Demand for Immunization Workbook - HCD4ihcd4i.org/wp-content/uploads/2017/01/demand_for_immunization_full... · Demand for Immunization Workbook A Human-Centered Field Guide for Investigating

BETA

Make low-cost adjustments to immunization

programs to create outsized impact

Re-assess common assumptions about

health workers and caregivers

Conduct swift, low-cost field

research using rapid inquiry processes and techniques

Identify the most important

challenges facing users

Generate and experiment with solutions prior to investing in larger-scale

implementation

Demand for Immunization Workbook A Human-Centered Field Guide for Investigating and Responding to Challenges

1 | DEMAND FOR IMMUNIZATION WORKBOOK | BETA HCD4I.ORG (u: hcd4idev / pw: Unicef4i)

Immunization programs are people-programs. At every step of the way they involve people, from government officials to community health workers. Perhaps nowhere is the involvement of people more important than with users, or the people for whom the programs exist. Understanding the constraints under which users make decisions accounts for many of the successes and failures in expanding coverage with equity. The difference between how a program is designed and how it ultimately works can be quite stark.

This Guide:

Ultimately, this Field Guide aims to make the exercises of investigating, understanding and responding to the challenges facing users easier for you, and more effective for your programs.

01 Addresses the challenges affecting users of routine immunization programs — whether and how people engage with immunization services.

02 Leans on what’s already known to work quite well, pulling on a large body of existing knowledge.

03 Integrates thinking from fields beyond public health to look at these challenges through a new lens based on recent advances in our understanding of human behavior.

This Field Guide exists to help investigate, understand and respond to challenges of demand. It draws on insights from human behavior and employs human-centered methodologies to improve immunization outcomes.

What’s this for?


This workbook is a companion piece to the full Field Guide. For each question, this workbook provides a distilled set of instructions and corresponding tools (look for the tool icon ) meant to be immediately actionable. But before you start, know that this process is going to ask you to do a number of things differently:

How is this different?

Think in Days, Not MonthsWork fast and nimble. This entire process may be completed in a few days or a week. It shouldn’t take months. Trust your intuition (you know what you’re doing!).

Recruit Diverse RolesIdeally, each team member holds a different role so your team has diverse and complementary perspectives. Feel free to recruit members of the community or health care providers!

Work in a Team of 3-5While input from many parties is important, it can lead to a slow process that tries to appease too many people along the way. There are moments — like brainstorming — where you will invite additional participants to join. But start with a core team of 3-5 members that will participate in the entire process.

Leave Your Desk BehindRegardless of formal training, you’re capable of leaving your desk and going into the field to observe and investigate challenges. Go to where the problem is! Interview health care workers! Observe carers!

Experiment and Experiment AgainSince this process occurs in short sprints, it encourages experimental trials that may not always work out. That’s OK! Instead of agonizing over the perfect solution, try many possibilities and observe what works for carers and providers in your community.

Share a StoryFacts are important, but stories make facts memorable (and this helps with brainstorming). Share your stories from the field. Whom did you meet? What did you see? How did you see it in a new way?

Make ItMock-ups, sketches, and role play give users a physical representation to experience and react to. Even a rough approximation of your idea will create clarity for you as the creator, and allow for realistic feedback from users.

Remember Everyone is CreativeThis process plays off everyone’s creativity, not just those who hold “design” positions. Everyone is familiar with the challenges and therefore capable of thinking about causes and designing solutions.

Jump in and Post-ItThis workbook encourages Post-It use, because Post-Its allow you to write down many possibilities instead of forcing you to commit to “the perfect” answer, lend themselves to collaboration (everyone can contribute ideas), and force you to distill your thoughts (one per square).


What’s our ambition?We start with an intended program outcome. This is an immunization outcome (say, an X% decrease in drop-outs), not an attitudinal or behavioral outcome (say, higher awareness of a vaccination).

What do we think we know?Take a moment to examine what we already know. What might we be assuming? What might we suppose we know more about than we really do? What ‘best practices’ could be called into question?

Process Overview

2

Assumptions Examples & Catalogue

Using the Assumption Examples below as a guide, finalize and record the main assumptions below.

Assemble Existing Knowledge

Gather available information about the challenge, past efforts, and the user-group in question.

Examine the Most Important

Mark stand-out pieces of information.

Inspect From Different Angles

Recognize assumptions the team brings and call them into question.

2a: Assembling 2c: Elevating2b: Examining

1

Ambition Formula

Formulate and document the final ambition statement below. Reference throughout the process.

Define the change in immunization outcomes that the team is capable of influencing.

Clearly delineate exactly which community of children we are concerned with and why.

Program Challenge Map

Describe how a group of people are or are not using the services being provided to them.

1a: Prioritizing 1c: Framing1b: Defining


Prompt Formula

Create “How might we?” springboards that will prompt teams to think about solutions.

Insight Formula

Use prioritized information and corresponding diagnoses to extrapolate truths and formulate insights.

Finalize Insights

Make sure each insight is articulated succinctly and helps us make sense of what we’ve gathered in the field.

3c: Proposing

Observe Users

Observe intended users within the environments that shape their day-to-day lives and behaviors.

Developing a Research Plan

Choose which activities, including observations and stories, should be used while allowing for flexibility later.

Collect Stories

Allow users to speak about specific events and experiences.

Recording Field Research

After each day of field research, quickly synthesize and record the information you’ve gathered.

3

3a: Exploring

Diagnostics Worksheet

Ask yourself why this is happening, drawing from research and educated guesses.

Share in Action

Share information from the field to help everyone internalize what you observed.

Debate Hypotheses

Can we prove ourselves wrong? What might we have overlooked? Misinterpreted?

Finalize Diagnoses

Revisit hypotheses to delete, modify, or rewrite as final diagnoses.

Identify in Action

Find patterns, surprises, and commonalities from research and cluster together.

Filter Findings

Choose the most important to consolidate into prioritized pieces of information.

