Revitalising Home-based vaccination records in the Africa region

Back to example work

Role: Project lead

#Design research, #Behavioural design, #Strategic design, #Capacity building

Background

Home-based records (HBRs) are vital medical documents issued by health authorities, offering a comprehensive history of an individual's primary healthcare services, including vaccinations. Maintained by caregivers within households, they not only document care provided but also serve as reminders for future healthcare needs such as upcoming immunisation visits.

Since the inception of the Expanded Programme on Immunisation (EPI) in 1974, HBRs have played a pivotal role in enhancing the effectiveness and efficiency of immunisation programs globally. However, retention rates in many countries remain alarmingly low, posing a significant concern, especially in nations with high birth cohorts. Furthermore, the reliance of most governments on complex multi-partner financing for home-based records jeopardizes their sustainable availability.

Objective

The WHO Regional Office for Africa (WHO/AFRO), with funding from the Bill & Melinda Gates Foundation (BMGF) and support from UNICEF, initiated a project aimed at developing redesigned prototypes for Home-Based Records (HBRs). The project also seeked to reconsider the broader systems supporting HBRs in five African countries: Cameroon, Ethiopia, Liberia, Nigeria, and Uganda.

The project aimed to:

• Develop new designs informed by behavioural insights, ultimately enhancing the adoption and retention of HBRs by both caregivers and health workers.
• Assist health administrators in ensuring a consistent supply of HBRs to health facilities.

Methodology

Addressing the complex challenge of Home-Based Record (HBR) prevalence, funding models, adoption, and retention required a strategic approach that considers the broader system perspective. Our first step to tackle this complexity was reviewing existing literature and documents, and conducting interviews with key stakeholders to identify the key actors and relationships we needed to focus on.
In my capacity as the project lead, I guided a team of researchers and designers in applying a human-centred approach. This approach aimed to simultaneously address the needs of HBR's three primary user groups.

• Caregivers: Responsible for safeguarding the HBRs and bringing them to immunisation visits and other healthcare encounters.
• Health workers: Tasked with updating HBRs at each visit with the child, utilising HBRs for counselling sessions with caregivers, and incorporating data from HBRs into reports for health administrators.
• Health administrators: Responsible for ensuring HBRs are available and utilised by caregivers, conducting quality assurance, and supervising their usage by health workers.

Understanding and addressing the needs of these three user groups was crucial to improving the effectiveness and utilisation of Home-Based Records (HBRs). To accomplish this goal, we conducted field research in Liberia using ethnographic methods. This involved visiting and observing vaccination activities in diverse settings including urban, peri-urban, and rural health facilities. Additionally, we conducted in-content interviews with caregivers, health workers and health administrators to gain insights into the entire process of preparing, producing, distributing, and using home-based records.

Through this research, we identified individual, social, and structural barriers to adoption, as well as key motivations and drivers that could be leveraged to improve adoption rates. This holistic approach enabled us to develop strategies aimed at making HBRs more effective and enhancing their utilisation.

Based on the research conducted in Liberia, we formulated a replicable research framework comprising conversation and observation guides. We then provided guidance to Ministry of Health stakeholders from the other four countries, facilitating them to replicate the fieldwork in their respective contexts.

These activities enabled MoH stakeholders to gain a deeper understanding of the needs of different user groups and develop empathy towards them. Moreover, they questioned pre-existing assumptions regarding the challenges related to effective use and adoption of HBRs. The insights gathered from this research were instrumental in informing subsequent design decisions.

Following the research phase, a cross-country workshop was held in Kampala, Uganda. The workshop brought together health administrators from Cameroon, Ethiopia, Liberia, Nigeria, Uganda, and Rwanda, alongside regional and global experts from organisations such as UNICEF, WHO, and JSI. Stakeholders from Rwanda were invited to provide best-practice insights due to the notable HBR ownership and low drop-out rates observed in their country.

In this workshop, Ministry of Health (MoH) stakeholders from the Immunisation and Maternal and Child Health departments of each participating country brought valuable insights gathered from the research conducted in their respective countries. These insights served as crucial inputs to the workshop, facilitating cross-country learning and enabling teams to move beyond conventional assumptions, grounding their decisions on real data.

During the four full days of the workshop, participants worked collaboratively within their country teams. They followed a structured process, progressing step by step from identifying user needs to crafting practical and actionable implementation plans. This intensive workshop format fostered rich discussions, encouraged knowledge sharing, and facilitated the development of tailored strategies to enhance the effectiveness and utilisation of Home-Based Records (HBRs) across the participating countries.

Results

The opportunities identified in the workshop can be grouped in two categories, which complement each other to maximally impact the utilisation of HBRs.

Improvements to the design of the HBR tool:

• Enhancing Perceived Value: Implementing design features to heighten the emotional appeal of the HBR for caregivers, emphasising its importance and benefits.
• Enhancing Usability: Incorporating images to enhance the usability of the HBR, making it more intuitive and user-friendly for caregivers.
• Reducing Burden for Health Workers: Streamlining the process of completing the card for health workers, reducing administrative burdens and improving efficiency.
• Optimal Integration: Striking a balance in design between stand-alone vaccination cards and integrated handbooks.

Improvements in the HBR system:

• Awareness and Advocacy: Conducting awareness campaigns and advocacy efforts to educate stakeholders about the importance and benefits of HBRs, fostering support and buy-in at various levels.
• Building a Business Case: Developing a compelling business case for HBRs, highlighting their potential impact on health outcomes, cost-effectiveness, and long-term sustainability to secure funding and support from stakeholders.
• Obtaining Sustainable Funding: Securing sustainable funding sources to support the production, distribution, and maintenance of HBRs, ensuring their continued availability and effectiveness.
• Designing Effective Supply and Distribution: Developing efficient systems for the supply chain and distribution of HBRs, ensuring timely availability at healthcare facilities and accessibility for caregivers.
• Defining and Negotiating Integration Levels: Establishing clear guidelines and negotiating the optimal level of integration of HBRs within the healthcare system. 

Participants came out of the workshop with three key outcomes: 

• Paper prototypes and digital files of refined HBRs, with improvements based on design principles tailored to the identified user needs. 
• A roadmap to address identified challenges in the HBR system (preparation, production, distribution and use of the HBR)
• An implementation plan for the paper prototype and system solution with immediate, actionable, next steps. 

Following the workshop, country teams took the workshop results forward by engaging with decision-makers and key stakeholders in their countries to support implementation. Regional and local partners collaborated closely with each country team, providing support and guidance throughout this process. This collaborative effort ensured alignment with local priorities, facilitated the implementation of proposed solutions, and promoted ownership and sustainability of the initiatives at the national level.