By Lauren Braun (MSc Public Health, Health Economics stream).
Each year around the world 4 million children die before age 5, and 1 out of 5 of those children dies of disease that could have been prevented if they had been vaccinated on time. As part of my undergraduate Global Health program at Cornell University, I spent a summer working at a Ministry of Health clinic in Cusco, Peru. My job was to follow nurses into rural villages to look for moms at their homes and remind them that their children were overdue for routine vaccinations. It was disturbing to me that so many indigenous, low-income moms didn’t remember to bring their children in to the clinic for vaccinations on time, because I saw that vaccines were provided to children at no cost to parents, and parents knew vaccines were important for their children’s health.
The reason moms came late was because they were handed a small paper reminder, which quickly got lost and the date forgotten. That meant that nurses had to leave overcrowded clinics to go door-to-door in remote villages to remind moms, and unused vaccines expired and had to be thrown out. Most importantly, being vaccinated late put children at a higher risk of contracting and dying of these preventable diseases.
After learning more about the problem from nurses and moms, I designed a simple bracelet adapted to their resource-poor environment so that moms could remind themselves of their children’s vaccination dates. This way, I thought, moms could be empowered with knowledge of their children’s health record in a way they could understand, giving them a sense of ownership and a more equitable method of engagement as a partner in keeping children healthy.
After I graduated from college, I received a Grand Challenges Explorations grant from the Bill & Melinda Gates Foundation to test the bracelets’ feasibility in Peru and Ecuador. I quit the corporate job I had at the time and founded Alma Sana Inc., a nonprofit social enterprise whose mission is to ensure that every child, no matter where he or she lives, gets life-saving vaccinations on time. After a very successful initial research study we’re ready to reach more moms and babies – in Nigeria, Pakistan, and Colombia – and measure our impact on vaccine timeliness, coverage, and completion.
Human-centered Design for Low-income Moms
Our bracelets were designed specifically to fit the needs of uneducated moms living on $1.25 or less a day. Designed with indigenous moms and nurses, the bracelet uses only numbers and symbols – no words – to convey a child’s entire vaccination record. Corresponding guides help nurses and moms decode the symbols.
By looking at the bracelet, a mom knows the number and type of vaccines her child has received and the date of the child’s next immunization. Each symbol represents a different vaccine, and each number represents the child’s age in months. Nurses hole punch out symbols on the bracelet to show that a child has been vaccinated. It is designed to be worn by the child from birth to 4 years. Nurses can easily put it on babies with minimal time and effort. The bracelets are highly customizable to local culture and needs and cost about $0.10 each. They are also waterproof, durable, comfortable, and baby-safe.
Beyond reminders, the bracelets can help increase moms’ awareness about the individual vaccinations her child requires and received. The majority of moms, when asked, don’t know the names of the vaccines their children have received and the diseases these vaccines protect against. This information is important to build community champions for vaccinations, which has the potential to increase vaccination timeliness and reduce moms’ concerns about vaccines.
Our Phase I Results
Our Phase I study results from Peru and Ecuador were very positive:
In addition, all nurses said the bracelets should be incorporated into government vaccine protocol, saying they were “practical”, “good for the mothers” and “an easy way of reminding mothers about vaccinations. One nurse in Ecuador said, “Mothers are now arriving to vaccination appointments on time. Before initiating this program, we had problems with the mothers’ punctuality.”
Scaling and Measuring Our Impact
We are currently fundraising for our Phase II study which will be a larger trial in three countries – Nigeria, Pakistan, and Colombia. Nigeria and Pakistan are two of three counties worldwide that have not yet eradicated polio, a debilitating illness contracted in childhood. Vaccine preventable diseases such as pneumonia, diarrhea, measles, pertussis and tetanus are the leading causes of child deaths in these countries. For example, in Nigeria, they account for about 30% of all under-five deaths. Besides death, the associated disabilities exert physical, social and economic burden on children, their families and communities. It has been estimated that more than 600,000 lives can be saved and $17bn in economic losses averted in Nigeria over a 10-year period if the country can achieve 90% coverage with Hib, pertussis, pneumococcal, measles and rotavirus vaccines.
We are proud to have exemplary implementation and evaluation partners, including researchers from the London School of Hygiene & Tropical Medicine and Johns Hopkins University, already lined up for all three countries. The Ministry of Health of each country is also on board as an informed partner and passionate advocate of our work.
We will be doing a randomized controlled trial and impact evaluation so that we can determine the bracelets’ effectiveness at improving vaccine coverage and timeliness compared to current reminders as well as the bracelets’ cost-effectiveness. We will also determine their economic feasibility by conducting a willingness-to-pay survey with potential customers and distributors, including moms, vaccine suppliers, and Ministries of Health.
We will create a new bracelet design for each country. We’ll adapt the colors, symbols, and layout to each local context based on pre-testing with parents so that each country’s bracelet is custom-made to fit parents’ unique needs, preferences, and cultural values. Based on moms’ feedback from Phase I study, we will add more bracelet sizes to fit the child as it grows.
With definitive evidence of the bracelets’ impact after this study, we will be able to set up long-term partnerships with Ministries of Health, NGOs, and others to implement the bracelet intervention on a large scale at the district or national level. Alma Sana is included on UNICEF’s Innovation Map as a “locally adaptable” innovation for child’s health, and last year I was nominated for Forbes’ 30 Under 30 Social Entrepreneurs. Our work has also been recognized by the New York Times and Fast Company, and Alma Sana was a 2014 nominee for the CLASSY Awards, the largest social impact award ceremony in the United States. If you would like to learn more about our human-centered design process and Phase I study, here is my TED talk.
As we prepare for our Phase II trial, I invite you to join us in spreading the word about our work with your global health and medical communities and consider donating to our cause.