Understanding Vaccination Barriers: Mozambique Human-Centered Design Co-creation and Assessment Report

"...expect our audience to use the project's bottom up assessment approach as a model for how to co-create priorities with stakeholders at the district, facility, and community level..."

MOMENTUM Routine Immunization Transformation and Equity is a United States Agency for International Development (USAID)-supported project that works toward a world in which all people eligible for immunisation - and, in particular, underserved, marginalised, and vulnerable populations - are regularly reached with high-quality routine vaccination services. This report describes why and how the project used human-centred design (HCD) in its co-creation and assessment approach to identify causes of under-immunisation in Mozambique and to mitigate them.

HCD is a collaborative problem-solving approach that provides creative methods for deeply understanding human behaviour to develop new ideas and solutions directly with the intended user or beneficiary. It aligns with the MOMENTUM Routine Immunization Transformation and Equity project's focus on putting people at the centre while introducing and testing targeted interventions to foster resilient systems and communities, engage local partners, and improve the quality and use of data.

In July and August 2021, to understand the root causes of non-vaccination and dropout, the project engaged community and health system stakeholders through in-depth interviews and co-creation workshops in locations where stakeholders work and live (two each in Zambézia and Nampula) to solve problems that emerged from the in-depth interviews. Stakeholders included but were not limited to district Expanded Program on Immunization (EPI) staff, facility nurses, vaccinators, community health workers (CHWs), community and religious leaders, and caregivers of zero- and under-immunised children. As part of our HCD approach, the project continued to explore solutions through direct co-creation with key local stakeholders that were identified as influencers in their community during the assessment phase. (See the report for full details on the bottom-up approach that informed the subsequent workplanning approval process with national and provincial EPI stakeholders.)

As the report outlines, the project also designed the approach to align with Gavi's IRMMA (identify, reach, measure and monitor, advocate) framework to identify and ultimately reach zero-dose and under-immunised children.

"Solution briefs" were the bridge between the data collected during the interviews (e.g., root causes of missed vaccinations) and how the project developed solutions with key health system and community stakeholders in the district and provincial co-creation workshops. In total, each district took approximately 2 weeks from kickoff to interviews to workshop.

Among the findings from the interviews: Mothers wanted to get their children vaccinated, but they faced many challenges outside of their control. However, a challenge identified with combating barriers to immunisation is the pervasive perspective among both health system and community actors at all levels that mothers' negligence is the problem for children not getting vaccinated. The HCD methods the project used (see page 21 of the report) were the Mothers' Vaccination Ecosystem and Solutions Co-Creation Activity. The former method helped workshop participants to "walk in a mother's shoes" and understand how people in her life positively and negatively influence her ability to vaccinate her children. Once participants gained empathy for mothers' lived experiences, project leaders invited them to develop solutions with this reality in mind. Co-creation workshop solutions that were proposed focused on supporting mothers in getting their children vaccinated - e.g., strengthening health-system/community relationships, enlisting community resources for mothers' transport to vaccination services, organising mobile brigades according to vaccination need, and mobilising EPI activities.

Following the conclusion of our data collection efforts through baseline surveys, in-depth interviews, and co-creation workshops, the MOMENTUM Routine Immunization Transformation and Equity team used the results of the co-creation and assessment phase and organised joint planning with EPI staff at district and provincial levels and then prioritised interventions to remove barriers illuminated in the priority districts. Ongoing activities include:

• Implementing the workplan based on the co-creation and assessment phase;
• Advocating with other key stakeholders to implement activities or solutions identified through co-creation process, including for the integration of health services;
• Disseminating results among key health stakeholders to consider in further planning; and
• Co-creating improvements in immunisation directly with local stakeholders.

Based on the HCD experience described above, the project built into its first full project year workplan (October 1 2021 - September 30 2022) ways to continue to co-create solutions to vaccination challenges. This approach includes:

• Partnerships: reinvigorating community health councils to work closely with health facilities to plan and communicate mobile brigade efforts;
• Community engagement with social and behaviour change: working on male engagement (husbands, brothers, uncles) to promote importance of immunisation, as findings show they support mothers getting children vaccinated;
• Service experience: strengthening healthcare worker (HCW) capacity to provide respectful and responsive care; and
• HCD innovations group: working with HCWs and community members to implement a client-centred solution and iteratively improve upon it through short testing cycles

According to the project, their approach added value as compared to traditional assessment approaches in that it:

• Identified challenges from the community and caregiver (especially mother) perspective, which would not have been uncovered in interviews with health systems actors or from quantitative survey data;
• Worked with community members and others outside immunisation, which enabled their understanding of how to improve services based on the needs and preferences of clients;
• Focused on zero-dose children and gender barriers, which helped identify the root causes of barriers to immunisation that are typically hidden or not observed in approaches that focus on the general population; and
• Leveraged the "Vaccination Ecosystem" tool, which showed HCWs mothers' immunisation barriers and led to empathy for mothers.

Solutions emerging from the co-creation workshops are only the beginning of our work with district and community stakeholders. It was challenging to adequately translate them into project activities in the allotted time frame, and we continue to build on what we learned into our PY2 activities.