3b: Scrutinizing

What’s standing in our way?What’s preventing users from engaging with what we’re providing? What are they doing now, and what would we like them to be doing? To find out, we conduct user research. The result is a set of insights.

Process Overview (continued)


How could we respond?Given what we know about users, how can we shape their environments and influence their behaviors to support our ambition? This is ultimately a creative process: generating ideas and testing them out.

Designing in Action

Make ideas concrete through physical approximation

Brainstorming Concepts

As a group, quickly generate as many ideas as possible.

Prototyping in Action and Prototype Planning

Define learning goals for each prototype; select prototyping activities, and document your learnings and evaluations.

Prototype Learning and Prototype Evaluation

Iterate as you go—filter feedback and invite user co-creation to gain ever-deeper learnings.

Evaluating Concepts and Idea Examples

Select 2-3 ideas per prompt that show promise.

4a: Concepting 4c: Prototyping4b: Designing

Improve the Idea

If the idea isn’t working, step back into the creative concepting and design exercises laid out in question 4 and re-deploy.

Create a ‘Live’ Adaptation Plan

Define the key evaluative questions and corresponding methods to measure them.

Assess Risks

In the field, record the risks and if possible, adapt ideas to be more risk-resilient.

Adjust the Measurements

Revisit the initial Adaptation Plan to improve what you’re measuring and learning.

Scale the Improved Idea

Continue the implementation process with improvements to both your idea and your Adaptation Plan.

Assess Diagnoses & Unknowns

Evaluate accuracy of diagnoses and identify what we still don’t know much about.

5a: Planning 5c: Improving5b: Assessing

How could we improve?This last phase is about continuous inquiry — iteratively improving ideas over time in response to the challenges presented in user research. Implementation will be an exercise in always-on user research.

4

5

Process Overview (continued)


Field Guide pages 33-49

Program Challenge Map Typically, program challenges can be summarized as issues of Use, Follow-through, and Timeliness. For example, carers may be initially engaging services (Use), but only irregularly coming for scheduled visits (Follow-through). Or they may be coming for their child’s full course (Follow-through), but coming weeks or months late (Timeliness). Or, of course, they may simply not be engaging with services at all (Use). The below Program Challenge Map offers a quick way of narrowing in on what the possible program challenge might be in your own context.

Use: Is the user-group

engaging with immunization services?

Follow-through: Do they complete

the schedule or are they dropping out?

Timeliness:Do they have

difficulties coming on schedule?

Tool #11c

List community characteristics:

Initially using Not using Following through

Dropping out

Irregularly coming

Not on schedule On schedule



Tool #21c

Ambition Formula An Ambition = desire for U (user-group) to change from C (current state) to I (improved state) by addressing P (program challenge). The tool below helps to separate out each element of the ambition formula.

C Current State (1b)

I Improved State (1b)

P Program Challenge (1c)

to change from

to

U User-group (1a)

by addressing

Our Ambition is for

Examples:

Our ambition is for U Roma children

to change from C 60% MMR coverage

to I 75% MMR coverage

by addressing P parents with irregular use of health services

Our ambition is for U children in Liberia’s bottom income quintile

to change from C 35% full immunization coverage

to I 80% full immunization coverage

by addressing P use — those who have never engaged with an immunization service

Our ambition is for U infants in the Paracentral region

to change from C 24% delay in rotavirus vaccine

to I no delays in rotavirus vaccine

by addressing P timeliness — receiving the vaccine on time (before 32 weeks)

Follow- through?

Timeliness?

Use?


Field Guide pages 50-61Tool #32c

Assumptions ExamplesA thorough accounting of the possible assumptions we’re at risk of making will help to avoid missteps down the road. To help in the process, here is a short-list of general assumptions that have certainly been made before. It’s likely that you’ll recognize many as they span contexts and communities. While this is by no means exhaustive, we hope it’s a helpful starting place when thinking about the assumptions that we and our team members might inadvertently bring to the table.

InformationCorrecting misinformation with accurate information will not necessarily change minds; in fact, corrective messaging carries the risk of unintended consequences.In a randomized trial, interventions designed to correct misinformation about autism-MMR ties only served to reinforce existing beliefs. None of the interventions studied — ranging from information explaining the lack of evidence of an autism-MMR tie and information about the disease prevented by MMR, to dramatic images and narratives about the disease — increased parental intent to vaccinate. In fact, some did the opposite.1

1 Nyhan et al (2014), Effective Messages in Vaccine Promotion: A Randomized Trial

MisconceptionsIncorrect knowledge, such as misconceptions about vaccines and diseases, does not always (or often) impair vaccine uptake. Misconceptions may exist, but those misconceptions may not necessarily regulate vaccination decision-making very much. In Mozambique, mothers shared various misconceptions about vaccines with researchers. However, the researchers also found that “taboos and misconceptions [did not] play an important role in the decision not to vaccinate.” Instead, the “overwhelming barrier” was simply distance to services.2 Another group of researchers in India, after successfully using micro-incentives to increase coverage, commented that “while [study participants] might appear to believe in all kinds of things, there is not much conviction behind many of those beliefs: otherwise they would not change their minds so easily.”3 2 Sheldon & Alons (2003), A study to describe barriers to childhood

vaccination in Mozambique

3 Banerjee et al (2010), Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives

ConsiderationGiven the importance of immunization, it’s sometimes taken as a given that carers engage in an active decision-making process: thoughtfully weighing costs and benefits, and either deliberately taking or not taking actions. However, very often, the decision is not given such due consideration.Reflecting on “current theories” surrounding the decision to vaccinate, one group of researchers commented that they “rest upon an assumption of carers who reflect upon the decision to vaccinate or not vaccinate; who calculate the benefits and costs.” However, “[i]t is not clear that carers actually make reflected choices concerning vaccination.”4 Said another way by a researcher reflecting on his field experience:

“It is my impression that in most contexts vaccinations are not thought about very much.”5

4 Holte et al (2012), The decision to vaccinate a child: An economic perspective from southern Malawi

5 Nichter (1995), Vaccinations in the Third World: A consideration of community demand



Assumptions Examples (continued)

