Participants for this study were recruited from three health facilities across urban (Lusaka Province) and rural settings (Southern Province). Focus group participants were recruited using a set list of inclusion criteria, where participants 1) were mothers younger than 45 years of age, 2) had one or more children, and 3) had experience using the UFC. These criteria were used to capture perspectives from mothers who were currently using or had recent experience using the UFC system. In-depth interviews were conducted with nurses in charge and clinicians at each of the three health facilities, and with the District Health Director or Information Officers at the district level. In Lusaka Province, focus groups were facilitated at Chawama First Level Hospital, and participants were recruited from an ongoing longitudinal study tracking infant ear growth. They were approached during one of their clinic visits, had the study described to them, and underwent a consent discussion. Participant requirements were narrow enough to address bias and broad enough to account for diversity in opinions; all mothers were familiar with the SEARCH system and had been introduced to the biometric tool prior to recruitment. In the Southern Province, focus group discussions were facilitated at the Naluja Rural Health Centre, and participants were recruited from the waiting room where mothers were attending the clinic for antenatal visits. We conducted FGDs with 59 mothers across the three health facilities. Participants were recruited until budgetary and timing constraints didn’t allow for further interview recruitment. Each participant was compensated with 50 Kwacha.

Key informant interviews were conducted in both urban and rural settings. Recruitment targeted clinic staff, including clinicians and head nurses, working at the clinics where the FGDs were conducted, in addition to the Information Officer and District Health Officer from the Kalomo District (Southern Province). Potential clinic staff participants, whom the recruiter and facilitator had a working relationship with, had the purpose of the study described to them and underwent a consent discussion. Each participant was compensated with 50 Kwacha.

Participants received information on the study in their preferred language (Nyanja, Bemba, or Tonga). After confirming that they understood the study, they gave written informed consent to participate and have audio recorded. Interviews lasted between 45 and 60 minutes. Shorthand field notes were taken during and after the interviews; they were later filled out and completed.

The number of mothers in each FGD ranged between 5 and 7, a standard and manageable focus group size, with one facilitator (A.H. or E.M.) guiding the discussion. Facilitators were affiliated with Right to Care Zambia and the University of Zambia and work as a data quality officer and researcher respectively; both are males with master’s in Public Health and trained through Collaborative Institutional Training Initiative (CITI) in good clinical practice, Health Insurance Portability and Accountability Act (HIPAA) research data security, National Institute of Dramatic Art (NIDA) good clinical practice, pharmaceutical and health product management, social epidemiology, implementation, and monitoring and evaluation. Relationships between the researchers and participants were established during the organization of FGDs and the SEARCH project. The FGD guide included a set of preliminary questions to gather information about participants, including their age, number of children, marital status, and familiarity with biometrics. The SEARCH system was then demonstrated in real-time to all participants, followed by a discussion centered around a series of questions about the UFC system, and finally a set of questions relating to how a biometric system for identification coupled with a digitized registry would be received from a personal and community perspective.

Similarly, the key informant interview guide included a first set of questions aimed at gathering information about the interviewee, including job position, length of time working at current post, and previous experience using biometrics. The SEARCH system was demonstrated, followed by a set of questions centered around the current UFC system, and finally a set of questions about how a biometric system might be perceived from the perspective of a provider. All participant materials including information sheets and interview topic guides can be found as extended data ⁵ .

Figure 1 explains our process for data analysis. All recordings from FGDs and KIIs were translated from local languages into English and transcribed into Word documents. Four reviewers (P.L., M.K., J.S.S., L.E.) used NVivo 12 software (QSR International) to conduct an iterative qualitative analysis of these transcripts. This process involved a first read-through of all transcripts, establishing a codebook to define emerging themes as codes and sub-codes, a first round of review, an iteration of the codebook, and a final round of review. Coding techniques and disagreements were resolved through virtual collaboration and in-depth discussions about the data.

