Stakeholders´ perspectives of a design thinking-informed intervention to reduce zero-dose burden and improve immunisation services in Kano State, Nigeria: a qualitative study

¹Corona Management Systems, Jabi, Abuja, Nigeria, ²Niger Delta University, Wilberforce Island, Bayelsa State, Nigeria, ³State Primary Health Care Management Board, Kano, Kano State, Nigeria, ⁴Ministry of Health, Kano, Kano State, Nigeria, ⁵Federal University, Dutse, Jigawa State, Nigeria, ⁶Senior Manager of Research, Sabin Vaccine Institute, Washington DC, United States

^&Corresponding author
Ebuka Nwafia, Corona Management Systems, Jabi, Abuja, Nigeria

Introduction    

Immunisation remains one of the most cost-effective public health interventions globally, against vaccine-preventable diseases (VPDs) [1]. Despite this, many children remain deprived of immunisation, particularly zero-dose children (ZDC) who have not received a single dose of a diphtheria, tetanus, and pertussis (DTP)-containing vaccine [2]. The continued occurrence of ZDC can be attributed to both supply- and demand-side factors [2-4].

Nigeria bears a significant zero-dose burden with most of the ZDC residing in the northern region, which is characterised by conflict, nomadic populations and a high number of urban slum settlements [5-8]. The country's immunisation programme is driven by the Reaching Every Ward (REW) strategy [9], an adaptation of the Reaching Every District (RED) approach developed by the World Health Organization (WHO), United Nations Children's Fund (UNICEF), and partners that aims to strengthen immunisation service delivery in countries [10]. This strategy has successfully increased infant vaccination coverage in many parts of the country, although coverage remains suboptimal [11].

Inadequate microplanning has been identified as a major deficiency in immunisation programming in many countries, including Nigeria. It is a major supply-side factor that systematically excludes children, especially those living in urban slums, hard-to-reach, and conflict-affected areas [3,12-15]. Quality microplanning requires immunisation staff who can create microplans that prioritise communities with poor access to, or with low utilisation of immunisation services. Community input is also essential in developing an inclusive microplan as community members' experiences and understanding is essential in reaching all eligible households [12,16-19]. However, microplanning is often conducted by health workers without or with marginal involvement of the communities served. This often results in inaccurate mapping of the catchment population and exclusion of new settlements. Defaulter tracing is also difficult in rural communities that lack traceable house addresses. Developing and updating a highly sensitive microplan and conducting optimal routine immunisation (RI) exercises, therefore requires collaboration with community members, using a strategy that puts them at the centre of the planning and implementation activities.

Design thinking (DT) or human-centred design is a problem-solving approach that originated from the industry [20], but is now being increasingly applied in public health interventions, including immunisation programmes, to improve adoption and service delivery [18,21-27]. It involves a consensual identification of problems by the provider and the end users (Diagnose); co-creation of strategies for the uptake and sustained utilisation of services thus created (Design); collaboration in conducting activities to fulfil the design (Implement); and joint monitoring and measuring of the impact of the intervention (Evaluate) [21]. Its emphasis empathy, collaboration, and ideation are suited for addressing health challenges in diverse contexts, which are often encountered in the immunisation landscape. The approach was used as an intervention in this study that aimed to reduce the zero-dose burden and improve vaccine uptake in urban slums in Kano state, Nigeria. This qualitative study assessed stakeholders' perceptions of the DT approach. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines was used to report our findings [28].

Methods     

Study setting: the study was conducted in Kano State, located in the northwest of Nigeria. The population of the state in 2023 was 15,271,374, projected from 2006 census [29]. With 334,000 ZDC in 2023, Kano State has the highest number of ZDC in Nigeria. It also has 15 out of the 100 zero-dose priority Local Government Areas (LGAs) in the country. The 15 priority zero-dose LGAs accounted for 130,515 of the 334,000 ZDC in the state. In close consultation with the state and supported by available data, two of the priority LGAs with many slums were chosen as the intervention LGAs (Ungogo and Nasarawa) and two as control LGAs (Taruani and Kumbotso). Kano State's immunisation programme is coordinated by the Director of the State Emergency Routine Immunisation Coordination Centre (SERICC). The immunisation programme is supported by WHO, UNICEF, and other development partners. Health professionals, traditional and religious leaders strongly influence health decision-making, including vaccination, and are seen as critical stakeholders in health interventions in the area. Poor staffing, inadequate funding, numerous hard-to-reach populations, contentious socio-cultural beliefs and attitudes are some of the major challenges facing the state's immunisation programme [12,13,19,30].