IntentionsStrong intentions are not always sufficient (or even necessary) for action-taking. Even the smallest of barriers can work to keep the gap between a positive intention and a corresponding action open.Among subjects in a Hong Kong study that reported being likely, very likely, or certain to get vaccinated against swine influenza, less than 12% actually did. Strengthening intentions futher would have been unlikely to nudge vaccination coverage up. Instead, as the study found, vaccination planning proved a more significant determinant of uptake than intention, such as by “suggesting where, when and how to get vaccination, improving and publicizing accessibility of vaccination centres and opening times.”6

6 Liao (2011), Factors Affecting Intention to Receive and Self-Reported Receipt of 2009 Pandemic (H1N1) Vaccine in Hong Kong: A Longitudinal Study

AccessMaking it easier to access vaccinations, while often important, does not necessarily translate into increased coverage. Similarly, increases in access do not always adequately explain high coverage.In India, a program provided free immunization camps in 60 villages. In each, a social worker educated communities about the program, about the vaccines, and identified eligible children. However, researchers found that “adequate supply of vaccines and education only increased the share of fully immunized children to 17%” (up from 6%).7,8 In Malawi, researchers found that coverage was actually higher in some areas where carers walked long distances, and vice versa, suggesting that “easy access to vaccinations (short travelling and waiting time) cannot explain why the demand for childhood vacciantions in the study area is so high.”9 7 As quoted in Cappelen et al (2010), Demand for Childhood Vaccination:

Insights from Behavioral Economics, referencing Banerjee et al (2010), Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives

8 A concurrent incentive program doubled that coverage figure, by comparison.


ResistanceResistance risks being understood as an irrational rather than a rational reaction. Although people may express resistance in religious or other belief-related terms, entirely rational reasons such as previously experienced or communicated negative events are often at play.A review of polio eradication programming noted that in Nigeria, “memories of a disastrous Meningitis vaccine test which killed several thousands is still current; in India, the association between a government with a history of sterilisation campaigning, and Auxiliary Nurse-Widwives who are used both to deliver Polio vaccine and to ‘advise’ parents in favor of family planning (under a minimum monthly quota), can be traced to the ‘myth’ of OPV and infertility.”10

10 Unicef, Social Mobilisation and Communication for Polio Eradication: Documentation in Nigeria, India and Pakistan (2002-2003)



Assumptions CatalogueFollowing the Assumption Examples Tool as a guide, document existing assumptions about the challenge, past efforts, and the user-group in question. Do we sometimes assume that providing more information to this user-group is usually better? That ensuring they ‘value’ vaccinations is necessary? Take a moment to consider the possible assumptions that you and your team might carry with you. This should be no more than a quick reflection exercise.


Preparing for Step 3: Setup Field Recordings During question 3, each step will yield distinct outputs. These Field Recordings are designed to give you a place to capture them.

Set aside a part of your workspace — space behind your computer screen, an open wall, or the back of a used poster — to track your team’s progress and findings in a shared space. The matrix to the right demonstrates how this might look using tape and Post-Its.

Each row represents a distinct challenge facing the intended users of your routine immunization program. During question 4, we’ll use these Field Recordings to generate solutions to the challenges that they describe.

Field Recordings Icon This icon indicates where you should pause and add your final Post-Its to the designated Field Recording area.

Information:

What’s going on?A piece of information from an observation or a story that relates to user behavior.

Diagnosis:

Why is this going on?Hypothesis of why we’re seeing what we’re seeing or hearing what we’re hearing.

Assumptions:

How could we be wrong?Acknowledgment of any assumptions we might be making or biases we might have.

Prompt:

What does this imply for us?Framing problems as opportunities to prepare for generating solutions.

Insight:

What’s our challenge?Deriving a common truth from the key piece of information and associated diagnosis.

3b3b 3b 3c3c

FR

Field Guide pages 64-71Tool #53


Developing a Research Plan: Observation in ActionCollect information from the field that may be impeding or facilitating immunization outcomes among your user-group(s). Consider observing people in various environments.

MethodologyUse observational research activities (examples below) with a judgment-free lens that yield a record of what’s happening.

Combine with ‘Stories in Action’ to design an integrated research plan from both.

After each day of field research, record synthesized notes in the ‘Observational Notes.’

Tips• Develop a research plan but

allow for spontaneity

• Balance passive observation with experiencing users’ lives directly

• Record as much as possible —even the seemingly mundane

Shadowing Witnessing activities conducted by a user, such as by working alongside a mother for a day, or accompanying her on a clinic visit.

Home VisitsDeveloping deeper relationships with a select user or group of users through an immersive experience, such as a full day at their home.

First-hand experience Experiencing an event as the user yourself, such as by moving through a clinic experience as though you’re a patient.

Artifact Collection Examining information from materials, such as investigating home-based records or clinic education materials.

Non-Participant Observation Removing oneself from direct observation and instead using less intrusive mechanisms to gather material, such as by setting up a camera (like a GoPro) in a clinic waiting room.

Tool #63a Field Guide pages 70-93

Peer-to-peer Observation Involving users directly in observation, such as by equipping health care workers with daily journal forms to document what they observe and find important throughout the day.


Developing a Research Plan: Stories in ActionCollect information based on what we hear in the field that may be impeding or facilitating immunization outcomes among your user-group(s).

Interviews• Informal interviews can be useful to familiarize

oneself with the environment and build rapport with users. These conversations can be conducted without much planning, serving as a prerequisite to more planned lines of inquiry.

• Unstructured interviews are conversational, but usually scheduled and deliberate. These are best used once you have a sense of what you’d like to initially learn more about.

• Semi-structured interviews involve the use of pre-designed guides to ensure you are probing the most important topics, while still allowing each conversation to delve further into the most relevant and interesting areas for the participant.

