UNICEF Demand For Health Services Field Guide V1 2016 PDF

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Demand

for Health

Services

A Human-Centred Field Guide

for Investigating and Responding

to Challenges

Process Overview

How could

we respond?

What do we

think we know?

What is our

objective? How could

we improve?

What stands

in our way?

FINAL OUTPUT

Adaptation Plan and

Proven Solutions

FINAL OUTPUT

Tested Solutions

FINAL OUTPUT

Field Notes Map

FINAL OUTPUT

Objective Statement

FINAL OUTPUT

Creative Prompts

5a4a3a2a1a

Plan for Iteration

Devise an Adaptation Plan for

each draft initiative. Deﬁne the

key evaluative questions, possible

risks, measurable criteria, and

corresponding indicators to track

progress over time. Adjust the

Adaptation Plan after each phase

of implementation.

Adaptation Plan

Evaluate

Eectiveness

Assess each revised idea in the ﬁeld

using the Adaptation Plan as a guide.

Evaluate the accuracy of diagnoses

and determine what we still know

little about.

Improve Initiatives

Implement adaptive changes that

respond to ﬁndings.

Conceptualise

Solutions

With an extended team, quickly

generate many possible solutions.

By the end, we will identify the most

promising solutions.

Assess Concepts

Concept Examples

Design Quick

Examples

Make ideas concrete through initial

outlines, models or rough sketches

of ways to implement promising

concepts.

Design Examples

Prototype Designs

with Users

Take draft ideas into the ﬁeld to test

with, and get feedback from, users.

Prototype Planning

Prototype Evaluation

Explore The User’s

Environment

Choose which activities, including

observations and interviews,

should be used for research. Collect

information in the ﬁeld. Record

what is seen, heard, felt, and said.

Research Plan Template

Discussion Guide Template

Record Field Research

Interpret

Collected Stories

Share information from the ﬁeld.

Identify patterns, surprises and

commonalities. Analyse key

ﬁndings to hypothesize why this is

happening.

Diagnostics Worksheet

Theme Examples

Assemble Existing

Knowledge

Gather available information about

the challenge, past efforts, and the

individual or community in question.

Recognise

Assumptions

To help avoid bias, document the

possible assumptions that you and

your team might carry with you.

Assumption Examples

Assumption Catalogue

Compose

Learning Goals

Clarify what you hope to get out of

the research. These learning goals

will help you to decide the research

methods to use during Question 3.

Journey to Immunization

Field Notes Map

Prioritize a

User-group

Clearly delineate exactly which

community we are concerned with.

Deﬁne the

Improved State

Specify the change in immunization

outcomes that the team is capable of

inﬂuencing.

Describe the

Biggest Obstacle

Explain how the user-group is or is

not engaging with services.

Common Obstacles

Objective Formula

Propose

Opportunities for

Design

Translate diagnoses of the root

causes of the challenge into

creative prompts for design,

or re-design.

Persona Proﬁle

Relationship Map

Prompt Formula

p. 34 p. 46 p. 62 p. 104 p. 116 p. 154

p. 134 p. 160

p. 138 p. 162

p. 34

p. 47

p. 84

p. 35

p. 52

DEMAND FOR HEALTH SERVICES

INTRODUCTION

How to use this:

a road map

Part II. Guiding Principles

Part I. Introduction 02

24Part III. Five Big Questions

Welcome! This section provides an

overview of the purpose of this resource,

an introduction to the methodology, and

advice on how to get the most out of it.

Each principle is grounded in evidence and

offers a way of thinking about users —

the people immunization programmes

try to serve — a little bit differently.

Taken together, these principles will be

helpful at each step in part three.

Part III is the heart of this Field Guide.

It presents ﬁve general steps — or

ﬁve big questions — to move through

when investigating and responding

to challenges involving users.

Small Is Big 14

Intentions Are Not Actions 16

Knowing Is Not Enough 18

Truths Are Buried 20

Context Comes First 22

Attention Is Elsewhere 24

What is this for? 04

Why now? 06

How is this dierent? 08

What is our objective? 30

What do we think we know? 42

What stands in our way? 56

How could we respond? 112

How could we improve? 148

This Field Guide

will help you to:

Save Money

Make low-cost adjustments

to programmes before

scaling the solution.

Find New Solutions

Integrate thinking from

ﬁelds beyond public health

that bring systems thinking

and experimentation

to build innovative,

scalable solutions.

Save Time

Conduct swift, low-

cost ﬁeld research and

test solutions before

investing in larger-scale

implementation.

Reduce Inequities

Identify the most

important challenges facing

the most disadvantaged.

Close the

Empathy Gap

Collaborate directly, or “co-

design,” with the people

we are trying to serve.

DEMAND FOR HEALTH SERVICES

INTRODUCTION

A new approach to

demand for services

This ﬁeld guide introduces human-centred design as an

approach to addressing challenges related to community

demand for basic health services like immunization.

Human-centred design is a problem-solving

process that begins with understanding the

“human factors” and context surrounding

a challenge and works directly with

users — the intended clients or consumers

of services — to develop solutions that are

viable and appropriate in a given context.

Designing for people and their everyday

interactions helps uncover and solve the right

problems using local capacities and resources.

No expert has more knowledge than a

caregiver, nurse, or a community health

worker about how to solve their most

pressing problems. The methodologies in

this toolkit acknowledge this by focusing

on collaboration and designing with — not

for — the people we seek to serve.

Human-centred design works to uncover

latent needs that service providers and

programme recipients may not even

know they have before the process

begins. The approach is “bottom up”

in the sense that both problems and

solutions are deﬁned and developed

locally, not imposed from elsewhere.

While this guide primarily focuses on issues

and examples related to immunization, the

process and tools are relevant to a broad

range of health programmes that depend

on generating community demand for

services. Please adapt and deploy this

approach for your own programme priorities.

2 3

DEMAND FOR HEALTH SERVICES

INTRODUCTION

When vaccinations are available, affordable

and acceptable, populations can remain

persistently under-immunized. “Our results

suggest that… even a fully reliable supply

system has a relatively modest effect on

uptake of immunization... when access

was good and a social worker constantly

reminded parents of the beneﬁts of

immunization, more than 80 per cent did

not get their children fully immunized.”1

How should we respond? The following

three scenarios demonstrate the

types of complex challenges a human-

centred approach responds to:

Availability Fails to Drive Demand2

Immunization camps—a newly implemented

outreach effort—have made signiﬁcant

advances in making immunization more

physically accessible for a particularly

hard-to-serve population. In recent

surveys, this population has expressed a

near-universal desire for vaccinations.

Despite the heavy investments made in better

provision, a recent evaluation of the outreach

programme found that a sizeable majority of

this population is still un- or under-immunized.

Eorts to Promote Demand Backﬁre3

In response to a pocket of vaccine resistance

among a subset of a certain population,

a regional immunization programme

launched a large-scale communications

campaign. Messaging emphasized the

life-saving beneﬁts of vaccines.

In follow-up surveys, researchers discovered

that instead of decreasing resistant

attitudes, the campaign increased them.

Proximity to Services Does

Not Predict Coverage4

An assessment of inequities in

immunization outcomes revealed sharp

differences between communities within

a district. A programme team began

planning new ways to expand access.

During its planning, the team encountered

a confounding paradox: in areas where

coverage is high, caregivers tend to walk

long distances to seek out vaccines; and in

areas where coverage is low, caregivers are

more proximate to immunization services.

What is this for?

1 Banerjee, et al. (2010), Improving immunisation Coverage in Rural India: Clustered randomised controlled

evaluation of immunisation campaigns with and without incentives.

2 Generalized example based on empirical evidence from: Banerjee, et al. (2010), ibid.

3 Generalized example based on empirical evidence from: Meszaros, et al. (1992), Cognitive inﬂuences on parents’ decisions to

forego pertussis vaccination for their children.

4 Generalized example based on empirical evidence from: Holte, et a.l (2012), The decision to vaccinate a child: An economic

perspective from southern Malawi.

All services are designed, including how

they are promoted, operated, and delivered.

For immunization to be supported by

demand, it is essential to gain a deep

understanding of the people we are serving;

not only what they need and desire, but

what limitations they face, what motivates

them and what is important to them.

The human-centred approach combines a

research methodology that focuses on the

needs of people, a design methodology

that allows for innovative solutions and

an implementation strategy that uses a

wide systems view. As demonstrated

below, the approach demands that we

consider the constraints, opportunities and

interactions of an existing ecosystem.

The process also accounts and corrects for

human error on the side of the researcher,

designer and implementer by starting small

and incrementally testing and improving

ideas. We invite and encourage anyone

who is observant, curious and inquisitive to

follow this process — it uses that expertise

to lead you through proving or disproving

assumptions and conclusions along the way.

•

Trying to meet

many demands

in the community

Needs to get to

clinic and road is

washed out

Childcare

mother

father

family

caregivers

Healthcare

health worker

community volunteer

doctor

nurse

Sister needs help

watching children

Cell phone has

not been paid

this month

Balancing new

training with

current patients

Son at home is

sick and requires

immediate care

Intent

A human-centred approach

DEMAND FOR HEALTH SERVICES

INTRODUCTION

A focus on equity

Immunization today remains one of the

most effective interventions in global

public health. However, inequity divides

those who beneﬁt from their right to

immunization from those who do not.

Sometimes, inequity is driven by the

availability of supply or physical access. But

in most cases, the situation is more complex.

This Field Guide comes at a moment

of recognition and consensus about

equity.5 The global health community has

underscored the importance of prioritizing

the most susceptible populations rather

than exclusively focusing on coverage. This

pro-equity principle requires that health

programmes systematically identify and

reach the least visible and most marginal.

We need to better understand the challenges

facing these groups and identify opportunities

to improve the way services are provided.

This makes human-centred approaches all the

more important — an emphasis on the lives

and lived environments of the communities

immunization programmes intend to serve.