Coded data was exported into Excel 15.37, and categorized into three main codes of relative advantage, sociocultural compatibility, and pragmatic compatibility. Within relative advantage, codes were categorized as either relating to the existing UFC system or the proposed biometric system, and further identified as being either positive or negative. Sub-codes for relative advantage included data management, data quality, patient experience, cost, efficiency, availability of records, and privacy. Within sociocultural compatibility, partner acceptance, religion (including fear of Satanism, which is a common concern in Zambia), and fear or political distrust were identified as sub-codes. Within pragmatic compatibility, technological challenges, sustainability, and community uptake were identified as sub-codes.

Perspectives from mothers, healthcare workers, and government officers, are presented below. We defined relative advantage as the gap between negative comments made about the current UFC system and positive comments made about the proposed biometric system, and we defined compatibility as the sum of sociocultural barriers to adoption of the proposed system and pragmatic challenges to implementation.

Data from a separate longitudinal study, where Zambian mothers came for their child’s periodic immunization visits, captured the degradation of the under five card over time (unpublished data). In this study, each mother was given a brand new UFC at their first visit, and the UFC’s physical condition was empirically measured at each visit for a period of 6 months. The data collector recorded characteristics relating to the condition of the UFC. Based on how many characteristics were selected, the card was categorized into one of the following: like new (like new selected), minor damage (1 characteristic), moderate damage (2 characteristics), or extreme damage (3 or more characteristics). Characteristics included cracked, crinkled, stained, faded, ripped or torn, water damaged, folded corners, and ink bleeding. We calculated the proportion of cards falling into each category, grouped by visit during the data collection of the longitudinal study (unpublished data).

In total, ten focus groups were conducted, seven at the Chawama Clinic in Lusaka Province (urban), and three at the Naluja Rural Health Clinic in Southern Province (rural) ⁶ . All participants were from the local community, received care at the clinics where the focus groups were conducted, and had experience with the UFC paper-based system. A majority of participants were married (70%), and had 2–3 children (43%). In total, 36% of participants had heard of or used a biometric prior to being interviewed, and 64% had not ( Table 1).

Key informant interviews were conducted with healthcare workers and government officials. In Lusaka Province, interviews were conducted with the nurse in charge at Chawama Clinic and the nurse in charge and clinic officer at Railways Clinic. In Southern Province, interviews were conducted with a clinic officer and the nurse in charge at Naluja Rural Health Clinic, the Kalomo district health officer, and the Kalomo information officer ( Table 2).

Across 17 transcripts total, including focus groups and key informant interviews, we categorized comments made about the current system and the newly proposed biometric system as either positive or negative. A total of 489 negative and 26 positive comments were made about the UFC system, while 49 negative and 399 positive comments were made about the proposed biometric system. We further categorized all positive and negative comments into 7 themes. Themes identified and coded for were data management, data quality, patient experience, cost, efficiency, availability of health data, and privacy ( Figure 2). We discuss these below.

Data management. Participants emphasized that the UFC is easily damaged or forgotten, often rendering patient health data hard to use, inaccessible, and when lost, irretrievable. While most respondents had no experience using a centralized biometric system, they noted that if patient records were reliably maintained centrally, they could be accessed easily. Data management concerns made up 40% of all negative comments made about the current UFC system (195 comments). In contrast, 43.9% of all positive comments related to the proposed biometric system were categorized as relating to the opportunity for improved data management (175 comments).

Data quality. Participants expressed similar grievances about data quality when the UFC is absent. It was noted that in the case of a missing UFC, it is often up to the caregiver to recall what vaccinations and healthcare the child has received, often rendering patient data incomplete and inaccurate. Data quality concerns accounted for 16.6% of all negative comments made about the UFC system (81 comments).

In contrast, participants noted that it would be difficult to lose or damage a biometric, and that if a centralized biometric system were used for record keeping this would result in more accurate patient data. Healthcare workers noted that given accurate patient data, the quality of the delivery of care would improve. While the majority of comments regarding the proposed system were positive (56 comments, 14% of all positive comments), a few raised concerns about the reliability of accurate identification using the proposed system given ear growth and how that could negatively affect data quality (6 negative comments).