Photo DocumentationPhoto documentation allows users to self-select what they find important. Equipping a user with a basic camera and loose instructions (say, to take pictures of what makes her think of ‘health’) is a tangible mechanism to gain intimate perspective —and to draw out more stories.

Show and TellUser-guided tours allow users to show their environment and share about their experiences within them: say, a health care worker walking through a clinic. Combining a guided-tour with informal interviews can prompt users to share stories when cued by their context.

Card Sorting Card sorting can complement interviews by providing a hands-on way to engage users in providing perspectives. By using simple pictures or illustrations on index cards, users can sort processes they experience or desire (say, a sequence of events) or rank preferences (say, their priorities for the week).* These activities can serve as a foundation for conversation and elicit deeper narratives from users.For more on card sorting methods, see The Field Guide to Human-Centered Design by Ideo.org

Field Guide pages 70-93Tool #73a

Tips• Record as much as possible —

even the seemingly mundane

• Develop a research plan but allow for spontaneity

MethodologyUse interactive research activities with a judgment-free lens.

Combine with ‘Observation in Action to design an integrated research plan from both.

After each day of field research, record synthesized notes in the ‘Narrative Notes’


HOW

are people doing this?Place Post-It Here

WHAT

are people doing in this situation?

Place Post-It Here

WHY

are they doing it this way?

Place Post-It Here

Describe settingPlace Post-It Here

1

most surprising / important observation

Place Post-It Here

Recording Field Research: Observational NotesThis adaptable tool is used after a day in the field. Record distillations of your findings on Post-Its to answer questions like the suggestions on this worksheet.

Tips

• Review this worksheet before you conduct field research to focus your observations

• Balance the predetermination of what you’ll be looking for in the field with open-endedness

• Synthesize as soon as possible — the longer you wait, the fuzzier your recollections



QUOTES

What did people say?Place Post-It Here

ACTIONS

What did people do?Place Post-It Here

BELIEFS

What did people think?Place Post-It Here

EMOTIONS

What did people feel?Place Post-It Here

Recording Field Research: Narrative NotesThis adaptable tool is used after a day in the field. Record distillations of your findings on Post-Its to answer questions like the suggestions on this worksheet.

Tips

• Review this worksheet before you conduct field research to focus your observations

• Balance the predetermination of what you’ll be looking for in the field with open-endedness

• Synthesize as soon as possible — the longer you wait, the fuzzier your recollections


1

most surprising / important observation

(something to investigate further)

Place Post-It Here

Tool #93a


Methodology

Empathetically transcribe what you’ve seen and heard in the field to your team members.

Using material gathered from the field, choose one or a combination of the below sample activities to share information.

Tips

• Treat each activity playfully—err on the sides of creativity and informality

• Rely as much on ‘sensory’ sharing as possible—default to using visuals, audio, etc

• Combine this exercise with ‘Identify in Action’—they’re meant to go hand-in-hand

Share in Action

Gallery WalkPlace large printed photographs taken in the field around a room. Each picture should communicate something notable you / your team observed.

Presentation Set-up a slideshow to share photographs and quotes from the field. Remember to keep it based on observations and stories, without including your opinions (yet).

Storyboards Draw up simple storyboards to walk your team through a story, a process you observed, etc. Look at the event through a user’s perspective.

Video or Audio Share Did you capture any audio or video in the field? Maybe you set up a camera (example: GoPro) to capture daily movement through an environment. Sharing these assets can help to transport team members to the field.

Field Guide pages 94-119Tool #103b


Independent AnalysisAfter (or during) ‘Share,’ individual team members should note important information — one thought per Post-It — according to the Criteria for Important Information below.

Group Analysis & Generation Share Post-Its from the Independent Analysis in small groups. Use each other’s Post-Its to generate additional notes about what seemed important (refrain from knocking down what others share).

Organize ShareGroup the Post-Its by common theme on a wall— what collectively stood out to the group?

Identify in Action Isolate the most important pieces of information (from

‘Share’) to be unpacked further (during ‘Diagnose’).

Using the criteria below, highlight key observations and stories through both individual and group reflection.

Tips

• Combine this exercise with ‘Share in Action’— consider sharing and identifying important information during the same team work session.

• Mark down one piece of information per Post-It!

Surprise:

Does the information cause you to raise an eyebrow?

Familiar:

Have you seen this before in other contexts?

Patterns:

Are there recurrences you spot across stories and observations?

Criteria for Important Information

Add final key pieces of important information to your Field Recordings.


FR


Diagnostics WorksheetFor each key piece of information isolated by you/your team during “Identify in Action”, create a diagnosis by responding to each of the following:

Field Guide pages 94-119Challenge Examples pages 112-117

Tool #123b

i Create 3+ Hypotheses Ask yourself why this is happening. On Post-Its, write various “whys” that help to explain / make sense of the key piece of information.

ii Debate HypothesesCan we prove ourselves wrong? What might we have overlooked? What might we have neglected to inquire more about? What might we have misinterpreted?

Add lingering assumptions from the debated hypotheses to your Field Recordings.

iii Refine Hypotheses Revisit hypotheses to delete, modify, or rewrite to reflect any new information surfaced during the debate. Articulate a ‘final’ diagnosis for each piece of information.

Add final diagnoses to your Field Recordings in line with the key piece of information they explain.

FR FR



During the diagnostic process, our scope of possible diagnoses will in many ways be limited by ourselves. It’s impossible to spot and evaluate the entire universe of potential reasons for what we see and hear in the field. In large part, we rely on our own existing knowledge that attunes us to what we should look for, and on our own explanatory models that we’ve developed over time. Unfortunately, there’s little way around that.

The best we can do is to incrementally expand our knowledge — to widen our scope of possibilities. The more options we have in the back of our minds about what to look for — the underlying reasons behind the problems we spot — the better.

These examples offer some recurring challenges that constrain and impede the ability of users to successfully make use of immunization services.

They are by no means exhaustive. In fact, we hope that many of the challenges you may be familiar with are not here, and that at least some of the challenges listed here are less frequently discussed. Reviewing these challenges might help to prompt new thinking about why the problems we witness in the field persist.

