Applying Design Thinking to Improve Microplanning Processes for Zero-Dose Children and Missed Communities in Nigeria

Background

In 2022, Nigeria had the second highest number of zero-dose children (ZDC) globally, with 2.3 million unvaccinated children ⁽¹⁾. Conflict, displacement, and structural barriers (e.g., lack of access to routine primary healthcare services for certain populations and a shortage of healthcare workers) contribute to areas with the lowest immunization coverage in the northern regions ⁽¹⁾, especially in Kano State. According to Gavi, the Vaccine Alliance, Kano State has had highest population of ZDC since 2018, with 12% of the country’s ZDC residing in the state ⁽²⁾. Despite various interventions implemented by the National Primary Health Care Development Agency and the National Emergency Routine Immunization Coordination Centre, the number of ZDC in the country remains high. There is evidence that slum settlements are missed in immunization efforts and microplanning.

Research Questions and Objectives

This research evaluated the structural determinants of ZDC through the lens of caregivers, exploring key issues that include the contributions of conflict and ethnicity on being ZD, and the intersections of gender and these structural determinants.

Primary Research Question

Can implementing a design-thinking and health worker capacity-building approach towards microplanning improve the quality of microplanning practices and enhance identifying, reaching, and immunizing ZDC and missed communities in Ungogo and Nasarawa local government areas (LGAs) in Kano State?

Applying Design Thinking to Strengthen Microplanning 

As part of efforts to reduce the prevalence of ZDC in Kano State, a research team from Corona Management Systems analyzed the structural determinants of zero-dose (ZD) cases in urban-slum settlements in Kano State. A design thinking approach was utilized to strengthen the capacity of health workers in the microplanning process for immunization programs (defined in the call-out box). Health worker capacity-building activities were participatory and focused on the accurate mapping and updating of health facility catchment areas to help identify where ZDC reside. Investigators hypothesized this intervention would improve immunization access for ZDC and missed communities. 

Design Thinking and Microplanning 

Design thinking is an iterative process that teams use to understand users, challenge assumptions, redefine problems, and create innovative solutions ⁽³⁾. The approach is non-linear (as shown in the figure) and comprises five phases: Empathize, Define, Ideate, Prototype and Test. Design thinking is particularly useful to tackle problems that are unknown or not well defined.

Microplanning is an intervention that integrates the planning of activities with community engagement, mapping, and other strategies at the local level. It is considered a critical intervention to identify and further understand the needs of ZD and missed communities.

Methodology

Conducted between March 2023- August 2024, this study utilized a quasi-experimental controlled before-and-after study design and employed a mixed-methods approach to investigate the issues and factors contributing to ZD status in urban slums in Kano State, Nigeria. The study was implemented in three phases: pre-intervention (2 months), intervention (12 months), and post-intervention (3 months).

Study Setting

The team purposively selected four LGAs in Kano State, Nigeria with a high burden of ZDC and prevalence of urban-poor settlements. Two LGAs were chosen for the intervention (Ungogo and Nasarawa) and two LGAs were chosen for the control arm (Tarauni and Kumbotso). We adopted a three-stage cluster sampling technique:

1. Selection of 10 wards (clusters)
2. Selection of 8 settlements, 2 per LGA
3. Selection of 40 eligible households for the interviews

The microplanning capacity building approach was co-designed and deployed with the health care workers across all the health facilities within the intervention LGAs, while the control communities continued to receive standard capacity-building and support by National Primary Health Care Development Agency, Kano State Emergency Response Immunization Coordination Centre, and other implementation partners.

Study Population and Sample Size

There were three different cadres of study participants:

• Parents/caregivers of children aged 0–23 months
• Health workers and immunization program managers at state, LGA, and community levels in selected settings
• Community and religious leaders

Using the estimation formula for Multiple Indicator Cluster surveys, the team recruited a total of 1600 parents/child caregivers (400 per LGA) for the quantitative household survey. Respondents for the qualitative data collection included all cadres of study participants, purposively selected based on data collection needs and assessment of participant sociodemographics and community or professional role and/or designation.

Study Phases and Methods

Pre-Intervention Phase

This phase sought to understand the structural, behavioral, and social determinants (including gender) of ZDC and establish a baseline across all study LGAs. Utilizing a mixed-methods approach, the team undertook a quantitative survey, qualitative assessments including key informant interviews (KIIs) and focus group discussions (FGDs), and a focused ethnography.

