# Can a visual self-learning tool improve immunisation awareness? Evidence from a quasi-experimental pilot study in Madhya Pradesh, India

## TL;DR

A visual tool called the Routine Immunisation Wheel improved vaccination knowledge among caregivers and health workers in India, showing promise for low-literacy settings.

## Contribution

The study introduces and evaluates a low-cost visual self-learning tool to improve immunisation awareness in resource-limited settings.

## Key findings

- Caregiver knowledge scores improved significantly in the intervention district compared to baseline and control district.
- The tool was fully adopted by health workers for due listing and counseling, showing high utility.
- The tool effectively bridges knowledge gaps in immunisation schedules and benefits.

## Abstract

Immunisation coverage in low- and middle-income countries continues to face challenges due to persistent gaps in vaccination schedule knowledge among caregivers and health workers. The Routine Immunisation Wheel was developed as a low-cost visual tool to complement existing systems like Mother Child Protection (MCP) cards and community healthcare worker visits in Madhya Pradesh, India. This pilot study evaluates the tool’s effectiveness on improving knowledge and awareness among caregivers and frontline workers (FLWs), as well as its potential for scaling within routine immunisation programs.

Using a mixed-methods approach, we conducted a quasi-experimental pilot comparing intervention and control districts with 384 caregivers per arm and more than 60 FLWs (vaccinators/Auxiliary Nurse Midwife (ANMs), mobilizers Accredited Social Health Activists (ASHAs) and Anganwadi Workers (AWWs). Statistical analysis included descriptive statistics for demographics, mean scores with 95% confidence intervals for knowledge domains, independent samples t-tests for group comparisons, chi-square tests for proportions, and thematic analysis of qualitative feedback.

At endline, caregiver knowledge scores in the intervention district were higher than at baseline for immunisation schedule (mean: 53.7% vs. 35.6%, p < 0.05), immunisation benefits (mean: 87.4% vs. 62.5%, p < 0.05), and session site awareness (95.1% vs. 89.8%, p < 0.05). When compared with the control district at endline, the intervention district had, on average, higher scores for immunisation schedule knowledge, immunisation benefits and session site awareness (all p < 0.05). The tool demonstrated high utility among health workers, with 100% adoption by ANMs for due listing and counselling.

The routine immunisation wheel effectively addresses critical knowledge gaps in routine immunisation through its dual functionality as both caregiver reminder and healthcare worker job aid. These results highlight its potential for integration into broader immunisation strategies, especially in low-literacy, resource-limited settings.

The online version contains supplementary material available at 10.1186/s12889-025-25318-z.