Description of the intervention for microplanning strengthening and service delivery: the controlled before-and-after quasi-experimental study involved four LGAs in the state and was implemented using DT in which multiple stakeholders were involved in the diagnosis, design, implementation, and evaluation of the intervention. The study, underpinned by Gavi's IRMMA (Identify, Reach, Monitor, Measure, Advocate) framework, was conducted in three phases: pre-intervention, intervention, and post-intervention [31]. The intervention sought, inter alia, to identify ZDC and missed communities in the pre-intervention phase; reach them with the package of intervention and monitor vaccination uptake to ensure optimal intervention; and post-intervention, measure vaccination coverage and advocate for adoption and sustained use of positive findings. The intervention package comprises a two-day hands-on training for immunisation staff and significant community stakeholders to enhance their capacity to develop accurate and comprehensive immunisation microplans, on-the-job mentoring of frontline immunisation staff, technical and financial support for quarterly updates of facility microplans, and support for planned outreach sessions. In alignment with the co-creation approach, some stakeholders involved in the intervention design and implementation were invited and participated in the training as facilitators.

Study design: a phenomenological qualitative study was conducted, which involved key informant interviews (KIIs) with immunisation program officers, in-depth interviews (IDIs) with community leaders and focused group discussions (FGDs) with frontline immunisation staff of intervention health facilities to explore respondents' subjective experience with their participation in the training/microplan development and other aspects of the project. The study was carried out post-intervention between July and August 2024.

Study population: the study population comprised immunisation programme officers at the state, the intervention LGAs and the health facilities, and community leaders from the two intervention LGAs of Ungogo and Nasarawa.

Recruitment of study participants: a list of stakeholders from the Ministry of Health, development partner organizations, intervention LGAs, and communities who were involved in the project from the inception meeting to the end of the intervention was compiled. We employed a purposive sampling strategy to select study participants. Further, we selected community leaders who lived in the area and understood the contextual health and social dynamics of the population. Written informed consent was obtained from all participants before the interviews were conducted.

Data collection: data were collected using KII, IDI, and FGD guides. Themes were developed a priori and explored participants' experience and perceived impact of the DT approach. The interviews and FGDs sought their views on the impact of vaccination coverage and on reaching ZDC and missed communities, challenges in implementing microplans, and recommendations for improving vaccination in the communities. Interviews and discussions were conducted at participants' conveniences, without interference from non-participants. Interviews with state and local government technical officers were done in English language, while those with community members were done in Hausa language.

Data analysis: the research team used NVivo software (version 12) for thematic analysis of transcribed data, following a general inductive analytical approach [32]. AO carefully transcribed the audio recordings verbatim from the audio recording into written Hausa and subsequently translated them into English to ensure responses stayed true to their context. During the coding phase, EN, UI, and AO independently engaged in an in-depth review and initial coding of the English transcripts. Each researcher systematically coded data segments, identifying preliminary concepts and emerging patterns independently. The researchers then convened to compare their individual codes, reconcile discrepancies, and consolidated. Subsequently, AO, EN, MA, and UI collectively undertook the identification and refinement of themes and sub-themes. This iterative process involved thorough discussions and consensus-building until a unanimous agreement on the final thematic structure was achieved. Data collection, analysis, and reporting were guided by the recommendations of the COREQ guidelines [28].

Ethical considerations: ethical approval was obtained from the Health Research Ethics Committee of the Kano State Ministry of Health (SHREC/2023/4478). All data collectors engaged were trained on the ethical conduct of research in addition to training on the data collection methodology and approach. Oral informed consent was obtained from all study participants after explaining the study rationale to them, and that their participation was voluntary. Their permission was obtained to record the interviews. The recordings were deleted from the recording devices used as soon as the transcription was completed, in keeping with standard ethical practice.

