is Christian related Zionism [25]. The two districts have similar characteristics. Both are rural and patriarchal communities. This means that an individual family’s membership derives from and is recorded through the father’s lineage. Inheritance of property, names, rights or titles passes through male kinship [33]. Concerning their social position in the household, men occupy the dominant position. The man is the head of the family and guardian of the children–while women occupy a subordinate position [34,35]. In Manhiça district, the qualitative study was conducted in both communities and health facilities, where the biometric registration prototype pilot project was implemented. These communities included Manhiça village, Maragra, Taninga, Palmeira, 3 de Fevereiro and Xinavane. The study was also conducted in Bilene-Macia district, particularly in Bilene-Macia village. However, Bilene-Macia district did not implement biometric registration pilot project. This district was included in the qualitative study for comparative analyse. The study participants were healthcare providers working in the health facilities where the biometric prototype was tested, caregivers whose infants and children participated in the pilot biometric prototype system, caregivers whose infants did not participate in the pilot biometric prototype, and all study data collectors. Recruitment and interviews took place between October 2019 and January 2020. The study applied purposive sampling to select both healthcare providers and caregivers; and it utilized semi-structured interviews and focus group discussions (FGDs) to collect data, as shown in Table 1. All data collection tools were semi-structured, with mostly open-ended questions, organized in a logic sequence (from general to specific) allowing some, although limited, participant-driven expansion of the ideas being discussed. Semi-structured interviews were applied to assess acceptability, usability and barriers of the biometric registration among the healthcare providers. A purposive method was used to select the healthcare providers, and the interviews took place in the respective healthcare facilities at selected times when they were available and had a lighter workload, and lasted between 16 and 40 minutes. Focus group discussions were used to collect data with caregivers and data collectors to better assess the acceptability, usability and perceived barriers of the pilot biometric prototype from their perspective. In this study, caretakers were considered mothers or other adult female guardians aged 18 years and more, with infants or children aged between 0 and 5 years old. FGDs with caregivers comprised only women, and the size of each FGD varied between 6 and 10 members. A purposive method was used to access the members of FGDs among caregivers who participated in the pilot biometric prototype, while a convenience method was applied to recruit the members of the FGDs among caregivers who had not participated in the pilot biometric prototype. FGDs with the same data collectors were conducted in two different periods. The first FGD with 8 participants was conducted during the biometric prototype study, and it assessed the feasibility of the platform used to register infants and children; while the second in the end evaluated the overall process of the biometric prototype registration system. FGDs with data collectors were 4 women and 4 men. FGDs during the study lasted between 80 and 120 minutes. The inclusion criteria for the participants were as it is presented in Table 2. Semi-structured interviews and FGD guides were developed to collect data with the study participants. The semi-structured guide for healthcare providers consisted of exploring the risks of the paper-based registration system used to register infants; feasibility, acceptability and usability of the biometric registration, as well as the perceived barriers for the implementation of the biometric system in the health facility. The FGD among caregivers explored the acceptability and the perceived facilitators and barriers about the biometric registration; while the FGD guide among data collectors focused on the evaluation of the biometric device, feasibility, their experiences with caregivers during biometric registration and the perceived barriers regarding biometric registration. The guide of semi-structured interviews a FGDs were designed according to the research objectives focusing the main relevant elements of the piloted biometric prototype. Each guide focused on specific topics, but remained opened to the emergence of new related themes relevant to the study object. The study obtained ethical clearance from CISM’s Internal Scientific Committee, protocol number Ref: CC/034/SEPT/2008 and the Internal Ethical Review Board, protocol number Ref: CIBS-CISM/058/2008. Verbal information about the objective of the study was provided. Written, informed consent was obtained from all participants. Interviews and FGDs were conducted on the language the participants found most comfortable. All healthcare providers were interviewed in Portuguese while all FGDs with caregivers were conducted in local languages. All interviews were audio recorded following the consent of the participants. Three Social Scientists researcher of CISM collected data: two female and one male researchers. The researchers were under a supervision of a female research coordinator. All researchers conducted semi-structured interviews and FGDs. Each FGD was conducted by two researchers: one played a role of moderator and another recorded and took notes of the non-verbal behaviours and dynamic of the discussion. All researchers, including the research coordinator listened and evaluated each semi-structured interview and FGD before the performance of other interviews and FGDs. This process enabled to ensure the quality of issues discussed, identify and address possible gaps during data collection. All audio recorded data were independently transcribed. A total of four researchers: three researchers who collected the data and the research coordinator controlled the quality and accuracy of the transcriptions, comparing the audio recording with the written transcriptions and correcting them when was necessary. All approved transcriptions were shared with all members of the research team, who then read and preliminarily codded the interviews. The research team discussed and decided on the preliminary cods and categories emerging from the data, and NVivo software, a qualitative package for qualitative data analysis, was employed to summarize the data. A content thematic analysis approach [36] was used to define the themes emerging from the data. The identified themes and subthemes were discussed, refined and revised by all members of the research team. The subthemes enabled to identify relevant content in participants’ interviews, which were used to support each theme. The generated final themes were: perceptions of healthcare providers regarding the actual registration system used to register and identify children; acceptability of biometric registration prototype, and perceived facilitators and barriers of usability of the biometric registration prototype. These themes are presented in the results section.

The study mentioned in the description focuses on the acceptability and perceived facilitators and barriers to the usability of a biometric registration prototype for infants and children in Manhiça district, Mozambique. The study found that there is wide acceptability of the biometric registration prototype among healthcare providers and caregivers. The perceived benefits of the prototype included solving the inefficiency of paper-based registration and the perception of biometric registration as a “healthcare norm.” However, there are perceived barriers to the implementation of the prototype, including myths and taboos, lack of information, lack of time, lack of father’s consent, and potential workload among healthcare providers. The study concludes that while the biometric prototype was widely accepted, there is a need to address these perceived barriers and involve children’s fathers and other relevant family members in the process of biometric registration.