Prioritizing susceptible groups, better

understanding the constraints they face, and

resolving the challenges preventing them

from accessing vital health services has a

fresh urgency. This Field Guide provides

principles and a structured process to achieve

more equitable immunization outcomes.

Why now?

5 World Health Organization (2014), Making fair choices on the path to universal health coverage: Final report of the WHO

Consultative Group on Equity and Universal Health Coverage.

6 Hickler, et al. (2017), Efforts to Monitor Global Progress on Individual and Community Demand for Immunization: Development of

deﬁnitions and indicators for the Global Vaccine Action Plan Strategic Objective 2.

7 Reaching Every District and Reaching Every Community Strategy: A literature review and status report on strategies for reducing

immunization inequities in Africa (2015).

This Field Guide exists to help investigate, understand and

respond to challenges of demand. It draws on insights from

behavioural science and employs human-centred methods

to improve immunization outcomes.

A focus on demand

Any programme providing a health service

requires that users accept and seek out those

services. When for any reason that does

not happen, demand fails to meet supply.

In the context of immunization,“demand

is deﬁned as the actions of individuals

and communities to seek, support, and/

or advocate for vaccines and immunization

services. Demand is dynamic and varies

by context, vaccine, immunization services

provided, time, and place. Demand is

fostered by governments, immunization

program managers, public and private sector

providers, local leadership, and civil society

organizations hearing and acting on the

voices of individuals and communities.”6

The global health community has

increasingly highlighted the need to pay

greater attention to demand and the

“human factors” that often determine the

success and failures programmes.7 This

Field Guide is a response to this important

elevation of focus on demand for basic

health services like immunization.

Demand is

about behaviour

Challenges of demand revolve around

decision making and action taking. Constraints,

such as lack of medical records or language

barriers, can inﬂuence caregiver decisions to:

• Bring or not bring their children

to a health-care facility

• Receive or not receive a vaccination

• Return or not return for

subsequent vaccinations

In other words, demand is about the

complexity of people and why people

do or do not make decisions and

take actions. To increase demand for

immunization we must understand people’s

decisions and what inﬂuences them.

INTRODUCTION

6 7

DEMAND FOR HEALTH SERVICES

How is this dierent?

Experiment and

Experiment Again

Since this process occurs in short

sprints, it encourages experimental

trials that may not always work out.

That is okay — instead of agonizing

over the perfect solution, try many

possibilities and learn just as much

from what does not work as from

what does.

Share a Story

Facts are important, but stories make

facts memorable. Share your stories

from the ﬁeld. Whom did you meet?

What did you see? How did you see it

in a new way?

Make It

Mock-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 Creative

This 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.

Leave Your

Desk Behind

Regardless of formal training, you

are 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 and observe caregivers.

Think in Weeks,

Not Months

Work fast and be nimble. This entire

process may be completed in a short

amount of time. It should never drag

on for months. Trust your intuition,

you know what you’re doing.

Recruit

Diverse Roles

Ideally, each team member holds

a different role so your team

has diverse and complementary

perspectives. Consider team

members’ breadth of experiences,

not just varied titles and functions.

Work in a

Team of 3-5

While input from many parties is

important, it can lead to a slow

process. There are moments — like

brainstorming — where you will invite

additional participants to join. But

start with a core team of three to ﬁve

members that will participate in the

entire process.

INTRODUCTION

DEMAND FOR HEALTH SERVICES

Part II: Guiding Principles

Thinking About People

Health programmes are people-programmes. At every step

of the way they involve people, from government ocials

to community health workers. Perhaps nowhere is the

involvement of people more important than with users,

or the people for whom programmes exist. Understanding

the constraints under which users make decisions and

take actions accounts for much of the successes and

failures in expanding the reach and impact of health

services — particularly for the most vulnerable.

As many public health experts know, the contrast between

how a programme is designed and how it works can be stark.

Often, that is due to overlooked or less understood factors

regarding how people actually behave in the real world, as

opposed to how we assume they will.

The following six principles are intended as reminders when

investigating and responding to the human challenges facing

immunization programmes. They are grounded in what we

know to be true about human behaviour and can improve

the eectiveness of our eorts.

“Many parents do not seem

to reﬂect deeply about whether

or not to vaccinate their child,

and their decision often seems

to be based on rules of thumb

and limited information.”

Cappelen, et al. (2012), Demand for Childhood

Vaccination: Insights from Behavioural Economics.

10 11

DEMAND FOR HEALTH SERVICES

In Pakistan, data showed a signiﬁcant

drop-off between infants’ ﬁrst dose

of diptheria-tetanus-pertussis (DTP1)

and the third dose (DTP3).

Upon investigating the problem, researchers

noticed a common challenge for many of

the mothers: the physical ‘reminder’ card

that they received after the ﬁrst dose of

the vaccine was difﬁcult to interpret.

The standard card presented

mothers with two challenges:

• It was too small, 9cm by 8.5cm

when folded. The information

appeared crowded and disorderly.

• The next immunization date — the

most critical piece of information —

was handwritten by the staff at the

clinic, often in cramped and irregular

letters. Less literate mothers in

particular had trouble reading it.

In a randomized controlled trial, the research

team adjusted the card’s design to simplify

the information and make it easier for the

mothers to understand. Some mothers

in the trial received cards that were:

• Bigger: The card was larger, 15.5

cm by 11.5cm when folded.

• Eyecatching: The card was

bright yellow and used pre-printed

stickers with 42-point font.

• Harder to lose: The card was placed in

a plastic jacket with a hanging string.

• More legible: Only essential pieces

of information were included on the

outer sides of the card, which the

mother could see at a glance: the next

immunization dates and day of the week.

These small tweaks had an outsized impact:

67 per cent of the redesigned card group

completed the immunization schedule,

compared with 39 per cent of those who

received the standard card. Furthermore,

the intervention was cost effective: each

new card cost only 5 cents to produce.

Small, cheap and effective — this example

of success was made possible by closely

observing the challenges, however

seemingly minor, facing intended users.

7 Usman (2011), ‘Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: Redesigned

immunization card and maternal education’.

CASE STUDY

Minor Details Have an

Outsized Impact7

Often, seemingly small variables have outsized impacts on immunization

outcomes. We have a tendency to overlook these small things, like the

inconvenient barriers of dealing with immunization programmes that users

face — especially when small costs seem to pale in comparison to the

enormous beneﬁts of immunization. Because people do not always make

reasoned calculations weighing costs and beneﬁts, these small things

can dominate decision-making.

Consider a mother who has lost her child’s health card. She might think: Will

the health worker scold me when I arrive at the clinic empty-handed? Will I

feel ashamed? Am I even allowed a vaccine without the card in hand? What

began as a small event — a lost card — might lead to a big one, like a drop-off

in immunization and a child at risk of disease. Despite the beneﬁts of an

immunized child, minor problems (like the fear of getting scolded) shape

outcomes.

This suggests paying more attention to what might initially appear small.

Efforts to address the smaller things can sometimes be more impactful than

addressing seemingly bigger, more obvious challenges.

Small Is Big

GUIDING PRINCIPLES

DEMAND FOR IMMUNIZATION

Mozambique’s Ministry of Health instituted

an expanded immunization programme in

1979, but by the early 2000s, full coverage

rates remained low in many parts of the

country. In 2002, researchers set out to

understand the barriers standing in the

way of improved coverage, from the

attitudes of mothers and vaccine access,

to interactions with health-care workers.

A main objective was to determine what

mothers knew about the subject. The

study found that mothers’ knowledge

was generally low. For example, a

majority had no knowledge of key facts

about vaccine-preventable diseases, or

the ages at which a child should have

completed various vaccinations. Further,

many held misconceptions, such as

whether it was safe to vaccinate a sick

child; nearly a third thought it was not.

One might expect that this gap in knowledge

would negatively affect uptake. But despite

misconceptions and signiﬁcant gaps in

knowledge, mothers in Mozambique

overwhelmingly perceived vaccination as

important to a child’s health and actively

sought out vaccines for their children. In fact,

in an area where misperceptions were more

widely held, coverage rates were actually

higher. As the researchers found, “detailed

knowledge about vaccine-preventable

disease is not necessary to create or

maintain demand — study results show that

knowledge is low while demand is high.”

The case highlights a common assumption:

that there is a causal correlation between

knowledge and behaviour. Across studies,

the relationship is usually more complicated.

A study in the Gambia found that nearly

half of rural mothers could not correctly

name any vaccine-preventable diseases, yet

still actively sought out vaccines (national

coverage was 90 per cent).10 In the case

of Mozambican mothers, the lack of a

robust understanding also mattered little

when it came to seeking out vaccinations.

Whereas practical knowledge about when,

where and how to access vaccinations

can matter greatly, knowledge about

vaccine-preventable diseases and vaccines

themselves are often less directly tied to

immunization outcomes. Investing in the

enhancement of knowledge alone will not

necessarily yield an increase in coverage.

9 Sheldon and Alons (2003), ‘A study to describe barriers to childhood vaccination in Mozambique’.

10 Leach and Fairhead (2008), ‘Understandings of immunization: Some West African perspectives’.

CASE STUDY

Behaviour Is Inﬂuenced by

More Than Knowledge9

A common assumption is that knowledge is directly linked to behaviour, but

research suggests otherwise. Knowing about vaccines, having an accurate

understanding of their beneﬁts and understanding how they work, does not

necessarily correlate to high levels of coverage.8

In some cases, mothers with little or even inaccurate knowledge of how

vaccines work are diligent in getting their children fully immunized. For

example, in the following case study a survey among mothers revealed low

levels of knowledge along with signiﬁcant misperceptions. Yet, full childhood

immunization among many of these same caregivers was high. Perhaps these

mothers feel that getting their child fully immunized makes them good mothers,

and so they carry through, regardless of any misconceptions.

