Using Human-Centered Design to understand how data is used in delivering immunization services

In a small town one hour outside of the coastal city of Mombasa in Southern Kenya, Khadijia, a nurse working in the frontlines of the Kenyan immunization program, is managing a packed Maternal and Child Health (MCH) clinic. As mothers file in with their children for immunizations, she is organizing them, giving them basic health education, weighing the babies, checking their records, delivering the appropriate vaccines, and setting appointments for when they need to return.

Healthcare workers struggle to keep up with all of the data they are required to collect. Pictured above, a nurse in a health facility in Kenya, flipping between the various records books she needs to fill out during every immunization.

At times, mothers come without the MCH booklets, leaving her guessing or digging through records books to figure out what vaccines the child needs. Other times, she is pulled away from her work to counsel women on Family Planning or to handle emergencies. “That is a lot for one person to handle,” said Khadijia, recalling a specific day on which a mother came in for a delivery while she was working alone.

Every immunization also requires Khadijia to record data on a tally sheet and two separate records books so large they often compete for space on her small work table. Each form feels complex, requiring her full attention to fill out accurately. On busy days, she is overwhelmed and may take shortcuts on the paperwork to ensure all her clients receive service. Turning a mother away may mean a child never gets vaccinated.

A catalog of formal and informal tools used to record and analyze immunization data at the facility level. This is an excerpt from our initial Kenya findings report. The full report is available for download here.

Back in Mombasa, Mwangi, a key decision-maker at the County level, faces challenges of his own. He relies on the data Khadijia is collecting to fulfill his responsibilities, but has little control over the quality of what he receives. Without reliable information on facility performance and vaccine stock levels, he is often forced to use his intuition and past experiences to divide up the county’s scarce resources and make other decisions about the immunization program.

Our team recently spoke to Khadijia and Mwangi as part of a three country study, a joint effort between Sonder Collective and John Snow Inc. (JSI), to understand challenges around collecting and using data for decision-making in delivering immunization services. We conducted contextual interviews with healthcare workers and managers at all levels of the system in their place of work as well as broader observations of immunization activities at the health facilities.

Many of these challenges with data are well-known, but often poorly understood. Without knowing exactly why problems are happening, not just what they are, designing successful interventions can be difficult.

One of the 14 profiles our team generated across all levels of the system, outlining key challenges, decisions, and interactions for each. Download the full report is available for download here.

Our approach, called Human-Centered Design, is especially effective at uncovering root causes behind such systemic problems and translating them into actionable insights that can inform future products, services, and interventions. By engaging with individuals, taking time to understand their experiences, motivations, and daily struggles, we can examine the system anew from a user-biased perspective.

We came away from the research confirming many existing assumptions about the negative impact poorly designed tools, staff shortages, lack of training, and chronic lack of basic resources have on the collection and usage of data in the immunization program. But we also gained a much deeper understanding of day-to-day realities at the different levels of the system and saw many challenges in a brand new light. You can review our initial Kenya findings by downloading our report.

Over the next few weeks, we will also be sharing some of our reflections and key takeaways through this blog series, specifically around decision-making attitudes and behaviors, COVID-19-related insights, the tensions between formal protocoled planning activities versus reactive problem-solving, and the ad hoc tools and approaches used at the facilities. Stay tuned!

Read the next story in this series:
Re-framing how we think about decision-making: 3 lessons from healthcare workers and managers in Kenya

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.