Quantitative Data Collection and Analysis

Quantitative data were collected electronically from parents/caregivers across all study LGAs by trained data collectors using Open Data Kit (ODK) with a semi-structured questionnaire, based on the World Health Organization’s (WHO’s) behavioral and social drivers (BeSD) framework. Administrative immunization data were obtained from the District Health Information System version 2 (DHIS2) to monitor DPT 1 coverage at baseline and endline.

Data Analysis Using R, SPSS, and Excel

The quantitative data were analyzed using R, SPSS, and Excel. Adjusted odds ratios (AOR) were determined to show the relationship between the predictor variables (sociodemographic; and structural, social, and behavioral drivers) and the primary outcome variable (ZD status of children). Bivariate and multivariate analyses were conducted using the Chi-square test and geostatistical Bayesian logistic regression.

Key informant interviews (KIIs), focus group discussions (FGD), and immersive ethnographic observation were conducted only in the intervention LGAs over 12 weeks.  KIIs were conducted within the local Expanded Programme on Immunization programs.

Ethnographers conducted 12 weeks of immersive observation using semi-structured methods, across each intervention LGA. The observation period was divided as follows: community, 2 weeks; caregivers, 6 weeks (3 weeks each for both LGAs); health facilities, 4 weeks.

Thematic analysis was conducted using Nvivo, generating codes both inductively and deductively.

In preparation for the second phase of work, microplanning capacity gaps among health workers were identified through stakeholder consultations and focused group discussions.

Intervention phase 

Capacity-building for micro-plan development 

Based on the findings from phase one, tailored strategies were co-developed with health workers and immunization program managers to identify and reach ZDC. A microplanning training manual was collaboratively developed with key stakeholders and partners in the Expanded Programme on Immunization. Identified gaps and challenges from the situational analysis and the baseline data were carefully considered during the co-creation process to develop a manual tailored to meet the needs of healthcare workers. A two-day microplanning training program was subsequently conducted for 90 healthcare workers and Ward Focal Persons purposively selected from Nasarawa and Ungogo LGAs. The training included simulation exercises to address challenges in micro-plan development and re-orient participants to its core principles. 

Micro-plan implementation  

In line with the design thinking approach, relevant stakeholders, especially at the community levels, were engaged as part of the design and implementation of the health facility micro-plan. Community representation involved religious, traditional, women, youth and opinion leaders. Additional support was provided for the management of vaccine logistics for outreach sessions. Coordination and funding were also provided to support fixed and outreach vaccination sessions. Further, supportive supervision was provided to ensure efficient data management across health facilities in the two intervention LGAs.  

Post-intervention phase 

This phase evaluated the effectiveness of the intervention over a 12-month period after the training. Data on fixed and outreach sessions were monitored, including on updated micro-plans, antigens given, and the number of children reached through the sessions. Post-capacity-building qualitative assessments were conducted amongst Health Care workers through FGDs and a pre and post-test. The change in ZDC was compared across intervention and control communities.  

In both intervention and control LGAs, qualitative interviews and discussions were held with key informants at various levels. At the state level, we interviewed key immunization stakeholders, including the State Immunization Officer (SIO), the State Cold Chain Officer (SCCO), and representatives from a partner organization, the Clinton Health Access Initiative (CHAI). At the intervention LGA level (Ungogo and Nasarawa), interviews were held with the Local Government Immunization Officer (LIO) and the Officer-in-Charge (OIC). Additionally, we conducted in-depth interviews with community leaders, Traditional Birth Attendants (TBAs), and women leaders. Focus group discussions (FGDs) were also carried out with mothers, fathers, and health workers and quantitative surveys were deployed to Caregivers of children aged 0-23months.  

Results 

Understanding the structural determinants of ZDC 

Sociodemographic characteristics of participants in the household survey  

Around half of children were male in the intervention and control LGAs (51% vs 56%, respectively). A significantly higher proportion of children were within the 12–23-month age group in the intervention vs control LGAs (33% vs 19%, P=<0.001), with a mean age of 10.6 months and standard deviation of 6.6

Estimates of ZDC in intervention and control LGAs 

In intervention LGAs, the proportion of ZDC was reduced by 11% after the intervention versus pre-intervention. The difference in the proportion of ZDC between the control and intervention groups was statistically significant both before (P<0.001) and after the intervention (P=0.008). The reduced proportion of ZD children in the control groups may be attributed to other interventions and activities by the state government and partners. 