Addressing gaps in knowledge may be tempting. But focusing on knowledge

alone might take time and resources away from more effective strategies. When

we accept that it is possible to alter behaviour without ever changing what

is in someone’s mind, we open ourselves to more innovative solutions.

Knowing

Is Not Enough

8 Favin, et al. (2012), ‘Why Children Are Not Vaccinated: A review of the grey literature’.

GUIDING PRINCIPLES

DEMAND FOR HEALTH SERVICES

In Thailand, outbreaks of inﬂuenza have

had grave consequences. In 2008, the

H1N1 pandemic infected 8.4 million

people and caused 191 deaths. Despite

these headline-grabbing ﬁgures, a free

vaccination programme spearheaded

by the government only resulted in 38

per cent coverage in its ﬁrst year.

To improve coverage, one programme

designed a leaﬂet using a two-phased

approach. First, it sought to motivate

recipients to vaccinate by providing

information that, for instance, increased

perceptions of the personal risk of getting the

virus. Second, the leaﬂet helped recipients

with an action plan, including a ﬁll-in-the-

blank form about their planned appointment

at a health facility. The programme’s stated

goals were to strengthen intentions to

seek a inﬂuenza vaccination and translate

these intentions into behaviour change.

The programme achieved its ﬁrst

goal: recipients of the new leaﬂet had

much stronger intentions to vaccinate

compared to a control group that received

a traditional leaﬂet. However, there

was no signiﬁcant difference between

a control and an intervention group

regarding actual vaccination behaviour.13

Increased intentions didn’t lead to

action — something more was needed.

The ﬁndings afﬁrm that immunization

programmes should be designed to

facilitate the full journey to vaccination,

not simply to change attitudes, risk

perceptions, or stated intentions. That

effort requires correctly diagnosing and

addressing the particular bottlenecks

preventing individuals from turning positive

intentions into corresponding actions.

12 Payaprom, et al. (2011), ‘Using the Health Action Process Approach and Implementation Intentions to Increase Inﬂuenza Vaccine

Uptake in High Risk Thai Individuals: A controlled before-after trial’.

13 While action plans (also referred to in this Field Guide as ‘implementation intentions’) can be a helpful tool to bridge intention and

action, its unsuccessful use suggests that this solution did not adequately address the barriers keeping the intention-action gap.

CASE STUDY

Good Intentions

Are Not Enough12

An intention to get immunized does not always mean actually getting immunized,

and the act of getting immunized is not necessarily preceded by an intention to

do so. Intentions can be poor predictors of corresponding actions.11

Raising awareness of a vaccine’s beneﬁts, for example, may help people to form

positive intentions. Learning that a vaccine could save your child’s life can incite a

powerful form of motivation. But behaviour depends as much (if not more) on

removing the barriers to taking action as it does on forming intentions.

For example, a caregiver might report in a survey that she fully intends to get her

child vaccinated, but taking a day off of work to travel to the clinic simply is not an

option; or she is not clear on where exactly to go; or the clinic’s opening hours are

inconsistent, and she is not sure if making the trek will be worth it. The opposite

may also be true: if a caregiver has no intention of seeking out vaccinations, but

sees others in her community going to the clinic, she may go too.

Intentions may not lead to actions. Instead, we should focus on what it takes to

get caregivers to act.

Intentions Are

Not Actions

11 Webb and Sheeran (2006), ‘Does Changing Behavioural Intentions Engender Behaviour Change? A Meta-Analysis of the

Experimental Evidence’.

GUIDING PRINCIPLES

DEMAND FOR HEALTH SERVICES

What people believe, say and do can be three different things. During ﬁeld

research, we cannot assume consistency between what people say about

themselves and their actual behaviour.

Consider a survey that asks the question, “Why isn’t your child immunized

against x?” A caregiver might respond that the transport costs were just too

high. It might be true that transport costs are high, but do we know that’s

actually the reason? Perhaps the caregiver had never really ever thought about

why she had not got around to accessing immunization services. It wasn’t until

now — until faced with the question — that she came up with what seemed like

a plausible explanation.

How we explain our own behaviour is not always accurate. We often edit our

responses to questions to ensure they are consistent with each other

and socially desirable. We struggle to adequately recall past situations

because our memories are far from perfect. We are easily inﬂuenced by

the ways that questions are worded and framed.14,15

What people say is prone to error. This makes it critical to disentangle what

people self-report about their behaviours from what is actually happening.

We do this during ﬁeld research by combining interviews (asking people what

they think and feel) with observations (watching what people say and do).

One medical anthropologist in Malawi

uncovered contradictory evidence.

The self-reported data gathered by a

knowledge, attitude and practice (KAP)

survey was different from the qualitative

data gathered from interviews, focus

groups and participant observation.

The survey, which investigated issues of

malaria during pregnancy, was used to

interview 248 respondents. It asked about

the quality of service at a local antenatal

clinic. Survey responses were largely positive.

However, during in-depth interviews, mothers

voiced criticisms of the clinic’s services.

The researcher investigated what might

explain the discrepancy: mothers assumed

that the survey was being conducted on

behalf of the health centre itself, and that

a negative response might impact the

treatment they would receive in the future.

More generally, the researcher posited,

Malawians are simply “a polite people” and

“dislik[e] the idea of conﬂict.” Without the

probing discussion that naturally occurs

during in-person interviews, mothers

chose the ‘kinder’ response in the survey

that did not reﬂect what they actually

believed. Respondents were demonstrating

social desirability bias — a tendency to

say what we think others want to hear.

If the researcher had taken the results of the

survey at face value, a programme might have

focused on other issues while assuming that

mothers were happy with the services. What

people say is not always what they think.

Uncovering the determinants of attitudes

and behaviours requires continuous digging,

approaching questions from multiple angles,

and calling surface-level and initial responses

into question to see what is buried beneath.

16 Launiala (2009), ‘How much can a KAP survey tell us about people’s knowledge, attitudes and practices? Some observations from

medical anthropology research on malaria in pregnancy in Malawi’.

CASE STUDY

What People Say

Is Not Always What

They Think or Do16

Truths Are

Buried

14 Podsakoff, et al. (2003), ‘Common Method Biases in Behavioural Research: A critical review of the literature and recommended

remedies’.

15 Schacter (1999), ‘The Seven Sins of Memory’.

GUIDING PRINCIPLES

DEMAND FOR HEALTH SERVICES

People do not like waiting in line, whether

in a supermarket or in a clinic waiting room.

Long wait times have been associated with

failure to complete an immunization course;19

busy parents do not have the time to waste.

In Lagos, Nigeria one initiative to address

high drop-out rates took a careful look at

the intake process of a local health clinic.

After mapping the journey of a patient, the

researchers identiﬁed an opportunity to

make a simple change to the patient intake

experience. They divided the waiting

room into two groups: mothers coming

to immunize children were separated

from all other patients. The clinic created

a special immunization station where

caregivers were directed after checking in

at reception.20 There was no need for the

usual procedures of taking a patient’s history

and administering a physical examination.

This administrative change led to

a 24 per cent increase in monthly

vaccinations performed — with no cost

increase whatsoever. The percentage of

registered children fully immunized by

age 1 increased by 18 per cent and after

age 1 by 32 per cent. A small, deliberate

change to the clinic environment yielded

outsize changes in outcomes.

18 Ekunwe (1984), ‘Expanding immunization coverage through improved clinic procedures’.

19 Favin, et al. (2012), ‘Why children are not vaccinated: a review of the grey literature’.

20 The intervention also worked with heathcare workers to ensure that all children were receiving immunization, regardless of

whether or not they were ill or healthy.

CASE STUDY

Adjusting the Experience,

Not the Person18

One of the more common terms in public health is ‘behaviour change’. There are

entire ﬁelds devoted to the topic, and for good reason. The solutions to many

problems require changes in the way that people behave. However, a singular

focus on behaviour change can be misleading.

Consider a neonatal clinic that has recently redesigned its intake system to

decrease waiting times for immunization. Drop-out rates were a problem, and

waiting times were regularly cited as the cause. With a change in how patients

are directed through the clinical environment, we see changes in behaviour:

fewer drop-outs and more children fully immunized. But here, the focus was not

on asking users to change their behaviour; users were not being asked to do

much of anything. Instead, the programme altered the clinic’s environment to ﬁt

users’ preexisting preferences, like not wanting to wait in long lines. The change

was made to the context, not the person.

The distinction may seem slight, but is important. Changing the context in

which people behave often has more powerful implications for ‘behaviour

change’ than directly asking that people change their behaviour.17 This

means thinking more about the ways that services are being supplied, even

when we are addressing challenges related to demand.

Context

Comes First

17 Ross and Nisbett (1991), ‘The Person and the Situation: Perspectives of social psychology’.

GUIDING PRINCIPLES

DEMAND FOR HEALTH SERVICES

In poor areas of Pakistan, low parental

literacy presents vaccination programmes

with a challenge. In Karachi, the site of an

intervention in 2008, only 24 per cent of the

population in the study areas was literate.

Acknowledging this barrier, researchers made

a minor redesign to educational materials

provided to caregivers during home-based

outreach efforts. The redesigned materials

consisted of easy-to-understand pictorial

cards with only three messages for mothers

to process. The messages conveyed included:

• That vaccines save children’s lives

• The location of local vaccination centres

• The signiﬁcance of retaining home-

based health records — including

how they could help at the time of

a child’s admission to school.

The messages took just ﬁve minutes to

communicate, and a copy of the materials

designed for low-literacy audiences was

given to mothers after the interaction.

Each set cost Pakistan Rs. 80 (US $1).

The study tapped into an important insight

about the presentation of information. In

addition to addressing low literacy, the

pictorial messages, which took little time

to explain, eased the cognitive burden on

stressed and busy mothers; they did not

require mothers to think too hard about

them. Pictures proved easier to process

and recall than the verbal messages that

mothers in a control group received.

