The use of a speaking book® to enhance vaccine knowledge among caregivers in the Gambia: A study using qualitative and quantitative methods

Objectives To measure the usefulness of a Speaking Book (SB) as an educational tool for enhancing knowledge, understanding and recall of key vaccine-related information among caregivers in The Gambia, as well as its acceptability and relevance as a health promotion tool for caregivers and healthcare workers. Design and setting We developed a multimedia educational tool, the vaccine Speaking Book, which contained prerecorded information about vaccines provided in The Gambia’s Expanded Programme on Immunization. Using qualitative and quantitative methods, we then conducted a sequential study assessing the use of this tool among caregivers andhealthcare workers in The Gambia. Participants 200 caregivers attending primary healthcare centres in The Gambia for routine immunisation services for their infants, and 15 healthcare workers employed to provide immunisation services at these clinics. Outcome measures We calculated the median knowledge scores on vaccine-related information obtained at baseline, 1-month and 3-month follow-up visits. Wilcoxon’s matched-pairs signed-rank test was used to compare the difference in the median knowledge scores between baseline and 1-month, and between baseline and 3-month follow-up visits. Results Of the 113 caregivers who participated, 104 (92%) completed all three study visits, 108 (95.6%) completed the baseline and 1-month follow-up visits, and 107 (94.7%) completed the baseline and 3-month follow-up visits. The median knowledge score increased from 6.0 (IQR 5.0-7.0) at baseline to 11.0 (IQR 8.0-14.0) at 1-month visit (p<0.001), and 15.0 (IQR 10.0-20.0) at 3-month visit (p<0.001). Qualitative results showed high acceptability and enthusiasm for the Speaking Book among both caregivers and healthcare workers. The Speaking Book was widely shared in the community and this facilitated communication with healthcare workers at the primary healthcare centres. Conclusions Context-specific and subject-specific Speaking Books are a useful communication and educational tool to increase caregiver vaccine knowledge in low/middle-income countries. We conducted a study which used quantitative and qualitative methods to enrol caregivers and their infants attending immunisation clinics in 15 purposively selected primary healthcare facilities (PHCs) across four regions of The Gambia. The PHCs comprised of seven rural and eight urban centres that had not previously participated in vaccine-related research studies or clinical trials. Based on existing records, the Gambia EPI selected immunisation facilities with poorer performance compared with expected national outcomes to participate in the study. The project was conducted in close collaboration with the communications department of the Gambia EPI. Immunisation services are provided free-of-charge at all government facilities in The Gambia, and caregivers are encouraged to access the services closest to their home. Immunisation-related information should be routinely delivered during immunisation clinic days by public health officers (PHOs). For the purpose of this study, we defined a caregiver as an adult aged 18 years and above attending the immunisation clinic with an infant, and responsible for that infant’s day-to-day care. This included but was not limited to biological parents. The prototype of the richly illustrated, audio-visual educational tool called a Speaking Book was developed by a US-based company (https://speakingbooks.com/), with whom we collaborated. The SB concept can be adapted for specific purposes, and in our case, we adapted the text, recording and illustrations to vaccines routinely delivered by the Gambia EPI programme. During an iterative pilot phase, we developed a bespoke SB version and conducted four separate focus group discussions (FGDs) with the Gambia EPI programme managers, HCWs and caregivers attending EPI clinics to ensure that the final version of the SB reflected the local Gambian context. The final version of the SB was an A4-sized hard cover book consisting of 16 pages of colourful, culturally sensitive illustrations with short texts written in English and recorded narrations in the two most widely spoken local languages, Wolof and Mandinka. Each SB has a plastic panel with removable battery, which hosts a series of push buttons, each corresponding to a specific page in the SB. When activated, the push buttons trigger a soundtrack of the text on the relevant page. The soundtrack was narrated by two respected local actors, with the appropriate voice and tonal quality. The language could be selected via a switch button. Figure 1 shows some photographs of the SB (see online supplemental material 1). Photo of the Speaking Book. bmjopen-2020-040507supp001.pdf Following a wide literature search, we designed a structured questionnaire for the quantitative data collection. To assess the construct and content of the data collection tool, we pretested it with 25 caregivers and 5 HCWs