Results     

Participant characteristics

KII and IDI were conducted with 10 immunisation officers and two community leaders, respectively. Two FGDs were held with healthcare workers. Participants invited for the FGDs were RI focal persons for the intervention facilities. Table 1 and Table 2 summarise the characteristics of the participants interviewed and discussed with, respectively.

Perception of participants about the design thinking approach to the study

The use of DT was viewed as a game-changing strategy for fostering inclusivity and community ownership, and in improving the reach and quality of vaccination campaigns. Some of the participants observed that previous microplanning development and updates were a top-down activity with little or no involvement of the community. “When community leaders are involved, they advise their people, and the people adhere to it because they trust them.” - Community Leader, Nasarawa LGA. “These influencers know the nook and cranny of the community. They help health workers locate families and defaulters.” - Mid-Level Manager, Ungogo LGA.

Impact of design thinking on the training on microplan development and updating

Participants consistently highlighted the transformative impact of microplanning training, emphasising significant improvements in immunisation service delivery. They noted substantial enhancements in their understanding and practical skills, particularly in tracking immunisation defaulters and identifying catchment populations. One participant remarked “our experience was good because we understood the number of our population in various wards, and through microplanning, we could track defaulters effectively” - Health Worker Another respondent echoed these benefits, noting increased competency and confidence among healthcare workers: “this training guided them to conduct the activity effectively and helped achieve targeted settlement goals” - Mid- Level Manager, Nasarawa LGA Stakeholders recognised that prior to the training, microplanning was seen as a mere formality. However, post-training, health workers gained substantial knowledge and gained a better understanding of the importance of accurate microplanning in service delivery. As one stakeholder indicated, “the training helped them (health workers) in gaining understanding on what the microplan means and its importance.. before, it was just for formalities, but now they have good knowledge” (Manager, Nasarawa LGA). Further, respondents emphasised how the training empowered them to evaluate and enhance their work effectively, and improved capabilities in estimating vaccine needs for their target populations: “I learned about quality assessment in our hospitals.. now I can categorise and evaluate our work better” (Manager, Ungogo LGA). “we can now calculate the total number of vaccines needed for our population in a year, month, or week through the microplan” (Healthcare Worker, Ungogo). The training facilitated better identification and prioritisation of underserved or missed communities, involving community actors in microplanning processes, and aiming explicitly for zero-dose settlements. According to a mid-level Man from Ungogo, “the training guided us to target zero-dose settlements, ensuring no child was left out.” Another healthcare worker highlighted increased inclusivity and effectiveness, stating, “before the training, microplanning did not involve everyone… now it is done at the facility level, involving community leaders” (Healthcare Worker, Nasarawa).

Role of community influencers

Respondents emphasised that involving community influencers was pivotal in driving better engagement and trust. They were described as essential in connecting health workers and the communities. Additionally, these influencers' familiarity with the community allowed for better mobilisation and coverage. “The involvement of community leaders and influencers gave a good understanding between them and the health workers.” - Manager, Nasarawa LGA. “When community leaders are involved, they advise their people, and the people adhere to it… because they trust them.” - Community Leader, Nasarawa LGA. “These influencers know the nook and cranny of the community. They help health workers locate families and defaulters.” - Mid- Level Manager, Ungogo LGA.

Enhanced efficiency and effectiveness

Respondents noted that the DT approach increased outreach sessions and coverage by ensuring plans were tailored to the community's context. Additionally, the participatory nature of the approach fostered a sense of ownership within the community and encouraged vaccine uptake. “Health workers no longer work in isolation. Influencers ensure planning aligns with the community's daily routines.” - Healthcare Worker, Nasarawa. “Turnout is much higher now because the influencers mobilise people efficiently and spread the message.” - Routine Immunisation Officer, Nasarawa. “Involving us in planning has made us feel responsible for the health of our people, and they (health workers) work with us wholeheartedly.” - Community Leader.