Seventy-two per cent of infants in the

intervention group completed the vaccination

programme, compared to 52 per cent in

the control group. (Additionally, 81 per cent

in the intervention group retained their

home-based records, whereas 69 per cent

did so in the control.) The programme’s

design exhibited empathy with mothers

whose attention is often stretched thin

by other responsibilities. The low-cost

intervention asked less from mothers,

providing comprehensible information

through a simple format in less time.

24 Owais, et al. (2011), ‘Does improving maternal knowledge of vaccines impact infant immunization rates? A community-based

randomized-controlled trial in Karachi, Pakistan’.

CASE STUDY

Simplifying Information

for Busy Caregivers24

If you are reading this, you probably spend a lot of time thinking about

immunization. But that is not the case for everyone.

Most people, most of the time, are not thinking about immunization.

When they are, it is not always (or often) given very deep reﬂection — or even

much reﬂection at all. Consider an urban mother with three young children.

Crime in her neighbourhood is high and schools are underperforming, so she is

conducting at-home supplemental education. Her partner’s job does not support

the entire family, so she is also responsible for generating additional income. All

of this, in addition to many other day-to-day responsibilities, mean she is juggling

many things at once

We have the tendency to assume that people consider the universe of

possible costs and beneﬁts before making a decision. But that requires a lot

of thinking. Instead, most people make most decisions quickly, without

much reﬂection, and with many other priorities vying for focus.21, 22 In the

stressful context of poverty, it is safe to assume that vaccination will not be the

ﬁrst priority.23

If we remind ourselves that most people spend little time thinking about

vaccination, we will ask less of users and make our programmes simpler,

and easier to use.

21 Wheatley and Wegner (2001), ‘The Psychology of Automaticity of Action’.

22 Kahneman (2003), ‘Maps of Bounded Rationality: Psychology for behavioural economics’.

23 Shah, et al. (2012), ‘Some Consequences of Having Too Little’.

Attention

Is Elsewhere

GUIDING PRINCIPLES

DEMAND FOR HEALTH SERVICES

Part III: Five Big Questions

Questions Before

Answers

The variance in contexts, communities and challenges

makes the standardization of solutions dicult. Instead

of suggesting solutions, the human-centred approach

emphasizes questions to ask and the activities to pursue

when investigating challenges involving people.

To that end, the human-centred process is shaped by ﬁve

phases, or ﬁve big questions. Together, the answers will

support your ultimate objective of improving equitable

immunization coverage. Moving through these ﬁve questions

will guide your team’s problem-solving approach.

These questions are sequential and build upon one another.

It is likely that your team has already spent a lot of time

considering some of these questions, so use this as a

checklist. Evidence-supported answers to each will help

your team understand and respond to the challenges facing

users and holding immunization programmes back from

improved outcomes.

24 25

DEMAND FOR HEALTH SERVICES

How could

we improve?

Good ideas are not only

innovative, but also effective. This

last phase is about continuous

inquiry — measuring how the

ideas respond to the challenges

identiﬁed during user research and

making adjustments to improve

their efﬁcacy. Implementation

begins with deﬁning performance

indicators and continues as an

exercise in ongoing user research.

Five

Big ?s

Page 30 Page 42 Page 148Page 56 Page 112

What is our

objective?

We start with the user — the

child we are trying to reach,

the caregiver we are trying to

help and health workers. From

there we deﬁne the intended

programme outcome as a

measurable goal and focus on

the biggest obstacles we will

set out do address —obstacles

that must be researched a

proven during our user research.

The ﬁnal objective statement

focuses our work through

all subsequent activities.

What do we

think we know?

Before jumping into user research

(Question 3), it is helpful to review

what we already know. While

this involves taking stock of

existing knowledge like lessons

from past efforts (successful

and not) and of past research, it

also requires asking ourselves:

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?

What stands

in our way?

What prevents users from using

services? What do they do now

and what do we want them to

do? To ﬁnd out, we conduct user

research. Without understanding

user behaviour, interventions are

expensive guesses that might not

produce results. User research

should identify and explain the

variables facilitating or preventing

people from engaging with a

programme. The result is a set

of speciﬁc challenges to solve.

How could

we respond?

Given what we know about

users, how can we shape their

environments and inﬂuence

their behaviours to achieve

our objective? We start by

generating a large number of

potential solutions including

communications, clinic

experiences, incentives and

reminders. Once we identify

the best ideas, we test them

with users. This is a creative and

collaborative process: generating

ideas and testing them out.

Iterate or move onIterate or move onIterate or move onIterate or move on

26 27

DEMAND FOR HEALTH SERVICES

FIVE BIG QUESTIONS

expert knowledge low inﬂuence

creative mindset

proximate to

strategic piroities

technical mindset

not proximate to

strategic priorities

local knowlege high inﬂuence

Before You Begin

1 team

member

keep

informed

1 team

member

keep

informed

1 team

member

recruit as

advisor

1 team

member

keep

satisﬁed

Build Your Team

While input from many parties is important,

it can lead to a slow process that tries to

appease too many people along the way. To

work collaboratively, but not slowly, take

these two steps when building a team:

First, start with a “core team” of 3-5

members inside UNICEF that will participate

in the entire process. Ideally, each person

holds a different role so your team has

diverse and complementary perspectives.

The matrix below shows how you might

think about this — combining team

members with different knowledge sets and

mindsets. This team is the advocate of the

project, supports consultants when/if they

are needed during execution, and creates

excitement within UNICEF around the project.

Second, identify 1-2 “champions” in

the Ministry of Health to engage the

government, local authorities, and

local health workers. Alone we may go

fast but we cannot go far — so have

the support and active engagement of

ofﬁcials capable of instituting change.

Choose Your Advisors

Finding the right advisors and aligning

with existing priorities will secure political

support throughout the process. Even

if they are not familiar with digital health

deployments or human-centred design,

inﬂuential leaders can help get approvals

during ﬁeld research, recruit partners, ﬁnd

funding for the implementation, and provide

bureaucratic navigation along the way. The

matrix below, combined with the questions

that follow, should direct you to choosing 2-3

advisors that have inﬂuence and knowledge.

When choosing your advisors, ask yourself:

• Who must be involved in decision making?

• Who will be affected by this work,

and is interested in its success?

• Who should have inﬂuence

over how it adapts?

• How can we work with existing

government and community partners?

• What existing priorities and strategic

plans can we align with?

28 29

DEMAND FOR HEALTH SERVICES

FIVE BIG QUESTIONS

What Is Our

Objective?

Introduction: Problem Deﬁnition

As with any health intervention, we start with the

outcome we wish to achieve. Rather than adopt

an abstract goal and quickly move on, this section

advocates for a structured approach and dedicated time

to arrive at a precise objective.

An objective shapes all of the work to come and

signiﬁcantly inﬂuences the ways in which we go about

solving problems: the research we design, the challenges

we focus on, the ﬁndings we prioritize and the indicators

we select.

After answering this ﬁrst question, you and your team

will have a straightforward mandate to focus your work

throughout the process.

30 31

DEMAND FOR HEALTH SERVICES

Specify the change in

immunization outcomes

that the team is capable of

inﬂuencing.

Clearly delineate exactly

which community we are

concerned with.

Our objective is an immunization programme goal over a

speciﬁc period of time: how we aim to broaden coverage

and shrink inequities among a particular population.

Throughout the process, we will tie all of our interventions

in the ﬁeld directly back to our starting objective.

Formulate and document

the ﬁnal objective

statement to reference

throughout the process.

Objective Formula

Explain how the user-

group is or is not

engaging with services.

Common Obstacles

1a: Prioritize a User-Group 1c: Describe the Biggest Obstacle(s)

1b: Deﬁne the Improved State

Methodology

Final Output: Objective Statement

Current

State

Improved

State

Decisions Incentives &

Roadblocks

Actions

32 33

DEMAND FOR HEALTH SERVICES

Q1: WHAT IS OUR OBJECTIVE?

First describe the current or baseline

state and then set measurable,

achievable improvements.

Depending on your context, goals may

be set at the national level , or you

might have more ﬂexibility in using local

programme data to suggest feasible

improvements in your immediate context.

Your programme objectives should be

within the capacity for you and your team to

inﬂuence. Set clear, measurable, attainable

objectives that you can later evaluate.

Begin by identifying the group that requires

your attention. Use available data to prioritize

the people most in need of help. For

example, an equity assessment may have

recently revealed that a speciﬁc group is

still persistently under-immunized. Making a

speciﬁc population a priority prevents wasting

time and resources on general activities

directed to an unspeciﬁed population.

Prioritize a User-Group Describe the Biggest Obstacle

Deﬁne the Changed State

1a 1c

Delineate the Programme Challenge

Programme challenges provide a generalized

description of how a group of people are or

are not using the services being provided.

We deﬁne the programme challenge in these

generalized terms in order to avoid premature

diagnoses. Making a diagnosis early on

has the potential to mislead our research to

validate a pre-conceived solution instead of

leaving us open to innovative possibilities.

A programme challenge is descriptive of the

basic relationship between a user-group and

an immunization service. Intended users fall

into the following categories:

• Makes full use of services and

attends appointments on time

• Irregularly uses services

• Initially uses services and then stops

• Never uses services

Contemplate the Obstacles

After you clarify which of the programme

challenge categories your user-group

is experiencing, start to think about the

obstacles and underlying causes that

contribute to this current state.

What keeps users from acting or deciding

in a way that is most beneﬁcial for them?

What do users need the system to do?

What environmental factors contribute to

the problem? The biggest obstacles are

usually very human, meaning a bias, habit or

conﬂicting priority stands between the user

and the desired changed state.

This step is difﬁcult because it requires

describing a problem before we really

know the details of the problem. Existing

experience and knowledge can show us

where to start. At this point, we are not

interested in diagnoses, which we will get

to after a thorough user research process

(Question 3). Identifying a problem too early

has the potential to mislead our research and

block innovative solutions.