Challenge Examples

Tool #133b

“Are the people at the health clinic telling me the truth

about vaccinations?”

“I didn’t have time for it this week, but I will next week.”

“Why are these vaccines coming

from that country? Do they work

as well?”

“It seems there’s a lot I don’t know; maybe I

should learn more before making any decisions about vaccinations.”

“They tell me that vaccinations

will help my entire community, but I don’t see others doing it for

our community.”

“I know that the rumor isn’t true, but still, I

have heard about that side-effect before.”

“People like me in the community aren’t getting their

children vaccinated; this service isn’t really for me.”


Omission

Action can be scarier than inaction.People tend to favor harmful omissions over equally or more harmful commissions. In the context of vaccinations, carers can prefer to allow harm rather than do harm — such as allowing a child to get sick, rather than risk getting the child sick through side-effects — even if allowing harm is much riskier and more likely to occur.

In a hypothetical scenario provided by researchers, subjects preferred not to vaccinate a child when risk of death from disease was 10 in 10,000, but risk of death from the vaccine was 5 in 10,000 or less. The discrepancy is explained by the fact that even in the riskier scenario, parents are concerned that they might be directly responsible for harm (commission) more so than letting harm happen (omission).50

50 Ritov & Baron (1992), Status-quo and omission biases

Social Norms

Perceived group rules regulate behavior.People tend to behave in ways that conform to how they perceive others are or would be behaving in certain situations. Vaccination-related behavior can be affected by the degree to whether such behavior is or is not seen as a ‘norm,’ or a behavioral expectation in a community.

As one study illustrated, “[p]eople have their children vaccinated because everybody does so and it seems the normal thing to do. There are not necessarily deep reflections behind mothers taking their infants to the child health clinic. They do so because everyone else does, and because it is what good mothers seem to do.”53

53 Streefland et al (1999), Patterns of vaccination acceptance

Hidden Costs

Free isn’t always free.In addition to non-financial costs (such as travel time), small financial costs can also become large impediments, especially among the poor. Even when vaccinations are ‘free’, users can face fees for ancillary elements of immunization services — such as health cards — or encounter illicit fees.

In Malawi, researchers observed that although “there are no direct user fees, carers usually pay a small amount for a health card that is needed for the recording of vaccinations and other health status information.”51 In Nigeria, carers were required to show that they’ve paid into an annual development levy fund prior to receiving vaccines. Despite the ‘low’ cost (three US dollars), “[m]ost of the poor cannot afford to do this and so desert public facilities, especially children’s education and health services.”52


52 Oluwadare (2009), The Social Determinants of Immunization in Ekiti State of Nigeria

“It would be worse if the child died from the vaccine—because that is my fault—than

if she died from the disease.”

“I had to pay a fee before receiving my child’s health card

after she received the vaccinations.”

“I doubt that other mothers I know

get their children vaccinated this much.”

Challenge Examples (continued)

Tool #133b


Tool #133b

Inertia

Ambiguity and uncertainty foster inaction.The perception of missing information, conflicting information, or unknown probabilities can incline people toward inaction. When it is unclear whether the decision to vaccinate is evidently good or not, carers are more likely to opt for inaction — or non-vaccination — as the safer choice.

It’s easier to avoid taking an action like getting vaccinated than to search for accurate (or convincing-enough) information. As studies suggest, non-vaccinators in many cases are not ‘refusing’ as much as they are ‘fence-sitting’—what one group of researchers referred to as ‘a state of indecision’. This can be caused, for example, “when doctors present different information than friends…”54

54 Betsch et al (2015), Using Behavioral Insights to Increase Vaccination Policy Effectiveness

Service Experiences

The bad outweighs the good.Negative experiences tend to outweigh neutral or negative ones, proving ‘stickier’ in people’s memory of an event. This bias towards negativity suggests that ‘minor’ negative incidences during an immunization-related experience can overshadow the positives.

In Ethiopia, small negativities as perceived by carers risked dominating their memories of vaccination-related experiences. Researchers observed that “outreach vaccination teams tend to arrive late, but leave on time, speeding up vaccination practices to the extent that needles are used immediately after sterilization, when they are still hot.”56 While it may not be surprising that “[a]ttitudes and behavior of health staff… are frequently cited as discouraging children’s vaccination”57 in many contexts, the disproportionate power of negative incidences adds a challenging element to service experiences.56 Streefland et al (1999), Patterns of vaccination acceptance

57 Favin et al (2012), Why children are not vaccinated: a review of the grey literature

Attention Scarcity

The ‘now’ matters most.People tend to devote most attention to present tasks while neglecting tasks with consequences farther into the future, as with immunization. This bias towards the present is further aggrevated by poverty, which requires the poor to address pressing present concerns at the cost of dedicating mental resources towards the long-term. This can lead people to ‘defer’ health-seeking behavior, passing off actions and their associated costs (such as mental energy) to their future selves.

One study involving low-income parents in Baltimore found that for those “with limited time or resources... the importance of decision making about vaccines may be far less pressing than other issues in the family’s life... Among parents’ concerns, which included drugs, street violence, and negative peer pressure, immunization did not emerge as a high-priority issue.”55

55 Sturm et al (2005), Parental Beliefs and Decision Making About Child and Adolescent Immunization: From Polio to Sexually Transmitted Infections“I’m being told

different things by different people, so it’s better that I

just avoid this.”

“I didn’t have time for it this week, but I will next week.”

“I needed to focus on this week’s

harvest; I can think about vaccines later.”

“I was rushed, my child cried a lot, and I didn’t have any

time to ask questions. That’s what I

remember most.”



Tool #133b

Practical Knowledge

More effort means less action.Despite having a positive intention to access immunization, the effort to figure out how can de-incentivize action-taking. Needing to seek out practical information, such when and where to access immunization services, presents a cost (in time, in mental energy) and can therefore impede health-seeking behavior.