who provided feedback which was used to refine the wording of the questions and response options. The final version of the questionnaire consisted of five sections capturing the following: (1) sociodemographics of the caregiver (19 questions); (2) immunisation history and experiences of the caregiver (five questions); (3) sociodemographics of their child(ren) (10 questions); (4) a series of 8 multiple-choice questions with 39 correct choices assessing vaccines and immunisation knowledge of the caregiver; and (5) a series of 18 open and close-ended questions assessing the experiences of the caregiver on the use of the SB. A sample questionnaire is included in online supplemental materials 2 and 3. bmjopen-2020-040507supp002.pdf bmjopen-2020-040507supp003.pdf A qualitative approach was used to explore the perception of HCWs on the use of the SB as a health promotion tool when sharing vaccine information with caregivers during immunisation clinics. We carried out in-depth interviews (IDIs) with HCWs using 11 general, open-ended and non-leading questions. These included questions which explored the challenges they faced when sharing vaccine information with caregivers, impact of the SB tool on their work, outcomes since the utilisation of the SB and suggestions on the future use of the tool. The interview guide is in the online supplemental material 4. bmjopen-2020-040507supp004.pdf All study participants were sensitised on the study procedures and objectives. Participants were eligible for inclusion if they were caregivers with infants below 6 months of age attending one of the selected PHC centres in The Gambia, had been living at their current address for at least 6 months, were able to communicate in either Wolof or Mandinka, and were able to provide written consent. Purposive sampling strategy was used to select caregivers who met the inclusion criteria for enrolment into the study. During an initial sensitisation visit, the research staff educated the caregivers on the aim of the study and gave the caregivers an information sheet and consent form to take home and return on another date. Each caregiver who returned a completed consent form was then invited to participate in a baseline visit during which the questionnaire was interviewer administered to obtain sociodemographic information and to assess their baseline knowledge about childhood and maternal vaccines. Only one attempt was allowed for response to the questions. To assess the knowledge of caregivers, we computed a knowledge score which was calculated by assigning a score of 1 for each correct answer and 0 for each incorrect answer, with maximum and minimum knowledge scores of 39 and 0, respectively. Only sections 1–4 of the questionnaire were administered during this baseline visit. Subsequently, the mechanics of the SB were explained, and each caregiver was given a copy of the SB for use at home. Each PHC head was also given a copy of the SB to be used during health education activities in the facilities. Caregivers could listen to the SB as many times as they wished during the entire study period and were also encouraged to invite other people to listen along with them. Following receipt of the SB, the participants were requested to return to the PHCs for follow-up visits at 1 month and 3 months after the baseline visit. During each of these follow-up visits, the participants’ understanding, retention, utilisation of key information and experiences using the SB were assessed with the same questionnaire used at baseline. Section 5 of the questionnaire was also administered during this visit. At the end of the 3 months, we conducted IDIs with one representative HCW from each of the participating immunisation clinics. During this interview, we assessed their perception of the acceptability, potential efficacy and use of the SB as a health promotion tool for HCW delivering immunisation services in The Gambia. Qualitative data were audio-recorded and transcribed by the research team. The median knowledge scores were calculated at the baseline, 1-month and 3-month follow-up visits. We compared the difference in the median knowledge scores between baseline and 1 month, and between baseline and 3 months for the entire cohort and by subgroups using the Wilcoxon’s matched-pairs signed-rank test for non-parametric paired data. The subgroups used for analysis included region, age, household income and level of education of caregiver. The distribution of the scores is presented in tables showing median scores and IQRs as appropriate, with significance level set at p<0.05. All quantitative data were entered into Research Data Capture for proper documentation and analyses were performed using Stata V.13 (StataCorp, USA). For the qualitative analysis, we applied inductive thematic analysis in deriving our themes and subthemes as described by Braun and Clarke.18 We used NVivo (V.12) software to organise the qualitative data during the analysis. The public (caregivers and HCWs) were involved in the design of the SB and the questionnaires used for data collection tool.