If the data is nonexistent or incomplete at

this phase, deﬁne the biggest obstacle to

the best of your ability. You will return to

the objective statement after user research

(Question 3) to validate its accuracy or

revise it to reﬂect the additional insights

that data alone cannot always uncover.

34 35

DEMAND FOR HEALTH SERVICES

Q1: WHAT IS OUR OBJECTIVE? 1A: PRIORITIZE 1B: DEFINE 1C: DESCRIBE

Fears about Vaccines

Action can be scarier than inaction. When given an

option between inaction and action, people tend to

default to the status quo.

1. Identify the programme challenge in your

area, which can be categorized as issues

of Use, Follow-through or Timeliness. For

example, caregivers may be initially using

services (Use), but only irregularly coming

for scheduled visits (Timeliness). 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 using services at

all (Use).

2. Ask why this challenge may be happening,

and check all of the obstacles (or add your

own) that may be contributing.

The biggest obstacles have recurring

themes. Competing priorities, demands

for attention, conﬂicting beliefs, habitual

behaviours and social pressures are

examples of common obstacles that can

hinder the desired programme outcome.

These are some examples of recurring

challenges to prompt new thinking about

the problems you witness in your local

context.

3. Circle the biggest obstacle. This will be a

working assumption that we will question

and return to as we uncover more

information in user research.

Use:

Is the user-group

using immunization

services?

Follow-through:

Do they complete

the schedule or are they

dropping out?

Timeliness:

Do they have diculties

coming on schedule?

Common Obstacles

Social Norms

Vaccination is not a social norm or common practice.

Apprehension About

Health-care Workers

Uncertainty about capacity, knowledge of health

workers, or compassion shown by health workers.

Apprehension About System

Uncertainty about the Health System, Government

or body perceived to be giving the vaccine.

No Feedback

Health workers lack the input or authority to

improve or change services.

Recent News

The easier to recall, the more personal the story,

the more Inﬂuential.

Ignoring the Contrary

People tend to seek out and act on information

that conforms to their pre-existing beliefs.

Attention Scarcity

People focus on the most pressing challenge ‘now’,

which may not be vaccination given competing needs.

Complexity

When caregivers are unclear about next steps

and next vaccines, taking action is difﬁcult.

Supply Insecurity

Vaccination is unsafe, unpredictable,

unavailable or available in limited supply

as a result of regional insecurity.

Bias Towards Optimism

People overestimate the likelihood of positive events

occurring and underestimate the likelihood of negative

events occurring (contracting a disease).

Hassle Factors

Seemingly minor inconveniences can deter people

from acting on their intentions, such as getting to the

point of service.

Negative Experiences

Bad experiences from the past outweigh

the neutral or good.

Choice

People value what they choose themselves. For

example, choosing a reward over receiving an award,

even when the rewards are actually equivalent.

36 37

DEMAND FOR HEALTH SERVICES

Q1: WHAT IS OUR OBJECTIVE? 1C: DESCRIBE THE PROGRAMME CHALLENGE

The prioritized user-group, deﬁned change and described

obstacle can be put into a formula to arrive at the objective

statement:

Our Objective is for U (user-group) to change from

E (existing state) to I (improved state) by addressing

O (biggest obstacle).

The tool on page 40 demonstrates each element of the

objective formula.

Example #1:

Our objective is for children of recently

arrived migrant families in the capitol to

change from 50 per cent DTP1 coverage

to 80 per cent DTP1 coverage by

improving access for parents, most of

whom do not have health insurance.

While the example adequately accounts

for the user-group and the changed state,

instead of identifying an obstacle it suggests

a diagnosis: that the cause of under-

immunization is due to a lack of insurance.

While that may be true, we will wait until user

research (Questions 3) to fully investigate and

substantiate that claim. Instead, consider:

Our objective is for children of recently arrived

migrant families in the capitol to change

from 50 per cent DTP1 coverage to 80 per

cent DTP1 coverage by addressing caregiver

perceptions about the accessibility of services.

Perhaps the programme does not have

sufﬁcient administrative data to accurately

describe how this population is or is

not using vaccine services; but they do

have data indicating parents occasionally

seek out care at health centres. Rather

than making a diagnosis in the Objective

Statement, this revised version summarizes

the basic relationship between the Roma

and the service: irregular engagement.

Example #2:

Our objective is for children nomadic

pastoralists in the North to achieve full

immunization coverage by addressing the

obstacles and opportunity costs of accessing

services at ﬁxed sites by families on the move.

This objective statement avoids diagnosing

a problem and clearly articulates the

basic relationship between nomadic

pastoralist families and immunization

services. However, it leaves the changed

state unclear: is the objective to achieve

full coverage among all children, or a

certain percentage? What baseline is the

programme working from? Instead, consider:

Our objective is for children of nomadic

pastoralists in the North to change from

35 per cent completion of the childhood

vaccination schedule to 80 per cent

completion of the schedule by addressing the

obstacles and opportunity costs of accessing

services at ﬁxed sites by families on the move.

Example #3:

Our objective is for children of ethnic

minority background in a poor peri-urban

neighborhood to change from 30 per cent

loss to follow up (“drop out”) to less than

10 per cent loss to follow up by addressing

negative experiences at the point of service

that keep parents from returning to the clinic.

In this scenario, preliminary data suggests

that experiences at the point of service are

keeping some families from returning. The

objective’s variables are clear: a change

from 30 per cent drop out to less than 10

per cent, among minority children in the

peri-urban neighborhood, and a basic

description of the negative experiences

obstacle. This statement is ready to use!

While you should feel at liberty to

construct an objective statement ‘in

your own words’, ensure that the key

variables are accounted for, and that

no premature diagnoses are made.

Compare and ContrastFinal Output: Objective Statement

Deﬁning your objective is essential

for the following reasons:

Objectives help us to avoid

the tendency to jump

immediately to a diagnosis.

We start with the ultimate objective

of our work: equitable coverage. Too

often, programmes start with a diagnosis

instead: for example, unmotivated health

care workers (HCWs) are causing steep

drop-out rates among caregivers. It may

be true that some HCWs are not strongly

motivated. But perhaps this is correlating

to dropouts, not causing them; or perhaps

other variables are inﬂuencing dropouts

more than HCW motivation. By starting

with an objective, we avoid prematurely

diagnosing the problem before we have

adequately investigated and pouring

resources into efforts that might not pay off.

Objectives help us to avoid defaulting

to intermediate goals, such as

attitudinal or behavioural objectives.

For example, an existing dataset suggests

that a certain portion of a community doesn’t

value vaccinations; in surveys, residents

self-report skepticism about vaccines’

beneﬁts. It may be tempting to establish

an attitudinal objective such as “increase

the perceived value of vaccination among

mothers.” But do we know that an increase

in perceived value will lead to an increase

in coverage? Perhaps there is more to the

story, and deeper user research later on

(Question 3) will help us better understand it.

Objectives help keep our teams

accountable, linking our ﬁeld

interventions back to a clearly

deﬁned immunization outcome.

A clear objective acts as the ultimate check

on our work: does an intervention we are

implementing lead to positive changes in

equitable immunization coverage? While

we will aim to track the progress of our

solutions much later on (Question 5) with

mechanisms like intermediate indicators, we

are ultimately concerned with the impact

of our work. After clearly establishing an

objective within a particular context from

the outset, we will return to it often.

38 39

DEMAND FOR HEALTH SERVICES

Q1: WHAT IS OUR OBJECTIVE? 1C: DESCRIBE THE PROGRAMME CHALLENGE

Our Objective is for U (user-group) to

change from E (existing state) to I (improved

state) by addressing O (biggest obstacle).

The tool below helps to separate each

element of the objective formula.

E Existing State (1b)

I Improved State (1b)

O Biggest Obstacle(s)* (1c)

to change from

U User-group (1a)

by addressing

Our Objective is for

Examples:

Our objective is for U children of recently arrived migrant

families in the capitol

to change from E 50 percent DTP1 coverage

to I 80 percent DTP1 coverage

by addressing O caregiver perceptions about the accessibility

of services

Our objective is for U children of nomadic pastoralists in

the North

to change from E 35 per cent completion of the childhood

vaccination schedule

to I 80 percent completion of the schedule

by addressing O the obstacles and opportunity costs of

accessing services at ﬁxed sites by families on the move

Our objective is for U children of ethnic minority

background in a poor peri-urban neighborhood

to change from E 30 percent loss to follow up (“drop out”)

to I less than 10 percent loss to follow up

by addressing O negative experiences at the point of service

that keep parents from returning to the clinic

Objective Formula

* This biggest obstacle(s) are working assumptions that we will question during “What do we think we know?”

and return to during user research.

40 41

DEMAND FOR HEALTH SERVICES

Q1: WHAT IS OUR OBJECTIVE? 1C: DESCRIBE THE PROGRAMME CHALLENGE

What Do We

Think We Know?

Introduction: Critical Reﬂection

It is likely that you have some knowledge about the

programme challenge articulated in Question 1. But some

types of knowledge are more valuable than other types.

While general knowledge is helpful, a full accounting of

the speciﬁc challenges facing the intended users of an

health service are dependent upon local context and thus

require local investigation. Local knowledge — gathered

from years of local experience, research and

reﬂection — is of primary value.

This phase is about composing learning goals starting with

what we know and think we know — the local knowledge

that already exists among you, your team members and

your programme. Because this likely is not the ﬁrst time

your team has engaged in the process of investigating

and responding to challenges facing users, it is helpful to

begin the process by methodically reﬂecting upon your

existing knowledge.

Reviewing existing knowledge and recognizing

assumptions before we deﬁne our learning goals insures

against duplicating past eorts that didn’t succeed and

avoids overlooking areas of exploration if their past

conclusions are based on insubstantial evidence.

42 43

DEMAND FOR HEALTH SERVICES

2Methodology

To methodically account for the knowledge that already

exists, follow this three-step process.

