Ad-hoc health facility tools & workarounds

This is the seventh story in a blog series sharing insights from a Human-Centered Design research study of the immunization program in Kenya in early 2020. Please read the previous stories for more context on the work, our approach, as well as other insights from this research. A full report of the initial findings is also available for download.

On a typical summer day, about 70 women waited in front of a peri-urban health facility one hour from Nairobi, Kenya, to get their babies vaccinated. It was hot and crowded. Inside the clinic, a nurse and her small team were getting vaccine carriers, permanent registers, tally sheets, and notebooks ready to start a five hour immunization clinic marathon.

Approximately 12 at a time, moms filed into a small room and handed their Mother and Child booklets to the data recorder, who checked to determine the necessary vaccines. With only a few minutes per client, the clinic staff rushed to get the babies weighed and vaccinated, their data recorded, and mothers educated on important health information, quickly making room for the next group.

Team of healthcare workers in a facility during an immunization clinic.

Our team was observing the session as part of our research for the Vx Data Insights project, a partnership between Sonder Collective and JSI, aimed at understanding the challenges in collecting and using immunization data at all levels of the healthcare system. During this research, we observed healthcare workers responding to the extreme time and staff shortage pressures through innovative, ad-hoc approaches to data collection, a few of which we outline below.

Creating intermediate data collection tools

In a fast paced and often hectic environment, client data was often recorded informally on makeshift tools optimized for speed and convenience, then transferred over to the formal register books in bulk, during a less busy time. These intermediate data collection tools, while adding extra work for the staff, helped to streamline service delivery to the clients and ensure all babies were vaccinated.

In a facility with high maternity numbers, students avoided moving big ledger books from the immunization clinic to the ward by using slips of paper or the palm of their hand to write down the number of vaccine vials removed from the fridge in the neonatal ward before transferring it to the formal records later in the day.

A data recorder at an immunization clinic in Kenya records data in the Mother and Child booklets and the permanent register.

Afterwards, when the immunizations were given in the ward, the number of vaccinations were either recorded in an informal neonatal vaccination notebook or on a slip of paper and transferred to the permanent register or notebook later in the day.

Recording additional data points

Most of the recording tools have been optimized for collecting data needed at the higher levels of the system without necessarily supporting decision-making and management of immunization services at the facility level. Facility staff often found themselves recording additional data points to aid their work.

An informal card used by a student to record vaccinations given in the neonatal ward. This information was then transferred to the official register at the end of the day.

In more than one facility, we saw the use of lined notebooks to trace parents and guardians of children for follow up visits. The book, an informal defaulter register, was used to write down the names of those who came to the clinic and the dates when they were expected to return, why they did not return and when they planned to return.

Similarly, an antigen dilution and expiry book helped another facility track when a diluent was opened so that nurses could closely monitor when diluted vaccines would expire, therefore managing vaccine wastage.

Adjusting the timing of data collection to expedite services

During busy immunization clinics, staff often either pre-recorded or delayed the recording of data as services progressed. In one instance, the data collector, faced with a rapidly growing pile of books, would pre-record the vaccines that the children were about to get in the Mother and Child booklet and communicate them verbally to the nurse and student staff. Similarly, the nurse would often record immunizations on the tally sheets before a vaccination was given, or catch up updating the tally sheet later in the session.

Changing who collects data

In busy, understaffed facilities, students would sometimes take on the role of recording data. This allowed nurses to focus on service delivery while someone else recorded who received which vaccine, either in the neonatal wards or during immunization clinics. In more rural settings, Community Health Volunteers also stepped into this data recording role to decrease the burden on immunization nurses.

Faced with difficult trade-offs between providing quality services for their clients and fulfilling their data collection duties, healthcare workers find workarounds through the creation of informal tools, collection of alternate data points, adjustment of the vaccination workflow, and by redefining individual roles. While not always ideal or appropriate, these ad-hoc tools and workarounds offer us important insights.

Adjustments to the tools and protocols for data collection demonstrate that busy healthcare workers need simpler, more flexible processes that minimize the attention needed to capture data during their interactions with clients. Nurses rely on their observational skills to catch health issues, ensure appropriate treatment, and provide relevant health education. However, complicated and non-intuitive tools require their full attention, which is often not an option, causing many nurses to scribble data on makeshift tools instead and transfer it over later. Simplifying official tools could go a long way towards improving completeness and accuracy of the data.

Currently, tools also don’t support decision-making at the facility level, focusing instead on information needed for decisions made at higher levels of the system. Creating tools that allows nurses to collect more qualitative data in a systematized way could improve data usage for facility-level decisions.

*name changed to protect privacy

This story was co-written by Sarah Hassanen, Natasha Kanagat and Emilia Klimiuk.

From more insights from this study, stay tuned for additional stories in this blog series. You can also download our initial Kenya findings report for more information.

The Vaccine Data Discovery Research study is a joint research effort between Sonder Collective and John Snow Inc. (JSI) to apply the Human-Centered Design approach in order to uncover and prioritize data specific pain points and challenges that healthcare workers and managers at all levels within a country encounter in delivering immunization services in Kenya, the Democratic Republic of the Congo, and Mozambique.
Sonder Collective specializes in the application of Human-Centered Design to social and health challenges, particularly in low resource settings. The Sonder team has intensive experience conducting design research in maternal and newborn child health, sexual and reproductive health and rights, community health, health supply chains and HIV in Sub-Saharan Africa. John Snow Inc. (JSI) is a public health management consulting and research organization that works to improve health outcomes through strengthening health systems in partnership with country Governments. JSI works across immunization, maternal newborn and child health, nutrition, supply chain system design, paper based and digital information systems globally. JSI has led on immunization on USAID flagship projects like the Maternal and Child Survival Program, TSHIP and has been a key partner on MEASURE Evaluation for the past 20 years.



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Vx Data Insights

Vx Data Insights


A Human-Centered Design study in Kenya, DRC, and Mozambique to understand how data is used for decision-making in delivering immunization services.