The study was conducted in Manhiça and Bilene-Macia districts in southern Mozambique. Manhiça district has a population of approximately 208,466 inhabitants and is located 80 km north of the capital Maputo. It has 12 health centers and two hospitals, including the district hospital. The Manhiça Health Research Centre (CISM) has been running a demographic surveillance system in the area since 1996. Bilene-Macia district, located in Gaza province, has a population of about 150,554 inhabitants and has 9 health centers. Both districts are rural and patriarchal communities, where an individual family’s membership is recorded through the father’s lineage.

The study used qualitative research methods, including semi-structured interviews with healthcare providers and focus group discussions with caregivers of infants aged between 0 and 5 years old, as well as data collectors involved in the implementation of the biometric registration pilot project. The interviews and discussions explored the acceptability, usability, and perceived barriers of the biometric registration prototype.

Ethical clearance was obtained for the study, and written informed consent was obtained from all participants. The interviews and discussions were conducted in the language preferred by the participants and were audio recorded. The data were transcribed, analyzed using thematic analysis, and summarized using NVivo software. The themes that emerged from the analysis included perceptions of healthcare providers regarding the current registration system, acceptability of the biometric registration prototype, and perceived facilitators and barriers to its usability.

Overall, the study provides insights into the acceptability and perceived facilitators and barriers of using a biometric registration prototype for infants and children in Mozambique, highlighting the need to address barriers and involve relevant family members in the registration process.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the described study is the implementation of a biometric registration system for infants and children in low- and middle-income countries.

The study found that a biometric registration prototype, using smartphones and tablets to capture physical characteristics of infants and children for electronic registration, was widely accepted among healthcare providers and caregivers. Participants recognized the benefits of the biometric registration system, including its potential to solve the inefficiency of paper-based registration and its perception as a “healthcare norm.”

However, the study also identified several perceived barriers to the implementation of the biometric registration system, including myths and taboos, lack of information, lack of time, lack of father’s consent, and potential workload among healthcare providers. To address these barriers, it is recommended to:

1. Conduct community awareness campaigns: Educate the community about the benefits and importance of biometric registration for infants and children. Address any myths and taboos associated with the technology to increase acceptance and understanding.

2. Provide comprehensive information: Ensure that caregivers have access to accurate and detailed information about the biometric registration system. This can be done through community health workers, healthcare facilities, and other relevant channels.

3. Involve fathers and relevant family members: Engage fathers and other family members in the process of biometric registration. This can help address the barrier of lack of father’s consent and promote a sense of ownership and responsibility among all family members.

4. Streamline the registration process: Develop efficient and user-friendly registration procedures to minimize the potential workload among healthcare providers. This may include providing adequate training and resources to healthcare staff and optimizing the technology used for registration.

By implementing these recommendations, the biometric registration system can be further developed into an innovation that improves access to maternal health by ensuring accurate and efficient registration of infants and children.
AI Innovations Methodology
The qualitative study described in the provided text focuses on assessing the acceptability and perceived barriers and facilitators to the usability of a biometric registration prototype for infants and children in Manhiça district, Mozambique. The study aims to improve access to essential rights-based services, including healthcare, by addressing the issue of unregistered infants and children in both civil registration and healthcare records.

To improve access to maternal health, here are some potential recommendations based on the findings of the study:

1. Addressing myths and taboos: Develop targeted awareness campaigns and educational programs to address myths and taboos surrounding biometric registration. This can help dispel misconceptions and increase acceptance among caregivers and healthcare providers.

2. Providing information: Improve information dissemination about the benefits and process of biometric registration. This can be done through community outreach programs, health education sessions, and the use of local languages to ensure understanding and awareness among caregivers.

3. Involving fathers and relevant family members: Engage fathers and other relevant family members in the process of biometric registration. This can be achieved through targeted messaging and involvement in decision-making processes, addressing the perceived barrier of lack of father’s consent.

4. Streamlining registration process: Address the potential workload among healthcare providers by streamlining the biometric registration process. This can involve providing adequate training, resources, and support to healthcare providers, as well as optimizing the technology used for registration.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators that reflect improved access to maternal health, such as increased registration rates, reduced maternal mortality rates, improved antenatal care coverage, or increased utilization of maternal health services.

2. Baseline data collection: Collect baseline data on the identified indicators before implementing the recommendations. This can involve conducting surveys, interviews, or reviewing existing data sources to establish a starting point.

3. Implement recommendations: Implement the recommended interventions, such as awareness campaigns, educational programs, involvement of fathers, and streamlining the registration process.

4. Monitoring and evaluation: Continuously monitor and evaluate the impact of the implemented recommendations on the identified indicators. This can involve collecting data at regular intervals, conducting surveys or interviews with caregivers and healthcare providers, and analyzing the data to assess any changes or improvements.

5. Comparative analysis: Compare the post-intervention data with the baseline data to determine the impact of the recommendations on improving access to maternal health. This can involve statistical analysis, trend analysis, or qualitative analysis of the collected data.

6. Adjust and refine: Based on the findings of the impact assessment, make any necessary adjustments or refinements to the recommendations. This can involve scaling up successful interventions, addressing any unforeseen challenges, or identifying areas for further improvement.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health and assess the effectiveness of the interventions implemented.


Identifiers:
DOI: 10.1371/journal.pone.0260631
Research Areas:
Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Mozambique
Study Design:
Cross Sectional Study, Grounded Theory
Study Approach:
Qualitative
Participants Gender:
Male & Female
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