Strengthening Immunization Programs Through Tailored Approaches

Revolutionizing Vaccine Uptake Through Community-Centric Strategies

Vaccination is a cornerstone of primary healthcare, preventing an estimated 4.4 million deaths annually worldwide. However, the global underutilization of vaccines remains a concerning issue, with 20.5 million children either unvaccinated or undervaccinated in 2022. Particularly alarming is the fact that over 14 million of these children, referred to as “zero-dose,” reside in just 10 countries, including Nigeria, which has one of the highest numbers of zero-dose children in Africa and globally.

The reasons for non- or undervaccination are complex and multifaceted, often rooted in behavioral and social factors. Traditional approaches to increasing childhood vaccination coverage have typically focused on community engagement, sensitization, and mobilization activities, vaccination reminders, integration with other interventions, and vaccination campaigns. While these efforts have shown some success, there is a growing recognition that immunization program managers (PMs) and healthcare workers (HCWs) must develop tailored strategies to address the unique barriers faced by underserved communities.

​Skilled PMs and HCWs are crucial in providing quality primary healthcare services, including influencing vaccine uptake, which is essential for improving immunization coverage. However, in many resource-limited settings like Nigeria, there are significant competency gaps among PMs and HCWs in effectively using data to design and implement tailored immunization programs.

Harnessing the Power of Adult Learning Principles

To address these challenges, a growing body of evidence suggests that incorporating adult learning principles (ALPs) in the design and delivery of training for PMs and HCWs can significantly enhance their capacity to engage with communities and co-create people-centered, culturally appropriate, and data-driven interventions to improve vaccination uptake and equity.

ALPs recognize that adults learn best through participatory, self-directed, problem-based, and experiential approaches, where they can actively engage with the learning process and apply the knowledge gained to real-life situations. By incorporating these principles, training programs can be designed and delivered in a more effective and impactful manner, leading to improved learning outcomes and more successful immunization programs.

Empowering PMs and HCWs with Human-Centered Design Approaches

One promising approach to co-designing tailored vaccine strategies is the human-centered design (HCD) methodology, which involves engaging communities to understand the reasons for low uptake and co-creating viable and culturally appropriate solutions to address the identified challenges. The HCD for Tailoring Immunization Programs (HCD-TIP) framework provides “hands-on” tools and participatory approaches to work with communities in diagnosing barriers, designing targeted interventions, implementing the solutions, and evaluating the impact with continued community engagement.

By training PMs and HCWs on HCD-TIP approaches and equipping them with the necessary skills and tools, they can effectively engage with underserved communities, leverage local data, and co-create people-centered, practical, and low-cost solutions to improve vaccine uptake and coverage.

The Strengthening Capacity for Immunization Data Use Intervention

The Strengthening Capacity for Immunization Data Use (SCID) intervention, implemented in the Federal Capital Territory (FCT) of Nigeria, serves as a case study in leveraging ALPs and HCD-TIP approaches to empower PMs and HCWs in designing and delivering tailored immunization programs.

The SCID intervention had three key objectives:

1. Train PMs and HCWs on HCD-TIP Approaches: The study team, in collaboration with the FCT Primary Health Care Development Board (FCTPHCB), designed and delivered a training program for state and local government area (LGA) PMs and HCWs, incorporating ALPs to enhance their capacity in using data and HCD-TIP approaches to engage with communities and co-create tailored immunization strategies.

2. Provide Templates and Tools for Systematic Data Use: The intervention provided templates and tools to support the systematic use of data for diagnosis, intervention design, implementation, and evaluation, ensuring a structured and data-driven approach to tailoring immunization programs.

3. Introduce the Principle of “Good Enough”: The SCID intervention emphasized the importance of the “good enough” principle, which encourages PMs and HCWs to generate simple, people-centered, culturally appropriate, feasible, and low-cost solutions to address the identified challenges, rather than aiming for complex or resource-intensive interventions.

Enhancing Training Effectiveness Through ALPs

The SCID intervention’s training approach was guided by the participatory, experimental, and reflective ALPs, supported by the teach-back method for effective information delivery and reception. The training content was co-developed with the FCT Training Working Group (FCT-TWG), ensuring it addressed the specific needs and challenges identified through a comprehensive training needs assessment.

The training curriculum integrated technical and operational content on immunization data management, HCD-TIP approaches, and the application of ALPs at each stage of the HCD-TIP process, such as using brainstorming and reflection exercises during the diagnosis phase, group sessions and discussions in the design phase, and simulations and role-play in the implementation phase.

Evaluating the Impact of the SCID Intervention

The SCID intervention was evaluated using a mixed-methods approach guided by the Kirkpatrick training evaluation model, which assessed the participants’ reaction, learning, behavior changes, and results/outcomes.

Participant Reaction: The training was well-received by the participants, with a high level of satisfaction among LGA PMs (100%), state PMs (91%), and HCWs (85%). The majority of participants felt that their training expectations were either “moderately,” “mostly,” or “completely” met, and the training was perceived as highly relevant to their current roles.

Learning and Competence: The training led to a statistically significant improvement in the knowledge and competence of both PMs and HCWs. The pre- and post-training evaluation scores showed a 21% increase in the knowledge and competence of PMs, and a significant increase (P<0.001) in the knowledge and competence of HCWs.

Behavior Changes: Three months post-training, the majority of LGA PMs (75%), HCWs (72%), and state PMs (67%) reported an improved understanding of HCD approaches and applied the HCD-TIP principles in designing tailored immunization programs using data. Participants also cited enhanced collaboration with communities, improved communication skills, and more data-driven approaches in their work practices.

Results and Outcomes: During the 4-week testing period, the communities and health facilities that participated in the HCD sessions recorded significant improvements in the uptake of the pentavalent vaccine’s first dose (54%) and third dose (up to 188%), demonstrating the positive impact of the tailored strategies co-designed with the communities.

Lessons Learned and Recommendations

The SCID intervention’s success in strengthening the capacity of PMs and HCWs to design and implement tailored immunization programs through the application of ALPs and HCD-TIP approaches offers valuable insights for policymakers, program implementers, and researchers:

1. Conduct Training Needs Assessments: Ensure that capacity-building interventions are tailored to the specific needs and challenges of the target audience by conducting comprehensive training needs assessments.

2. Integrate ALPs in Training Delivery: Adopt a participatory, experiential, and reflective approach to training, incorporating ALPs to enhance the effectiveness and impact of capacity-building efforts.

3. Leverage Existing Structures and Platforms: Integrate training interventions into existing government structures and platforms, such as the FCTPHCB, to ensure ownership, sustainability, and continued support for PMs and HCWs.

4. Emphasize Continuous Evaluation and Refinement: Regularly evaluate training programs and incorporate feedback to identify areas for improvement and refine the interventions for maximum impact.

5. Promote Peer Learning and Mentorship: Establish platforms for continuous capacity-building, peer learning, and mentorship to sustain the application of HCD-TIP approaches and data-driven decision-making among PMs and HCWs.

6. Integrate Behavioral Science in Immunization Programs: Incorporate behavioral science principles in immunization data and programs to better understand the behavioral and social drivers of vaccine acceptance and hesitancy, informing the design of more effective and targeted interventions.

By adopting these evidence-based approaches, countries can strengthen the capacity of their immunization workforce, empower communities, and drive equitable vaccine coverage, ultimately improving primary healthcare outcomes and safeguarding the health and well-being of all individuals.