Perception of the co-creation process

The co-creation process emerged as a critical aspect of the intervention, with respondents highlighting its collaborative and inclusive nature. Respondents perceived that this participatory model enhanced the relevance and acceptance of the microplans and immunisation services. They outlined the structured process used to develop microplans, involving a diverse group of stakeholders. Some of the health workers highlighted that the training improved their understanding of utilising health facility data in microplanning. The comparison of population estimates with existing vaccination records helped health workers identify discrepancies indicative of missed settlements or ZDC. “The process begins with engaging key stakeholders such as ward focal persons, RI service providers, and community leaders to identify gaps and priorities.” - Health Educator, Nasarawa. “Each step is aligned with local needs, starting from community entry meetings to identifying challenges and moving to the data collection phase for informed planning.” - LIO, Nasarawa. “We held several meetings with community members, ensuring their perspectives were included in the final microplans.” - Cold Chain Officer, Ungogo. “We compared population data with vaccination records to identify missed settlements and zero-dose children.” - Healthcare Worker, Ungogo.

Collaboration across stakeholders

Respondents stated the different but complementary roles of stakeholders in vaccination. Traditional leaders were identified to possess an in-depth understanding of local demographics, whereas health workers were reported to contribute to quantifying vaccine needs and planning outreaches. Women's groups provide insights into barriers such as access to healthcare, transportation challenges, and household decision-making dynamics. Religious leaders help dispel myths or misinformation about vaccines, particularly in communities with low vaccine acceptance. “Traditional leaders provide knowledge about settlement demographics, while health workers offered technical expertise on vaccine requirements.” - Routine Immunisation Officer, Nasarawa. “Women's groups and religious leaders were part of the planning process, helping us address cultural barriers.” - Health Educator, Ungogo. “Because the community was involved in every step, we felt a sense of ownership and supported the plan fully.” - Community Leader, Nasarawa. “We were able to identify and vaccinate children in remote areas that were previously excluded due to poor planning.” - Cold Chain Officer, Ungogo.

Impact on vaccination coverage

The implementation of microplans was consistently linked to measurable improvements in vaccination coverage. Respondents reported increases in the number of children reached, particularly in previously underserved communities, attributing these gains to better planning and community engagement. The revised microplans targeted these gaps by prioritising hard-to-reach areas and tailoring outreach strategies. The updated microplans also enhanced session planning. Previously, health workers faced uncertainty about the location and size of target populations, leading to inefficiencies in resource allocation and time management. The revised plans, with input from community members, incorporated detailed data on settlements and population estimates. “Before the training and implementation of updated microplans, the coverage was low. Now, the health centres are often full, and many children are receiving their vaccines on time.” - Community Leader, Nasarawa. “We've seen an increase in the number of children completing their immunisation schedules, especially in areas that were previously hard to reach.” - Cold Chain Officer, Ungogo.

Impact on reaching zero-dose children and missed communities

Respondents emphasised that updated microplanning processes, supported by community-driven strategies, effectively addressed the challenges of reaching ZDC and previously missed communities. Reduction in ZDC was attributed to improved and targeted outreach activities. Outreach efforts included rigorous enumeration, strategic session planning, and community mobilisation led by trusted community influencers. “The microplanning really facilitated addressing zero-dose children because missed communities were identified and integrated.” - Manager, Ungogo LGA. “Through outreaches and accurate enumeration, we've significantly reduced the zero-dose numbers in our LGA.” - Manager, Ungogo LGA.

Challenges encountered with the design thinking approach and mitigation strategies