Patient experience. Focus group participants expressed feeling shamed and made to feel foolish by clinic staff when their card was lost or forgotten, often getting scolded by the clinic staff. Due to these negative experiences, participants shared that they have stayed home instead of visiting the clinic, compromising their child’s vaccination and growth schedule. Experience references made up 17% of all negative comments related to the UFC system (83 comments). An alternative perspective was also offered, where it was noted from a very few participants that they had not had difficulties retaining the UFC and therefore were satisfied with the current system (5 positive comments).

Cost. Participants noted a financial burden placed on the patient when a new card needs to be purchased. In some cases, this financial burden was a barrier to receiving care at the clinic ( Figure 2). While mentioned in both rural and urban contexts, there was greater emphasis on financial burden in rural settings. Financial burden of the UFC system accounted for 11.7% (57 comments) of all negative comments made. In contrast, participants commented that the cost of the proposed biometric system, which would not rely on paper identifiers that could be lost or misplaced, would not be placed on the patients, a positive change. Cost made up 12.8% (51 comments) of all positive comments to the biometric system.

Efficiency. Both healthcare workers and mothers made note of longer clinic wait times when cards are misplaced or forgotten, since priority is given to those who have their child’s UFC. Healthcare workers expressed frustration and concerns around efficiency when the UFC is absent. Without a known medical history of the patient, care becomes inefficient given that the provider does not reliably know which vaccinations have already been received. Without the card, the child will often have to be weighed before treatment is given or medications prescribed, delaying care. Many noted that if a biometric system were effective, it would drastically improve coordination of care and would lead to shorter wait times. A cautionary comment was made that if the users of the system are not properly trained, this could lead to longer queues and a further delay in care until the adopters of the system become comfortable. Efficiency references account for 5.1% (25 comments) of all negative comments regarding the UFC system. In contrast, efficiency references made up 16.5% of all positive comments made about the proposed system.

Availability of records. Government clinic stock-outs of the UFC were cited by healthcare workers across both Lusaka and Southern Provinces. For the UFC system, availability references make up 3% of all negative comments (15 comments).

Privacy. Healthcare workers interviewed expressed positivity toward the opportunities for concealing, storing, and securing patient health information with the biometric system. There were a total of 3 comments made on this topic, and all relayed that a digitized patient record system maintained centrally would improve confidentiality and could ultimately build trust in the health system.

Across the FGDs and KIIs, many comments were made about compatibility of the proposed biometric system. We defined general compatibility of the proposed system as the sum of sociocultural compatibility (partner acceptance, satanism, fear or political distrust) and pragmatic compatibility (technological concerns, community uptake).

Sociocultural compatibility. A total of 109 comments related to sociocultural compatibility of the proposed system were made ( Figure 3). Themes identified were partner acceptance (41 comments), satanism and religion (26 comments), and fear or political distrust (21 comments).

Partner acceptance (41 comments)

Participants gave varied feedback relating to partner acceptance of the proposed biometric system. Out of 59 FGD participants, 13 mothers (22%) expressed concern over their partner not understanding or accepting the biometric technology. Reasons included their partner’s aversion to western world technologies, fears of satanism or other malicious intent, and an unwillingness to support change.

The majority of women, however, claimed that their partners would accept the biometric system if they were given adequate information. Participants who believed their partner would accept the proposed system also commented on how the biometric system would save them from asking their husbands for money for a new UFC, providing additional advantages.

Satanism and religion (26 comments)

Satanism and religious objection was identified as a potential barrier to adoption of the novel biometric system. There was a commonly mentioned belief that without proper community sensitization, the public would accuse proponents and developers of the biometric system as using it as a means to spread satanism.

