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

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.

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