In studying barriers to childhood immunization in Mozambique, researchers found that two thirds of mothers at various ‘mobile brigades’ didn’t know when to return for the next vaccination. As the study concluded, this piece of missing information was in part to blame for suboptimal coverage — as opposed to knowledge about diseases or the perceived importance of vaccinations.58 Another study on flu vaccination in the U.S. found that even though logistical information such as the location of a clinic was technically available to participants, vaccination rates decreased when it wasn’t made immediately and easily available.59

58 Sheldon et al (2003), A study to describe barriers to childhood vaccination in Mozambique

59 Ross et al (2013), Using Behavioral Economics for Postsecondary Success

Optimism

It won’t happen to me.People tend to overestimate the likelihood of positive events occurring and to underestimate the likelihood of negative events occurring. This bias towards optimism can manifest itself in discounting the likelihood of contracting a disease or in overestimating the likelihood of surviving it, decreasing people’s motivation to seek out immunization services.

In studying parents who forewent a pertussis vaccine for their children, researchers found that many “believe that statistical analyses of pertussis and vaccine risks are accurate.” At the same time, they “believe that they do not pertain to their children.” This is in part due to a belief that “they have control over whether their child gets the disease or how it progresses”— an optimistic perspective on events that are largely out of their control.60 60 Meszaros et al (1992), Cognitive influences on parents’ decisions to

forego pertussis vaccination for their children

“I planned to take my child for

her vaccinations, but I didn’t know if the clinic was open.”

“Other people might get sick from that disease, but it won’t happen to my kid. And if it does, I can take care of it.”

Availability

The easier to recall, the more influential.People tend to rely on immediate examples that come to mind when calculating a probability to evaluate a decision. A bias towards ‘easily available’ information — such as a recent story — can skew the probabilities people make when evaluating the likelihood of possible adverse events.

Consider a story spreading through a community about an unlikely event, such as adverse effects from a vaccination. As one group of researchers concluded in regards to such a scenario, “negative side-effects of vaccination, because they are rare, may get more attention than positive effects of vaccination, both in the news and in the community more generally, and this may contribute to overestimation of the likelihood of such events.” The result is that “[t]he choice between vaccinating and not vaccinating can therefore be seen as a choice between two gambles,”61 rather than as a choice between a low-risk and high-risk decision.61 Cappelen et al (2010),

Demand for Childhood Vaccination: Insights from Behavioral Economics

“I recently heard about a child that

got very sick from the vaccine, so I think I’ll

avoid that one.”



Tool #133b

Confirmation

Comfortable information takes priority.People tend to seek out and agree with information that conforms to their pre-existing beliefs. Contrary information can be uncomfortable and so is more likely to be avoided. A bias towards information that confirms rather than conflicts with pre-existing beliefs can translate into not just ignoring contrary information, but doubling-down on pre-existing beliefs in the face of that new information.

In one study comparing vaccinators to non-vaccinators, when the latter “were presented with the sort of risk-benefit information that leads many medical and public-health experts to conclude that the risks of the disease are worse than the risk of the vaccine, they became more committed to nonvaccination, not less.”62 Another study witnessed a similar backfire effect, finding that corrective information designed to reduce misperceptions around vaccines actually “decreased intent to vaccinate among parents with the least favorable attitudes towards vaccines.”63

62 Meszaros et al (1992), Cognitive processes and the decisions of some parents to forego pertussis vaccination for their children

63 Nyhan et al (2014), Effective Messages in Vaccine Promotion: A Randomized Trial

Fundamental Attribution Error

Blaming the person, not the situation.People tend to place an undue emphasis on an individual’s characteristics, or elements of personality, to explain his or her behavior in a given situation rather than considering the situation’s external factors.

In the context of healthcare, especially among HCWs, this misattribution manifests itself as a “tendency to be judgmental and blame patients for their illnesses (dispositional causes) rather than examine the circumstances (situational factors) that might have been responsible. In particular, psychiatric patients, minorities, and other marginalized groups tend to suffer from this CDR [cognitive disposition to respond].”64 This might result, for example, in pegging a carer’s decision-making to inherent ‘laziness’ rather than to contexts of poverty, potentially affecting the equitable rendering of services by HCWs.64 Croskerry (2003), The Importance of Cognitive Errors in Diagnosis and

Strategies to Minimize Them

Status Quo

Past behavior predicts future behavior.When given the choice between continuing as-is or making a change, the latter often wins out. People tend not to change an established behavior unless the incentive to do so is compelling enough. Accordingly, past experience with vaccinations is a very strong predictor of future behavior; for those not vaccinated previously, it’s likely they will continue not to seek out vaccinations. Importantly, this is less a matter of strong beliefs or thoughtful decision-making and more a matter of comfort and .

As one study found, “those who had been vaccinated in the past were much more willing to be vaccinated than the average person, while those who had never been vaccinated were much less willing than the average person.”65 In fact, among those who had been vaccinated in the past, this bias towards the status quo trumped what might otherwise be problematic beliefs, such as their subjective probability of getting sick.65 Tsutsui et al (2010), A policy to promote influenza vaccination: A

behavioral economic approach

“Seeing that information from the health care

workers just makes me even more skeptical of it.”

“I’ll look into where and when I need to go for the

vaccines later.”

“She must be a neglectful mother;

she should be ashamed of herself for not getting her child immunized.”

“A new vaccination? I’ll just do whatever I did last year.”


Remember Prioritized Information + Diagnosis

Place Post-Its Here

Remember Prioritized Information + Diagnosis

Place Post-Its Here

Final Insight Place Post-It Here

Final Insight Place Post-It Here

Add final insights to your Field Recordings next to the diagnoses they reference.

Prioritized Information + Diagnosis

Insight FormulaFor each final diagnosis in your Field Recordings, use the insight formula to distill why we’re seeing what we’re seeing into a simple, universal truth about what is happening. This exercise in translation will serve as a critical transition point between the information you’ve analyzed and the upcoming process of creatively responding to that information by designing solutions.