Place your main learning goals on a wall

or board in a shared space. Document

the possible assumptions that you and

your team might carry with you next to

each learning goal.

Gather available information about

the challenge, past efforts and the

individual or community in question.

Mark key pieces of information that

show what we have learned, what we

should keep in mind, and the relevance

this information has to the present.

To help avoid bias, document the

possible assumptions that you and

your team might carry with you.

Assumption Examples

Assumption Catalogue

Using the “Journey to Immunization”

as a tool, clarify what you hope to get

out of the research. These learning

goals will help you to choose the

research methods to use during

Question 3.

Journey to Immunization

What is been

studied about

this user-group?

What is already

known about

the challenge?

What eorts

have been made

in the past?

yes and...

and also...

maybe but...

2a: Assemble Existing Knowledge 2c: Compose Learning Goals2b: Recognise Assumptions Final Output: Field Research Map

44 45

DEMAND FOR HEALTH SERVICES

Q2: WHAT DO WE THINK WE KNOW? 2A: ASSEMBLE 2B: RECOGNISE 2C: COMPOSE

Assembling and examining existing

knowlege are prerequisites to what

we think is the most important step:

recognizing our assumptions. In any

situation where we are asked to solve a

problem, we bring along implicit and explicit

assumptions — about the population we

are serving and the challenges they are

facing. This is an opportunity to discuss

assumptions prior to problem-solving.

Why, exactly, is recognizing assumptions

so important? Suppose an immunization

programme has long been challenged

by a certain population’s ‘refusal’ to

vaccinate. This non-vaccination behaviour

has led to a critical level of unimmunized

children, representing a stark inequity in

our district. In previous studies, this hard-

to-reach group has cited religious reasons

for refusal. We are now again attempting

to address the problem of low coverage,

and ‘existing knowledge’ points to a clear

reason for the persistence of the problem:

negative beliefs about vaccinations.

By recording this information, we can call it

into question. Maybe negative health beliefs

are, in fact, directly mitigating vaccination

outcomes. But it might also be true that

that is not the whole story. Perhaps we will

later discover in user research (Question

3) that a religious leader has long been

advising followers to avoid vaccination;

but outside the community’s view, many

in fact want to vaccinate their child. A

ﬁnding such as that would give us a very

different understanding of that population,

and suggest very different solutions.

The simple act of reﬂecting on possible

assumptions we might carry can help to

mitigate their inﬂuence down the line.

Assembling the available information on the

current challenge can be an overwhelming

task. Instead of casting too wide a net, we

encourage you to collate only those pieces

of information that fall into one of the

three categories of ‘existing knowledge’:

• Knowledge about the programme

challenge

For example, if the challenge is about

irregular use of immunization services, or

caregivers regularly accessing services late

and out of step with their immunization

course, it is possible that your team

already is aware of the situation.

• Knowledge about past efforts

Maybe this is the ﬁrst time your team is

attempting to address this problem. If not,

then it is possible to gather lessons from

past efforts, such as what has worked and

what has not — and, most importantly, why.

• Knowledge about the user-group

The population in question — the users you

are most concerned about — may have

been previously studied. It is possible that

some outside group your own programme

has already conducted formative research.

A review of the material you have assembled

does not have to be exhaustive. Because

examining existing knowledge can become

a time-intensive task, mark key pieces

of information (for example, a past effort

that went very well, or terribly wrong) and

spend more time with those outliers.

While the volume of material can be large, the

output of an examination does not need to

be. A thorough examination should result in

succinct answers to the following questions:

• In summary, what do we think we

already know about the situation?

• What have we learned from any

past efforts, and what should we

keep in mind during this one?

• What has been studied about these

users, and how relevant is that

information to the present?

2a 2b

Assemble Existing Knowledge Recognise Assumptions We May Have

46 47

DEMAND FOR HEALTH SERVICES

Q2: WHAT DO WE THINK WE KNOW? 2A: ASSEMBLE 2B: RECOGNISE 2C: COMPOSE

A thorough accounting of the possible

assumptions we are 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 made in the past. It is

likely that you will recognise many as they

span contexts and communities. While this

is by no means exhaustive, we hope it is a

helpful starting place when thinking about the

assumptions that we and our team members

might inadvertently bring to the table.

Information

Correcting 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.25

Misconceptions

Incorrect 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.26 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.”27

Consideration

Given the importance of immunization,

it is sometimes taken as a given

that caregivers 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 caregivers who

reﬂect upon the decision to vaccinate or

not vaccinate; who calculate the beneﬁts

and costs.” However, “[i]t is not clear

that caregivers actually make reﬂected

choices concerning vaccination.”28 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.”29

Intentions

Strong intentions are not always

sucient (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 per cent 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.”30

Access

Making 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 programme provided free

immunization camps in 60 villages. In each,

a social worker educated communities

about the programme, 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 per cent” (up from 6 per cent).31, 32 In

Malawi, researchers found that coverage

was actually higher in some areas where

caregivers 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.”33

Resistance

Resistance 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 sterilization campaigning,

and Auxiliary Nurse-Widwives who are used

both to deliver polio vaccine and to ‘advise’

parents in favour of family planning (under

a minimum monthly quota), can be traced

to the ‘myth’ of OPV and infertility.”34

25 Nyhan, et a.l (2014), ‘Effective Messages in Vaccine

Promotion: A randomized trial’.

26 Sheldon and Alons (2003), ‘A study to describe barriers to

childhood vaccination in Mozambique’.

27 Banerjee, et al. (2010), Improving Immunisation Coverage in

Rural India: Clustered randomised controlled evaluation of

immunisation campaigns with and without incentives.

28 Holte, et a.l (2012), The decision to vaccinate a child: An

economic perspective from southern Malawi.

29 Nichter (1995), ‘Vaccinations in the Third World: A

consideration of community demand’.

30 Liao (2011), ‘Factors Affecting Intention to Receive and Self-

Reported Receipt of 2009 Pandemic (H1N1) Vaccine in Hong

Kong: A longitudinal study’.

31 As quoted in Cappelen, et al. (2010), ‘Demand for Childhood

Vaccination: Insights from behavioural economics’,

referencing Banerjee, et al. (2010), Improving Immunisation

Coverage in Rural India: Clustered randomised controlled

evaluation of immunisation campaigns with and without

incentives.

32 A concurrent incentive programme doubled that coverage

ﬁgure, by comparison.

33 Holte, et al. (2012), The decision to vaccinate a child: An

economic perspective from southern Malawi.

34 UNICEF, ‘Social Mobilisation and Communication for Polio

Eradication: Documentation in Nigeria, India and Pakistan

(2002-2003)’.

Assumption Examples

48 49

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Q2: WHAT DO WE THINK WE KNOW? 2B: RECOGNISE ASSUMPTIONS WE MAY HAVE

Questioning Assumptions Assumption Catalogue

Public versus private beliefs

Immunization programmes are sometimes

challenged by the ‘negative health beliefs’

of the populations they are trying to reach.

Further, it is often assumed that programmes

must campaign to shift those beliefs as a

prerequisite to the programme’s success.

However, beliefs are often intractable in

the individual and reinforced by community

norms; they are not easy to change.

A programme in Zambia in 1999 was faced

with “hard to reach and hard to convince”

populations.35 Among these groups were

members of the Apostolic Church in

Zambia. The church’s doctrine explicitly

rejected all ‘Western’ medicine. This was

a belief that the community afﬁrmed;

publicly, all members adhered to it.

However, researchers discovered that,

privately, many people did want to participate

in the vaccination programme — but they

were worried about the reactions of their

fellow members.36 Researchers devised

an elegant solution: health workers

stayed late in the area so members could

come for immunization when fewer

people would be there to see them.

This group, which publicly denied the value

of vaccination, ended up vaccinating almost

all of their children. Without this additional

observation, the programme may have

assumed the need to change this publicly

articulated ‘negative health belief’. By putting

all assumptions on the table, however

seemingly bullet-proof, programmes open

themselves up to interventions that are more

responsive to the challenges facing users.

Tool

Using the Assumption examples on

page 55 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.

35 Communication for Immunization and Polio Eradication in Zambia: A joint case study by CBOH, MOH, UNICEF, WHO/AFRO and

USAID (1999).

36 This phenomenon is known as ‘pluralistic ignorance’, where a majority of group members privately reject a social norm while

incorrectly assuming that most others accept it. See: Miller and McFarland (1991), ‘When Social Comparison Goes Awry: The case

of pluralistic ignorance’.

Start with the “Common Obstacles”

identiﬁed on page 37 and used in the

objective statement. Do we really know for

certain that this is what stands in our way?

Consider assumptions of misinformation,

access, consideration, resistance, intentions

and misconceptions from the examples.

What else do you assume about the culture,

barriers, beliefs and health workers?

50 51

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Q2: WHAT DO WE THINK WE KNOW? 2C: RECOGNISE ASSUMPTIONS WE MAY HAVE

The gap between the change we are

supporting in the community (the objective

statement) and what we know and think

we know from past research (assumptions)

leaves us with what we still need to ﬁgure

out. These questions that need additional

research become our learning goals.

Do we know how decisions are made? Do

we know everything about the prioritized

user-group’s motivations, perceptions,

and trade-offs? Do we know about how

they are inﬂuenced by and interact with

their family, community, health system,

and political system? Do we know who and

what they trust? Do we know about gender

dynamics, community outreach mechanisms

and channels with the community?

Using the Journey to Immunization

model on this page, think about what

areas need the most attention, and what

we can learn at each stage. Reference

the Assumption Catalogue from

page 51 to further investigate the

questions that need to be answered.

While the model follows a caregiver

journey to immunization, consider the

journey of the health-care provider as

well, since both work in equal parts

toward the goal of immunization. What

must they know and prepare? What

cost and efforts must they make to be

present both physically and mentally?

