The Use of a Speaking Book® to Enhance Vaccine Knowledge among Caregivers in The Gambia: A Study Using Qualitative and Quantitative Methods

"Context-specific and subject-specific Speaking Books are a useful communication and educational tool to increase caregiver vaccine knowledge in low/middle-income countries."

Among the factors that may act as barriers to childhood immunisation in low- and middle-income countries (LMICs) are some caregivers' low literacy levels and low knowledge about vaccine-related issues. The Speaking Book (SB) is an illustrated audio-visual educational tool that has been adapted for use in various settings around the world (see Related Summaries, below). In this case, the researchers developed a SB that contains pre-recorded information about vaccines provided in The Gambia's Expanded Programme on Immunization (EPI). Using qualitative and quantitative methods, they conducted a sequential study assessing the use of this tool among caregivers and healthcare workers (HCWs) in The Gambia.

During an iterative pilot phase, the researchers 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 is an A4-sized hard cover book consisting of 16 pages of colourful, culturally sensitive illustrations with short texts written in English and recorded narrations by two respected local actors 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 of which triggers a soundtrack of the text on the relevant page.

The researchers distributed this tool to 113 caregivers visiting immunisation clinics and evaluated changes in vaccine knowledge over a 3-month period. In short, they saw significant improvement in vaccine-related-knowledge scores, with the median scores nearly doubling at 1-month and nearly tripling at 3-month follow-up visits, compared with the baseline scores. This finding was independent of region of the country (urban or rural), age of caregiver, household income, or highest level of education. The SB was given to the caregivers to take home, thus giving them several opportunities to listen to and understand the information in the book, which might have contributed to the ongoing improvement over the 3-month period. The caregivers suggested that it would be important for mothers to receive a copy of the SB at their first clinic visit, especially while pregnant or when their babies are newly born.

The caregivers found the SB increasingly easy to use, and most of them stated they understood all the information in the book. Almost unanimously, they trusted the messages in the book and approved of the illustrations, which were adapted to the local context. The initial stakeholder consultation in the design phase of the book was therefore very important. The caregivers reported discussing and sharing content of the SB within their family, community, and social groups, using a variety of platforms such as peer group meetings and community and religious gatherings. "This is likely to lead to a significant and possibly measurable multiplier effect."

At the end of the 3 months, the researchers also conducted in-depth interviews (IDIs) with 14 of the 15 HCWs at the immunisation clinics to assess their perception of the acceptability, potential efficacy, and use of the SB as a health promotion tool for HCWs delivering immunisation services in The Gambia. They described general challenges at the clinics, independent of the SB (e.g., caregiver attitudes and organisational factors). In that context, the HCWs reported that the SB had empowered them to answer concerns and questions of caregivers, emphasising the importance of the local language translations that presented vaccine information in a simple, easy-to-understand manner. HCWs reported increase in productivity and improved clinic attendance and considered the SB to be an important health promotion tool. Among their suggestions: Incorporate additional languages to make use of the book with more caregivers of different language backgrounds.

While the study found that SB was able to significantly improve vaccine-related knowledge, a knowledge gap remained. Because two-thirds of the caregivers reported that HCWs were their usual source of information about vaccines (not the media), further training and retraining of the HCWs to deliver additional information to the caregivers is advisable, in the researchers' estimation.

In conclusion: "Vaccine confidence remains high in countries like The Gambia, but in the overall context of increasing vaccine hesitancy worldwide, tools such as the SB or similar approaches tailored to local context might add significant value to engage individuals and communities in communication about the personal and societal value of vaccination. They could be an important countermeasure to vaccine hesitancy..."