Examples:

Private discussions prevent new mothers without a family history of vaccination from breaking with the status quo.

In the face of more concrete and everyday issues in the present, carers defer clinic visits to their future selves.

Poor working conditions keep demoralized HCWs from putting what they’ve been taught into practice.

Tool #143c

FR


Add final prompts to your Field Recordings next to the insight they respond to.

How Might We

+ Verb

+ Response to Insight

Prompt Formula Use the prompt formula to articulate a creative springboard for each of your insights. Make sure that your prompts are open-ended, respond directly to the problem, and feel like a mandate to explore interesting ideas.

Examples:

How might we sensitize HCWs to the tough challenges facing poorer patients so that they demonstrate empathy?

How might we give mothers a compelling-enough reason to act today rather than wait to return to the clinic?

How might we reveal to parents the actual volume of community members accessing vaccinations, demonstrating a widespread social behavior?


FR

[Verb] [Response to Insight]

How Might We


How Might We


How Might We


How Might We


How Might We


Brainstorming ConceptsGenerate a large quantity of possible solutions to each of the prompts drawn from your Field Recordings.

Rules of Brainstorming:• Build off each others’ ideas —

combine streams of thinking

• Aim for quantity over quality

• Go for wild ideas!

• Turn off phones! Concentrate on the ideas for short, intense spurts

• Draw what you can — a picture is worth 1,000 words

• Don’t eliminate ideas — and don’t play devil’s advocate (save for the next step: evaluating)

Converge With a large volume of ideas on the table, coalesce around recurring themes — what “categories” of ideas are surfacing among us?

Diverge When brainstorming solutions, always begin by going for quantity — large volumes of ideas that generate as much brainstormed material as possible, no matter the quality.

PlanSchedule an uninterrupted period of time and invite additional participants. Divide the available time between each prompt. Collect materials for participants to write and draw on — see below for tips on hosting a brainstorm.

Tool #164a


Hosting a BrainstormFacilitating a productive brainstorm can be challenging—too often, brainstorms become undisciplined conversations. To get the most out of a brainstorm, clearly communicate and enforce the rules (e.g. time).

Materials matter—have plenty of

post-its, notepads and pens

Include evidence from the field –

photographs and quotes – to make the problem more

tangible

Place a few “wild” example ideas to

encourage creative thinking

Alternate activities between individual sketching, partner

collaborating, and group sharing

Separate prompts and

brainstorm ideas around each separately



DudsThese ideas are neither responsive

to the prompt nor easy to make happen. Discard them!

Place Post-It Here

Building BlocksWhile it’s possible that your program

could feasibly make these ideas happen, they need work. Build off of these to make them more responsive to the challenge captured in the prompt.

Place Post-It Here

Innovative possibilitiesIdeas that are clearly responsive to the prompt, but may be difficult to imagine

your program implementing.

Place Post-It Here

Obvious WinsIdeas that are relatively

easy to make happen, and directly respond to the prompt.

Place Post-It Here

Evaluating ConceptsAfter brainstorming, use this chart to organize ideas for each of the prompts you brainstormed against. (You’ll need to create multiple charts — one for each prompt.)

Place each Post-It (containing one idea each) into the quadrant that intuitively makes sense. At the end, select 2-3 ideas from the obvious wins & innovative possibilities that are interesting and show promise.

Very Responsive to Prompt

Unresponsive to Prompt

Safe Out there



Idea ExamplesThe following example are meant to instigate your team’s creativity, drawing inspiration from various ways that other immunization programs have creatively responded to the challenges facing their users. These examples are not meant to be an exhaustive list of solutions. Instead, examples from solutions elsewhere can help to energize your team’s own brainstorming efforts.

Social ProofAs social beings, we modify our behavior by conforming to perceptions of group norms and expectations. For example, people are generally more likely to follow health advice when it’s presented in groups of peers, rather than individually.

Practical InformationPractical information enables users to locate and process only the most critical details about a program. It tackles issues of vagueness on the one hand and over-communication on the other, providing only the necessary information for people to follow through on their intentions to access services.

Action CuesAction cues are reminders built into a program’s design that prompt users to do something. They help to address issues like forgetfulness and procrastination, which prevent people from following through on positive intentions. Successful action cues elevate critical information to the user in visible, timely and actionable ways.

Micro-incentivesMicro-incentives are small, motivating bonuses given to users that tip the scales towards adoption of a desired behavior. They often help to cancel out small costs that discourage users from accessing services, giving people a small reward for doing something that is often perceived as an inconvenience.

Follow-throughFollow-through ideas help to bridge positive intentions with corresponding actions. Sometimes, decisions are easier to translate into actions when the actions feel concrete and achievable. Other times, creating a ‘deal’ with your future self can increase the likelihood of action. Either way, follow-through ensures that decisions translate into actual behavior.

Structuring ChoicesWays of structuring choices can have a powerful influence on an individual’s decision-making. The same information presented in different ways can result in different outcomes. In other words, thoughtfully designing how choices are presented can shape the choices that are made.

HCW IncentivesRewards are an age-old mechanism to modify behavior. Importantly, rewards may take many forms. While salary bumps and opportunities for career advancement can be instrumental to improve HCW performance, so too can public recognition, symbolic affirmations of social status, and feelings of reciprocity.

FeedbackSystems of regular feedback can help to encourage positive behaviors and discourage negative ones. Establishing feedback systems between the community and health care workers (HCWs), or among HCWs themselves, can serve as powerful performance motivators.

Identity SaliencyIdentity is fundamental to behavior. And individuals, of course, have more than a single identity: a woman can be a mother, daughter, wife, head of a business, community activist and member of a particular clan within a particular ethnic group — all at the same time. While identities co-exist, some become more influential than others — or more salient — in different contexts.

Modified ObjectsSmall details in the design of objects with which users interact can have an outsized impact on an object’s intended function. Attributes like physical design, content, and the way information is presented can all affect whether or not an object ‘does its job’.