2c Compose Learning Goals Journey to Immunization

1st vaccination

Fully vaccinated

2nd vaccination

Awareness

Knowledge &

Cost & Eort

After Service

Preparation

Point of Service

Intent 2

Knowledge and Awareness

Awareness of vaccination, of disease, of

service (when/where) and how to get it.

Intent

Overcoming the gap between intention

and behaviour. Caregivers readiness

to vaccinate is determined by three

things: their attitude towards the speciﬁc

behaviour, their subjective norms and

their perceived behavioural control.

Preparation

Preparing for vaccination including

consideration of the disease/vaccination/

service, planning the logistics of accessing

services, ﬁnding transportation, arranging

child care and mitigating opportunity costs.

Cost and Eort

Cost is not only ﬁnancial – there is effort

to ﬁnd the time and make the required

trade-offs to travel to the point of service.

Opportunity, transport, lost income,

uncertainty of service, and social and

security costs are all part of this step.

Point of Service

All aspects of the vaccination experience,

including client satisfaction, interpersonal

communication with health workers, missed

opportunities and health center experience.

It is also important to remember the health

workers’s experience, and how that effects

their ongoing perceptions and performance.

After Service

Short-term factors include immediate

feedback, understanding the next steps

and getting home from the clinic.

Long-term factors include side effects,

cues to action, reminders, reinforcement

and vaccination as a social norm.

Surrounding Mental

and Social Models

Surrounding every stage are socio-

ecological levers that help us understand

what rationalization and logic cannot.

Consider interwoven levels of inﬂuence on

each step: subjective/social norms, trust,

conﬁdence, social values, community-

level political structures, inﬂuences and

interactions such as gender dynamic

within families, inclusive and adaptive

immunization policy with health systems,

community outreach mechanisms

and channels with the community.

52 53

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Q2: WHAT DO WE THINK WE KNOW? 2C: COMPOSE LEARNING GOALS

Learning Goal:

What do we

not know?

Research questions

that will be

investigated during

user research.

Assumptions:

What do we

think we know?

Acknowledgment of

any assumptions we

might be making or

biases we might have.

Theme:

What is really

happening?

Recurring information

from observations and

interviews that relates

to user behaviour.

Prompts:

What does this

imply for us?

Redeﬁne challenges

as opportunities to

prepare for generating

solutions.

Diagnosis:

Why is it

happening?

Hypothesis of why we

are seeing what we

are seeing or hearing

what we are hearing.

2c 2b 3b 3c

Field Notes Icon

This icon indicates where you

should pause and add your ﬁnal

sticky notes to the designated

Field Notes area.

During research, each step will yield distinct outputs — your “Field Notes.”

The Field Notes Map is 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 sticky notes.

Each row represents a distinct Learning Goal from page 52 paired with any

Assumptions we must prove or disprove. At the end of the user research

process, you will have a ﬁnal ‘wall’ of completed Field Notes that synthesize your

ﬁndings. During Question 4, we will use these Field Notes to generate solutions

to the challenges that they describe.

Field Notes Map

54 55

DEMAND FOR HEALTH SERVICES

Q2: WHAT DO WE THINK WE KNOW? 2C: COMPOSE LEARNING GOALS

What Stands

In Our Way?

Introduction: User Research

This is the question that will require the most of your time

and energy.

This phase introduces human-centred approaches to

investigate the challenges facing intended users of your

programmes. What prevents the prioritized user-group from

fully engaging with an immunization programme? This phase

uncovers the variables that stand in the way of success and

prepares teams to generate smart solutions.

While this may be the most intensive part of this Field

Guide, we are guessing that it still stands in contrast to

many other resource-intensive approaches to research.

Rather than suggest multi-year longitudinal studies, or

time (and resource) heavy cross-sectional analyses, we will

introduce here the processes and techniques of rapid inquiry.

While it may require your steadfast focus, it need not require

unwieldy budgets. Basic resources, deliberate attention and

an energetic team are all you need to begin.

DEMAND FOR HEALTH SERVICES

People are complex and riddled with paradoxes. We

respond to well-planned programmes in unpredictable ways

and give answers to surveys that contradict our real-world

behaviour.

The principal challenge of this phase is that people designing

immunization programmes are usually not the same

people that use them. We are asked to design solutions to

problems we have not confronted personally. There is a gap

between our experience and the experience of the people

using the programmes, called an empathy gap.

Each user research method works to close that gap. The more

we can empathize with the lives and lived environments

of the people we intend to serve, the more eective our

programmes will be. Activities grounded in dialogue and

listening give us divergent perspectives on problems and new

inspirations for solutions. This is a methodical approach to

investigating, understanding and diagnosing problems built

on that premise.

This phase will yield a set of insights that help to clarify

what might be preventing users from fully utilizing

immunization services. What are the factors that shape how

people do and don not engage with our programmes? These

insights will allow us to create and test solutions.

Our goal is to design solutions that improve

immunization outcomes. To do so, we will

focus on the intended users of immunization

programmes. The human-centred research

methodology identiﬁes the constraints facing

users through immersive research exercises.

These exercises will prepare us to diagnose

root causes and propose new ideas.

Augmentation, Not Replacement

Many readers of this Field Guide are

well versed in research. The process

of understanding and diagnosing what

is going on in communities and why

is not new. Most teams already have

practiced and established methodologies

for researching these challenges.

So we don not intend to wholly replace

those. Instead, consider what follows

as opportunities for augmentation: a

way of considering human-centred

approaches to better understanding

intended users, and integrating those

approaches into your investigative work. It

is our hope that pieces of this approach

and the principles that guide it will help

to support existing research methods.

Working with People

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Q3: WHAT STANDS IN OUR WAY? 3A: EXPLORE 3B: INTERPRET 3C: PROPOSE

Each part of this process is tightly linked; skipping is not

advisable. However, it should be iterative. Rather than

only moving from one part to the next, it is likely (and

encouraged) that you will return to earlier steps.

3Methodology

Prompt Formula

Research Methods

Develop a Research Plan

Conduct Field Research

Record Field Research

Share User Stories

Identify Important

Information in Stories

Diagnose the Underlying Causes

Final Output: Creative Prompts

3c: Propose Opportunities for Design3a: Explore the User’s Environment 3b: Interpret Collected Stories

Gain a detailed understanding of

the challenges preventing better

immunization outcomes. Better

understand user’s conditions and

experience to ensure you address the

right problems.

Share information from the ﬁeld

through user stories. Analyse themes

within user stories to hypothesize

why this is happening. Develop

diagnoses to explain what the team

saw and heard, returning to the

ﬁeld to gather more information as

needed.

Transform our diagnoses into

actionable tools. Personas help teams

understand the prioritized user-group’s

thoughts, feelings, actions. Prompts

translate the technical diagnosis

into a simple question that points to

solutions.

Make sure each prompt is articulated

succinctly and helps us make sense

of what we have gathered in the ﬁeld.

Corresponding

Diagnoses

Creative

Prompts

Prioritized

Information

Theme 1

Theme 2 Theme 3

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Q3: WHAT STANDS IN OUR WAY? 3A: EXPLORE 3B: INTERPRET 3C: PROPOSE

Exploring starts broad, gathering as much information from

the ﬁeld as possible. This is about engaging in open-ended

inquiry — familiarizing ourselves with an environment, the

people in it and the challenges that it presents.

This methodology uses human-centred activities that help

us to develop an intimate familiarity with users and the

contexts that inﬂuence them. These activities are loosely

split between recording what we see happening in the ﬁeld

and what people say. Respectively, these are observations

we make and interviews we conduct. The observational

and narrative data we gather will serve as the raw material

used to analyse the challenges facing intended users of

our programmes.

Explore the User’s Environment

After each day of ﬁeld research, quickly

synthesize and record the information you

have gathered. Document what is seen,

heard, felt and said. Record as much as

possible — even the seemingly mundane.

i. Research Methods

ii: Develop a Research Plan

iv: Record Field Research

iii: Conduct Field Research

We will use two types of qualitative

research: interview techniques and

observational techniques, observing users

within the environments that shape their

day-to-day lives and behaviours. There

is a list of observational activities and

techniques for collecting and analysing

data at the end of this section.

Plan how you will go in the ﬁeld and

talk to people. Choose which activities,

including both observations (what we see)

and interviews (what others say), to use

while allowing for ﬂexibility later. Build a

discussion guide to help guide interviews.

Observe intended users within the

environments that shape their day-to-day

lives and behaviours. Interview intended

users and allow them to speak about

speciﬁc events and experiences.

DEMAND FOR HEALTH SERVICES

Q3: WHAT STANDS IN OUR WAY? 3A: EXPLORE THE USER’S ENVIRONMENT

Learn from Outliers

Finally, observational activities can help

to elucidate phenomena that quantitative

data cannot — such as learning from

the ‘extremes’ rather than only from the

statistically average. Whereas quantitative

research tends to focus on patterns and

aggregates, observational research can draw

out equally important insights from outliers.

For example, a survey might reveal that

only a small group within a large community

initiates immunization courses. Observational

research can help us to go beyond the

‘averages.’ Spending quality time observing

and speaking with this outlier group could

point us in the direction of what works

based on what they are doing differently.

—

The following examples show how

observational techniques aid in better

understanding users and their contexts:

Timing Activities

How long does it take someone

to complete a particular task?

Suppose we are researching the the day-to-

day work of health-care workers at district

clinics, investigating ways their work is being

made unnecessarily difﬁcult. What might

we learn from timing how long it takes them

to perform certain tasks? By gathering a

small sample of ﬁgures and comparing them

across clinics, we could pinpoint tasks that

use a disproportionate amount of their day.

We might learn that data-entry is absorbing

most of their time, encroaching on the time

they could devote to patients. This might

give us speciﬁc information to support

health-care workers, rather than general

information to ‘increase performance.’

Diagramming Movements

How are people interacting with

each other in a particular situation?

