Thinking Outside of the [Cold] Box: Implementing a Human-Centered Design Approach to Understand Barriers and Craft Solutions to Cold Chain Equipment Maintenance in Niger

"...engaged people directly involved and indirectly implicated in CCE management and maintenance to gain a nuanced understanding of their view of gaps in the system and included them in designing solutions to the challenges they face..."

Vaccines require cold chain equipment (CCE) to ensure quality and potency, yet the risk of CCE failing is well documented. The need for stronger maintenance systems is well known, but little has been done to understand the barriers from the cold chain technician's perspective. This human-centred design (HCD) study in Niger sought to better understand the gap in the current maintenance approaches from the technicians' perspectives and to collaboratively identify forward-thinking solutions.

This qualitative study used HCD approaches to ensure the engagement and collaboration of stakeholders at all levels of the health system. In February and March 2023, the research team conducted 20 in-depth consultations in 2 regions, Tahoua and Maradi, with participants directly involved in the management of the cold chain. After data collection, the research team led data synthesis and insight identification to serve as a starting point for 2 co-creation workshops, held in April 2023. Fourteen people participated in the first, an online co-creation workshop, and 20 people participated in the second, a 2-day in-person workshop, including 5 of the same participants from the online workshop. Ideas were fleshed out to include detailing how the idea will work, who would be involved, how the idea differed from others, and the problem the idea addressed. Ten additional stakeholders participated in a half-day validation session, which included national-level decision makers, partners, and donors, to begin socialiing the insights and ideas generated during the consultations and co-design workshops.

The insights that emerged from this HCD process were organised in 3 main areas: (i) The lack of system agility and ability to optimise resources constrains performance of the maintenance system; the absence of a clear system or guidelines on how to effectively use temperature data contributes to the lack of optimisation of available resources; (ii) the cold chain is often an afterthought within the overall context of immunisation services and should instead be prioritised; and (iii) knowledge sharing across the system and key stakeholders is ad hoc, with limited understanding of roles and responsibilities.

During both co-creation workshops, participants responded to 7 "How Might We?" questions, which were designed to convert problems identified through data collection and synthesis into design challenges. Through this process, participants identified an initial 15 potential solutions to explore; they then aligned around 4 final concepts to explore as potential solutions:

1. Create an online platform to connect people and to share knowledge across regions - The expectation with this concept is that the use of a digital platform would put the information at the fingertips of all those who need it, without any of the problems associated with traditional communication methods (email, WhatsApp, etc.).
2. Develop practical CCE technical resources in a variety of material formats, such as: printed and physical materials that can be used on a daily basis for quick problem solving with visual representations; videos that can show step-by-step instructions for resolving daily and common challenges with CCE and can be shared and stored on the online platform; and a training module with theoretical and practical knowledge and activities to ensure new staff feel confident to do their job.
3. Use gamification and friendly competition to motivate staff to value maintenance - Participants identified such an approach as a way to maintain frequent communication (through weekly challenges) and ensure that there is no loss of information. Offline activities can include recognising a maintenance "superstar" at the end of the year to celebrate achievements, bring together all stakeholders, and recognise efforts. This type of weekly competition and annual celebration and recognition is a way to strengthen the ties between stakeholders and motivate individuals to remain committed to preventive maintenance.
4. Develop a real-time maintenance tracking system - Such a system would remind people in charge of preventive maintenance of the daily and weekly tasks required for the CCE.

These concepts provide the basis for further exploration and prototyping of the different ideas to understand their feasibility and the level of interest and to test out different iterations of the concepts to be most appropriate for the Niger context and the CCE maintenance system.

Reflecting on the process, the researchers note that the co-creation workshops "created an opportunity for stakeholders to be involved in a constructive, creative and inclusive process that encouraged contributions and ideas from different perspectives. The key insights and challenges identified during data collection and synthesis informed the overarching principles of design and the concepts developed by participants during co-creation."

In conclusion: "This study took a unique HCD approach to engage people directly involved in CCE maintenance to more deeply understand challenges with the current system and create space to identify innovative solutions that are tailored to the context. The results demonstrate that stakeholders can identify potential solutions that have not been part of the typical approaches to a maintenance system. This HCD approach has implications for all global health challenges and demonstrates a methodology that can encourage key stakeholders to think about problems and solutions differently....[T]he tailored solutions that can be identified may be more successful and sustainable in the long run."