For context, fears exist in Zambia surrounding the ‘mark of the beast 666’ described in the book of Revelations. People are wary of the spread of evil and are concerned over the intention of innovators or outsiders. About 85–90% of Zambians identify as Christian; this is largely a result of missionary efforts beginning in mid-end of the 19th century. Some missionary organizations supported liberation movements and offered Christian-based schooling. Therefore, Christianity has been a key stakeholder in political efforts, education systems, and social issues in the country; Zambia was declared a Christian nation in 1991 and it is embedded in the 1996 constitution ⁷ .

Fear or political distrust (21 comments)

Respondents expressed concerns about implementing a new technology during a time of widespread fear and violence in the country. At the time when interviews were conducted, there had been several instances of murder by way of gassing homes with insecticides; subsequent riots broke out over frustrations with the inaction on behalf of police and the government ⁸ . Strangers entering the community to explain the biometric system would likely face adversity from the community. There were 21 comments made related to apprehension and distrust amongst community members. Respondents commented that fear and distrust could lead people to believe that the technology could destroy their children’s ears, that it could later be revealed that their children’s ears were being sold, and that they could be exposed to new diseases. Reasons for apprehension ranged from distrust in government to distrust in foreigners who developed the system.

Pragmatic compatibility. A number of system-level implementation challenges of the proposed biometric system were identified through key informant interviews conducted with healthcare workers and government officers. These challenges were defined as pragmatic compatibility, and revealed themes of technological, provider uptake, and sustainability concerns ( Figure 4).

Technological challenges (18 comments)

Interviews with healthcare workers and the information officer highlighted potential technological challenges of the proposed biometric system. Most notably, unreliable connectivity and electrical power.

For reliability purposes, health facilities are likely to resort to using the old system if they are unable to connect using the proposed system in real-time.

Similarly noted, poor electrical infrastructure in Zambia poses a significant burden in terms of maximizing successful implementation, especially in rural areas. The issue, however, is not limited to rural areas, urban areas also suffer consistent loss of electrical power. Because the biometric system would require a mobile device to be charged, unreliable access to electricity presents potential barriers to consistent use of the biometric identification tool.

In order for the biometric system to have value, it needs to work reliably and unhindered. Connectivity and electrical power limitations could pose significant barriers to effectiveness of the biometric system and consequently would adversely affect acceptance. To this end, the information officer in Kalomo noted that sustainability of the proposed biometric system is a cornerstone of successful implementation.

Community uptake (132 comments)

Users understanding the technology was referenced as a potential challenge for implementation 132 times across all transcripts. Throughout the KIIs it was noted that if the system is complicated or if the community is not adequately informed about the system, acceptance and use on the part of patients and healthcare workers could be delayed. Many mentioned an initial rejection or apprehension of something new, however many also claimed that given time and understanding healthcare workers would be able to adapt.

Data from a longitudinal study, where Zambian mothers came for their child’s periodic immunization visits, captured the degradation of the under five card over time. A total of 133 mothers were enrolled at their child’s first vaccination visit (6 days). Of the 133 mothers enrolled at the 6 day visit, 109 mothers returned at 6 weeks, 107 mothers at 10 weeks, 113 mothers at 14 weeks, 111 mothers at 4 months, 55 mothers at 5 months and 79 mothers at 6 months. We experienced a loss to follow up in the first few visits, and data collection paused for about a month mid-way through data collection for the 5 month visit due to coronavirus disease 2019 (COVID-19).

Figure 5 shows that by the seventh visit, 6 months after initiation with 79 mothers returning, the condition of the card degraded significantly (32% showing extreme damage, 41% moderate damage, 23% minor damage, and 5% like new).

Zenodo: Relative advantages and compatibility of a biometric patient identification tool in Zambia: a qualitative analysis, Underlying Data. https://doi.org/10.5281/zenodo.4900046 ⁶ .

This project contains the following underling data:

Zenodo: Relative advantages and compatibility of a biometric patient identification tool in Zambia: a qualitative analysis, Extended Data. https://doi.org/10.5281/zenodo.4899990 ⁵ .

This project contains the following extended data:

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).