Participants identified multiple challenges in implementing the DT approach, notably logistical constraints, insufficient funding, cultural resistance, and scheduling conflicts. Insufficient amounts of materials like immunisation cards and vaccines, and sometimes, low participation from all stakeholders in planning sessions, were also reported as challenges. Aligning the schedules of diverse stakeholders was challenging and sometimes caused delays. Transportation difficulties significantly impacted outreach to remote and underserved communities, leading to delays and reduced effectiveness. Inadequate financial support for stakeholder meetings hindered regular participation. Cultural resistance rooted in misinformation and fear of side effects presented ongoing barriers to vaccine acceptance in certain communities. Mitigation strategies adopted included prudent management of the intervention funds and prioritisation of settlements for outreach sessions, reduced stakeholder meetings, and continuous community education to address vaccine hesitancy. Respondents emphasised the importance of better coordination, advanced scheduling, and consistent funding to overcome these barriers and sustain progress effectively. “Some stakeholders had conflicting schedules, which delayed meetings and disrupted timelines.” - Manager, Nasarawa. “The differing priorities of government agencies and community groups made it hard to reach a consensus quickly.”" - Manager, Nasarawa. “Health workers often had to travel long distances without adequate transportation, delaying their outreach activities.”" - Manager, Nasarawa. “The lack of enough materials, such as immunisation cards and vaccines, sometimes disrupted planned sessions.”" - Mid-Level Manager, Ungogo. “In some areas, caregivers resisted vaccines due to cultural beliefs or fear of side effects.”" - Manager, Nasarawa LGA. "Sometimes community leaders or service providers were unavailable for meetings, which slowed the planning process." - Manager, Nasarawa LGA.

Recommendations for improving vaccination and vaccination services

Participants recommended strengthening financial support and resource allocation for immunisation programmes, particularly for outreach sessions and stakeholder meetings. Improved transportation infrastructure and logistical support were identified as crucial for reaching underserved communities effectively. Continuous community education and engagement were highlighted as necessary to counter misinformation, address vaccine hesitancy, and build trust. Additionally, participants emphasised the importance of structured coordination and communication among all stakeholders, to ensure timely and effective implementation of immunisation activities.

Supporting quotes included: “Better financial support and resources would ensure our outreach activities are consistently carried out without delays.” - Mid-Level Manager, Ungogo LGA. “Improved transportation facilities are essential to reach remote communities efficiently.” - Health Worker, Nasarawa. “Continuous engagement and education are critical in overcoming vaccine hesitancy within communities.” - Senior Level Manager, Nasarawa LGA.

Discussion     

The study assessed the perceptions of multiple stakeholders about the utility of DT as an approach to implement an intervention that aimed to improve the development and updating of a comprehensive immunisation microplan and deliver an inclusive immunisation service with zero tolerance for zero-dose. Our findings show a positive impact of DT on study outcomes as respondents stated its overall benefits, and specifically, the values it added to the microplan development training, the involvement of community members, the collaboration and synergy it engendered among stakeholders, and the improvement in vaccine coverage and reduction of zero-dose prevalence in the intervention area.

Stakeholders were unanimous in their acceptance of the approach and rated it highly for fostering collaboration and a sense of belonging among all parties involved in the interventional study. This is comparable with the views of participants in previous studies that used DT [22,23]. Solving problems as a people is culture-friendly and co-created solutions are more likely to be accepted and sustained [12,25]. A well-developed microplan is essential for identifying and reaching all eligible children in a catchment population [2,12]. The dual nature of the training, focused on capacity building and microplan development, allowed the trainees to learn and relearn immunisation microplanning and use the new knowledge and skills immediately to fine-tune the developed annual microplan. We believe this translated into the resulting better resource allocation, improved session management, reduced inefficiencies and reduced zero-dose prevalence observed at the endline survey. The participation of community members in microplan development was perceived by stakeholders as novel and transformative for routine immunisation in the intervention area. Frameworks such as the WHO's Tailoring Immunisation Programs (TIP) [21] and Behavioural and Social Drivers of Vaccine Uptake (BeSD) emphasise the significance of aligning immunisation activities with social norms as a strategy to improve vaccine uptake [33]. This presupposes understanding the culture, tradition and dynamics of the recipient community and is only achievable when the community is adequately represented in the planning and decision-making process. Many immunisation campaigns, fail to involve the community actively, a situation that has caused poor performance and suboptimal programme outcomes [34,35]. The immunisation staff are less familiar with the community compared to locals, who understand the settlement pattern and would have information about when and where new settlers live. This is important for an inclusive catchment population map that will maximise reach and ensure that no living quarters or groups are excluded [12,30].