Tool #184a Field Guide pages 144-153


Models

Physical models of an idea go beyond two-dimensional visualizations, offering a way to understand certain ideas more concretely. Ideas that would likely be three-dimensional once produced—from a micro-incentive to a reminder bracelet—are best to design with models.

Sequences

Some ideas possibly won’t require ‘making’ anything at all, but might instead change an experience. These ideas still deserve to be designed. Tools like storyboarding can help to elucidate how a new experience might unfold, sequence by sequence.

Visualizations

Visualizing an idea involves putting pen to paper. What does an idea look like? How does it work? Ideas that would likely be two-dimensional in reality—from a sticker to a poster—are best visualized.

Designing in Action Designing does not require designers. Ideas can be designed quickly, easily and cheaply by anyone with basic materials. For each idea that made it through the Evaluation step (tool #15), consider how the idea might be made more real while keeping designs ‘low-fidelity.’ Explore many different ideas without feeling committed to any single one too early on.

Visualization Example: Personal Pledge

Model Example: Health Card

Sequence Example: Clinic

Experience



Establish Learning GoalsWhat do we want to learn from putting this idea out into the field? Answer separately for each design (tool #19).

Enable Real Use CasesHow can we simulate a real-world experience? Consider the following when forming a mini-pilot:

• Choose a location where you have buy-in and support.

• Ensure that the desired user-group participates.

• Find HCWs or partners that will help administer the prototype.

• Create a simple tracking system to measure outcomes.

Iterate As You GoWhat could we tweak prior to the next prototyping activity? This is especially valuable when certain elements are distracting from the core idea.

Filter FeedbackLook back at the “Recording Field Research” worksheets (tools #6-7) — you will take notes on similar observations and narratives. How much weight should be given to each piece of feedback? Place more weight on actions, less on reactions to low-fidelity designs.

Invite User Co-creationWhere are there opportunities to more directly involve users in developing an idea? When a user asks a question, ask how they would solve it before providing your own answer or suggestion.

Protoyping in Action The fundamental method for prototyping is allowing users to experience and react to potential solutions. Prototyping activities should get as close to a real scenario as possible. However, prototyping should also be rapid, allowing us to learn and improve our ideas quickly.

The principles on this page serve to guide your in-field efforts:



WhenDecide precise times, such as when

you’ll begin and when you’ll conduct interviews. Also consider ‘over what time

period’, especially with mini-pilots.

Place Post-It Here

Learning Goal #1What do we want to learn from putting

this idea out into the field?

Place Post-It Here

WhereSelect the precise location(s) where you’ll introduce the prototype, such as a bundle

of clinics. Remember that the more an idea is prototyped in-context, the better.

Place Post-It Here

With WhomBe sure that you’re engaging the

intended user-group as defined in your Ambition. Remember that selecting a variety of people — say, both non-vaccinators and vaccinators — can generate more helpful feedback.

Place Post-It Here

Learning Goal #2What do we want to learn from putting

this idea out into the field?

Place Post-It Here

Prototype PlanningFor each idea, use this worksheet to develop a prototyping plan in preparation for gathering in-field feedback.


Describe prototyping activity


Observed weaknesses Place Post-It Here

Observed strengths Place Post-It Here

What do we still need to know? Place Post-It Here

Prototype LearningFor each idea, use this worksheet to capture learnings from prototyping activities. Transcribe a synthesis of field notes from prototyping here.



Is this idea currently designed to ask as little of users as possible?

Does the idea easily fit into people’s lives?

Is the idea actually appealing to users?

Is the idea being correctly used, processed, etc?

Is the tech required of the idea easily available?

Is the tech easily sustained over time?

Can your program actually make it happen?

How long will the idea take to move beyond a prototype?

What can be projected about possible costs?

Might the idea actually save the program money?

Is the idea honoring the program’s budget?

How near-term versus long-term are potential savings?

Desirability

Feasibility

Viability

Prototype EvaluationFor each idea, use this worksheet to evaluate the idea post-prototyping.



Define Implementation QuestionsDefine what we want to learn about and improve from phase to phase during iterative implementation.

Identify RisksAccount for external variables that may jeopardize an idea or interfere with indicators.

i ii iii iv v

Decide IndicatorsBased on your questions, determine what you need to measure.

Articulate JustificationDocument why each indicator and its associated means of verification were selected.

Determine Means of VerificationDetermine which methods to use for tracking the indicators and improving the idea (not for definitively evaluating its impact).

Adaptation PlanFor each idea, use the worksheet on the following page to develop an Adaptation Plan. Adjust the plan throughout implementation. Add additional rows as needed.

Tool #245a

Question Examples:

? Does the SMS reminder program make it easier for carers to follow-through on their intentions to vaccinate?

? Are more messages better than fewer?

? How important is timing?

Indicator Examples:

+ percent change in clinic visits

+ percent increase in on-time visits

Method Examples:

» Use clinics’ administrative data

» Enroll a sample of carers into the SMS reminder program and track

» Conduct individual interviews with carers after experiencing the program

Justification Examples:

» The two indicators address two related issues (forgetfulness leading to non-access or late-access)

» Admin data from clinics is a more suitable means of verification given short timeframe and limited budget

Risk Examples:

! Carers may not have reliable access to the same mobile phone — it could be shared

! Carers may not consistently pay for mobile phone service

! Carers may not have regular access to Internet

! Clinics may not regularly stock all vaccines



Adaptation Plan

Implementation QuestionWhat you want to learn about and improve from phase to phase

Remember the AmbitionWhat your continuous learning should support

IndicatorWhat you need to measure

JustificationWhy each indicator was selected

Means of VerificationMethods for tracking the indicators and improving the idea

Identify RisksVariables that may jeopardize an idea or interfere with indicators

i ii iii iv

v



Implementation Question Indicator JustificationMeans of Verification

i ii iii iv


Documents

Demand for Immunization Workbook - HCD4ihcd4i.org/wp-content/uploads/2017/01/demand_for_immunization_full... · Demand for Immunization Workbook A Human-Centered Field Guide for Investigating