Structural determinants of ZDC in Kano State  

Several structural determinants were found to significantly affect the likelihood of being ZD. Place of birth significantly affected vaccination status, with children born in health facilities more likely to be ZD compared with those born in other locations (AOR: 2.306, CI: 1.071, 3.227). This unusual finding aligns with insights from the ethnographic study, where caregivers who gave birth in health facilities expressed considerable concern about adverse effects following immunization, which discouraged them from going for subsequent vaccinations. The ethnographic study also revealed that caregivers believe that the lack of vaccinations has not negatively impacted their children’s health, indicating that they underestimate the preventive benefits of vaccines. 

The ethnicity of caregivers was also significantly associated with ZDC, with children of Hausa or other ethnicities having lower odds of being ZD compared with those from the Fulani ethnic group (AOR: 0.794, CI: 0.3, 0.996). This is likely due to the nomadic lifestyle prevalent among the Fulani, which may disrupt their ability to comply with the immunization schedule.  

In addition, married or cohabiting caregivers had a significantly lower odds of their child being ZD compared with those who are divorced, separated, single, or widowed (AOR: 0.391, CI: 0.103, 0.55). Larger households (more than 5 persons) were also associated with higher odds of children being ZD (AOR: 2.588, CI: 1.131, 3.086). Second-born children (AOR: 4.745, CI: 3.594, 5.55), and third-born/other birth order children (AOR: 3.198, CI: 2.236, 4.87) had a significantly higher odds of being ZD compared with firstborns. Further, female children had higher odds of being ZD compared with male children, though this effect was not statistically significant. Although statistical significance was lacking, qualitative interviews revealed that some caregivers believe vaccination could impair a female child’s ability to give birth in the future.  

Knowledge and access to vaccination 

A high proportion of caregivers (99% and 96% in intervention and control LGAs, respectively, P=0.078) have previously heard about immunization. Most of the information about immunization was provided by healthcare workers in the community (83% vs 53% in intervention and control LGAs, P<0.001). A significantly greater proportion of caregivers knew the purpose of vaccination in the intervention vs control LGAs (96% vs 92%, P=0.010). Most caregivers knew when to get the first dose of vaccines in intervention and control LGAs (83% vs 69%), with no statistically significant difference in knowledge between the two groups.  

Behavioral and social drivers of vaccination

The BeSD component of the household survey provided insights into parents’/caregivers’ thinking and feeling, social processes, motivation and practical issues around vaccination. A summary of the findings is provided in Table 2.  

Table 2. BeSD of vaccination among parents/caregivers 

Design thinking in health facility microplanning

Implementing a design-thinking and capacity-building strategy for microplanning and outcome monitoring increased the knowledge of healthcare workers and their ability to develop primary healthcare micro-plans. The intervention LGAs had a higher proportion of health facilities with health facility micro-plans, which were updated quarterly between Q3 2023 and Q2 2024, compared with the control group (Figure 1).

Figure 1. Facilities with updated primary healthcare micro-plans before and after implementation in intervention and control LGAs

Major themes from the KIIs reflected the improvement in knowledge on the development and implementation of health facility micro-plans, attributed to the design thinking approach to the training. Health workers also indicated that the outreach sessions helped in reaching more children with different antigens.

Recommendations  

• Design thinking can be incorporated into microplanning to substantially improve immunization micro-plans and reduce the number of ZDC and missed communities in urban poor and conflict-affected settlements. 

• Gender and socio-economic status are critical factors to consider in the development of primary healthcare and immunization micro-plans for health facilities. 

• Digitizing the microplanning process through Geographic Information Systems (GIS) mapping tools can be adopted to ensure more precise mapping of settlements. 

References 

1. Gavi. Nigeria Zero-Dose Landscape 2023 [Available from: https://zdlh.gavi.org/country-profiles/nigeria.
2. Gavi Zero-Dose Learning Hub. Nigeria Zero-Dose Situation Analysis 2023 [Available from: https://zdlh.gavi.org/sites/default/files/2023-12/ZDLH_Nigeria_Situation_Analysis_2023.pdf.
3. Interactive Design Foundation. Design Thinking (DT)  [Available from: https://www.interaction-design.org/literature/topics/design-thinking
4. Gavi. Microplanning: Evidence on pro-equity interventions to improve immunization coverage for zero-dose children and missed communities  [Available from: https://zdlh.gavi.org/sites/default/files/2023-09/9._microplanning_evidence_brief.pdf.
5. The Task Force for Global Health. Glossary Term: Microplanning  [Available from: https://campaigneffectiveness.org/glossary/microplanning/.
6. World Health Organization. Behavioural and social drivers of vaccination: tools and practical guidance for achieving high uptake 2022 [Available from: https://www.who.int/publications/i/item/9789240049680.