Furthermore, community and religious leaders have a strong influence on their members, especially in the northern part of Nigeria [14,36]. Their inclusion from the planning stage to conducting immunisation sessions might have contributed towards effective mobilisation of the intervention communities, reduction in cases of vaccine hesitancy and the demonstrable improvements in RI coverage and the reduction of zero-dose cases observed post-intervention. Our experience compares with findings from similar studies where participatory planning and implementation activities involving community influencers increased trust, reduced vaccine hesitancy, and improved coverage [26,37].

Notwithstanding its benefits, DT has some downsides. Its iterative and collaborative nature necessitates frequent meetings of stakeholders to achieve consensus on several aspects of a project, thus placing a demand on people's time and may disrupt participants' routine duties or other activities. Our respondents, with diverse interests and schedules, faced this challenge, which has been reported by other investigators [18,38]. In addition, stakeholders worked or lived at varying distances to the meeting/activity venues and some required transport incentives, which was sufficient. As a result, attendance at meetings was sometimes not optimal. Inability to meet regularly or embark on joint activities as scheduled might have affected the quality of decisions made or some implementation activities. Inadequate finance also affected the strict implementation of the co-designed intervention. Some outreach sessions could not be conducted, and the frequency of planned supportive supervision and on-the-job mentoring rounds was also reduced to fit the budget. This might have affected the delivery of a quality-assured intervention.

Study limitations: this study has some limitations that have implications for the interpretation of the findings. First, stakeholder representation was uneven, with only two community leaders interviewed, limiting insights into community perspectives on the design thinking approach. The selection of key informants and FGD participants was also male-dominated, reflecting prevailing patriarchal structures. This constrained the inclusion of female viewpoints that might have further enriched the findings. Additionally, while FGDs typically comprise homogeneous groups, participant selection in this study was role-based, resulting in mixed-gender groups. Despite this, both male and female participants engaged actively. Finally, as the quantitative findings manuscript is yet to be published, claims regarding the intervention's impact on zero-dose prevalence remain unsupported by peer-reviewed evidence.

Conclusion     

Conclusion This study demonstrates that by placing the end user at the centre of problem-solving, public health practitioners can address systemic barriers in innovative and practical ways. DT can significantly enhance immunisation interventions by creating stakeholder-driven solutions to barriers to vaccine uptake and coverage, improve the quality and content of the training, and facilitate the development of sensitive microplans. The involvement of the community at every stage of the intervention created a sense of ownership and contributed to identifying missed settlements, thus enabling more ZDC to be reached. Though the study suffered some limitations, these do not overshadow the benefits of DT as an effective approach for the intervention. We recommend the integration of DT to the REW strategy used for delivering RI services in the country. Future interventions should consider allocating enough resources to match the co-created intervention. The appointment of more females to leadership positions in immunisation programmes is advocated at the facility, local government and state levels. This can potentially improve the delivery of immunisation services in the state.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Abisoye Oyeyemi formulated the research goals and aim and performed the thematic analysis. Ebuka Nwafia prepared and drafted the initial manuscript and contributed to the thematic analysis. Ganiyat Eshikhena, Uche Ibe, Olamide Akeboi, and Godwin Idim coordinated planning and execution of the study. Mannir Ahmad and Alice Ogenyi were responsible for data collection and curation. Geraldine Mbagwu contributed to the formulation of the research goals and aim. Koko Aadum, Dupsy Akoma, Ifeoma Ezenyi, Auwal Idris, Sa’adatu Ibrahim, Abubakar Labaran Yusuf, Ibrahim Aliyu Umar, and Theresa Sommers critically reviewed and edited the manuscript. Chijioke Kaduru provided overall oversight and leadership for the research activity, including project design, supervision of project delivery, and supervisory authorship of the manuscript. All authors read and approved the manuscript.

Acknowledgments     

We thank the facilitators who supported the training of health workers on immunisation microplanning, the representatives of the development partners who played an advisory role in the study, and the officers of the Kano State Emergency Routine Immunisation Coordination Committee (SERICC). We are also grateful to the local government and facility immunisation staff who participated in the training and were instrumental in the successful execution of the intervention package, and the community members who attended the various meetings/activities and mobilised their communities for the study.

Tables     

Table 1: characteristics of participants at the key informant and in-depth interviews

Table 2: characteristics of participants at the focus group discussions

References