Suppose we are interested in learning more

about how new mothers experience health

services in a neonatal setting. Vaccinations

are only one aspect of care, and we are

concerned with how immunization ﬁts into

her broader clinical experience. Throughout

their visit, how does she move throughout

the space, from entering to exiting? With

whom does she interact at different

moments? Observation here takes the

form of diagramming people’s movements

and interactions. Perhaps we ﬁnd that

mothers spend most of their time waiting;

and the time spent engaged with care

providers is quick and intense. Vaccination-

related conversations get buried easily,

despite there being ample down-time

during which immunization education and

instruction could be delivered to mothers.

Identifying Patterns

How many caregivers perform an

activity one way versus another?

Suppose we are looking into home-based

records, investigating what happens outside

the clinic. While interviewing caregivers

during at-home visits, we notice that some

keep their records concealed in a box, some

keep them out in the open and some do

not immediately know where they are.

Throughout interviews, simply tallying each

record-keeping observation into one of

these categories could quickly reveal either

a dominant or varied behaviour. Perhaps a

majority know exactly where their child’s

health card is; but because they keep it out of

sight (the dedicated box), it is also out of mind.

Go Beyond Self-reporting

The things that people say and what people

actually do are often not the same. Having a

body of observational research can ensure

that we are checking against the say-do gap.

For example, perhaps we noted in our

assumptions from Question 2 that previous

KAP surveys have consistently found

respondent claims of seeking out clinics but

ﬁnding them closed during usual business

hours. Observational research could afﬁrm or

question this self-reported claim. Spending

time at clinics and with community members

provides the opportunity to see rather than

only rely on what we have been told.

Observational research might conﬁrm

what the KAP surveys suggested: clinics

appeared to open and close at inconvenient

times, perhaps inconsistent with their stated

hours. However, observational research

might also tell a different story: perhaps

at one point a certain clinic’s hours were

unpredictable; we might ﬁnd though that

this is no longer the case, and that over a

few weeks of observing clinic operations,

most appear to be open consistently

and in accordance with accessible hours.

Follow-up interviews with caregivers might

ﬁnd the belief of inconvenient hours was

spread throughout the community, de-

incentivising clinic visits among caregivers

who had never actually gone to the clinic.

Unearth the Details

Observational research can provide a

more complete assessment of challenges.

Intended users rarely identify exact problems

and solutions. However, observing people’s

behaviours and how those behaviours are

shaped by their environments can provide

additional clues. For example, we might

know that users report “poor interactions

with health-care workers” as a reason for

dropouts. But what exactly about these

interactions is negative? Interviews might

be helpful; but again, interviews are still

subject to self-reporting challenges. They

might reveal that health-care workers are

seen as rude. But rude how, and why?

Spending time observing these interactions

will uncover more details. We might learn

the typical clinic environment in a district

is chaotic and overburdened; the problem

lies with the clinic environment rather than

with the care providers. Observational

details about unorganised intake systems,

long waiting times and inefﬁciently tiered

tasking between health-care workers

and physicians could give us a richer

understanding as to why users cite “poor

interactions” as a reason for not returning.

Observations allow us to be open-ended. Whereas a survey

requires that we generate speciﬁc lists of static questions,

observing people, asking questions in context, and revisiting

our assumptions enables deeper understanding.

Research Methods: Observations

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Home Visits

Developing deeper relationships

with a select user or group of users

through an immersive experience,

such as a full day at their home.

Artifact

Collection

Examining information

from materials, such

as investigating home-

based records or clinic

education materials.

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.

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.

Research Methods: Observations

Collect information from the ﬁeld about what may be impeding or facilitating immunization

outcomes among your user-group(s). Plan observations for multiple environments and balance

passive observation with experiencing users’ lives directly. Try to refrain from judgement based

on your own experience. The point of this research is to understand the experience of the user.

First-hand

Experience

Experience an event as the

user yourself. Move through a

clinic experience as though you

are a patient. Work alongside

a mother or health-care

worker for a day. Accompany

a caregiver on a clinic visit.

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Q3: WHAT STANDS IN OUR WAY? 3A: EXPLORE THE USER’S ENVIRONMENT

Interviews provide us with speciﬁc

events, not generalized statements.

For example, rather than just learning that

users are ‘too busy’ to get a vaccination, we

might learn that a user is indeed busy; and

that as a new mother, she feels overwhelmed

with new responsibilities. While she intends

to get her baby vaccinated, she is struggling

right now to focus on properly feeding and

clothing him. She sees these essentials as

taking priority. Once they are taken care of,

and she feels like she has more time, she will

get to the clinic.

This richer story goes beyond a generalized

statement, and gives us more to analyse:

there is a gap between intention and action;

the emotional stress of being a new mother is

causing her to defer taking action; and there

may be perceived or real opportunity costs

to seeking out vaccinations such as less time

to focus on survival essentials like clothing

and food. Later, it will be much easier to

brainstorm solutions for these detailed facets

of her story than to a generalized and abstract

problem like ‘busyness’.

Interviews establish empathy with

users and mitigate judgement.

Despite our best intentions, it is hard to

reserve judgement — even subconsciously.

When learning about ‘suboptimal decisions’

made by others we may imagine that we

would have made a better decision. Stories

help to mitigate that tendency by inviting

empathy. When we learn, for example, what

it feels like to be a new mother in a particular

context — the pressing details of her day, the

mercurial emotions of motherhood — it is

easier for us to engage in the imaginative

exercise of putting ourselves into her shoes.

Empathy helps us to design solutions

for others, not for ourselves. Solutions

inﬂuenced by what we would have done

in that situation will be different (and less

effective) than solutions inﬂuenced by a

visceral understanding of the capacities

and constraints facing the intended users

of immunization programmes. Whereas

judgement separates us from others’ lived

experiences, empathy helps us to appreciate

them. Gathering ﬁrst-person narratives — in

users’ own words — helps get us there.

Lastly, there is an important caveat to

interviewing. While gathering stories is

important, this does not mean that we

should take all stories at face value. What

people believe and say is not always what

they do. Repeated observation of people in

context can help us to juxtapose stories to

what we see with our own eyes — which

is why comparing what we observe to the

stories we hear can be critical. Our next

step (3b: Interpret Collected Stories) will

help us determine what is really happening.

Interviews improve knowledge

transmission to our teams.

It is easier for our brains to remember

stories than numbers. Narratives are more

easily recalled, and so can be more easily

transmitted to others — and, in turn, more

easily acted upon. Imagine a bar graph

with ‘reasons for non-vaccination’ listed

across the x-axis: too busy, rude health

workers, and fear of side effects. Compare

that image to a storyboard of events as

recalled by a mother: how she planned to

go to the clinic that day; how she was asked

to watch over her neighbour’s children

instead; how she might have dragged

them along, but felt overwhelmed when

she imagined the chaotic waiting room of

the clinic. This is not to say the bar graph

is unnecessary; but it is not enough.

When it comes time to think about solutions

to the challenges faced by this mother in

an effort to get her child vaccinated, the

storyboard will help transmit empathic

knowledge to your team more than

numbers alone. Because narratives put

what we learn in context — because they

give meaning to otherwise abstracted

information — they help our teams to

make sense of what we see in the ﬁeld.

Incorporating listening tools into our ﬁeld research invites

users to tell us their stories. Open-ended questions in

particular unearth important information. Here are some

ways that open-ended questions produce new insights.

Research Methods: Interviews

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Inviting users to share stories about their lives, their local

contexts, and their engagement with immunization systems,

we can complement our observations with a more ‘active’

form of inquiry. I know that without

vaccines my child may get

sick. But what if she also gets

sick from the the side eects? I

think that it would be worse if the

child became ill from the vaccine,

because that is my fault, then if

she became ill from the disease.

That would be nature’s

fault, not my own.

They tell us the

vaccines are free, but

that isn’t right. I had to

pay a fee before receiving

my child’s health card. I

didn’t know that was

going to happen.

They tell me that

vaccines will help my

entire community. But

why then isn’t my entire

community contributing

by getting their vaccines?

Once others do their

part, then I will, too.

I planned to take

my child for her next

vaccination, but this week

was very busy, and you

can never be sure that

the clinic is open.

The rumour about

that vaccine probably

is not true. But I have

heard it so many times

from so many people.

Vaccines are for

poorer children.

Our children do

not require them

as much.

It seems just as

likely that my child

will get sick with or

without the vaccine, so

why should I spend so

much time and money

at the clinic?

Some children have

gotten sick from that

disease, but I don’t think

my child will. Even if she

does, I will be able to

care for her.

I took my children

to the clinic for their

immunization because I

am a good mother. Other

good mothers in our

community get their

children vaccinated.

I was told that

vaccines will not

help to make my child

healthier now, only

later, so there is no

reason to go now.

I don’t think

that many of my

friends are taking their

children to the clinic as

much as they tell us we

should. It’s just too much.

I don’t think others

are doing it more

than me.

Story

Quotes

Research Methods: Interviews

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Research Methods: Interviews

Interviewing should almost always be part of the research plan. Interviews collect what

people — caregivers, health-care workers, community leaders, families, communities — think

and feel, in their own words. Whenever possible, conduct interviews in the home of the

family, or a location where health services are offered.

Structured

interviews

These are scheduled and

deliberate conversations.

Use the Discussion Guide

(Tool #9) to ensure you are

probing the most important

topics consistently in each

interview so you have

points of comparison.

Photo

Documentation

This method allows users to self-

select what they ﬁnd important.

Give them a basic camera and loose

instructions (example: take pictures

of what makes her think of ‘health’)

to gain an intimate perspective—

and draw out more stories.

Show and Tell

User-guided tours allow users

to show their environment and

share their experiences within

them. For example, a health-care

worker might walk you through

a clinic. Combining a guided tour

with informal interviews can

prompt users to share stories

when cued by their context.

Card Sorting

This method can be used as an

activity within an interview. It

provides a hands-on way to engage

users and allow them to share their

perspective through non-verbal

means. By using simple pictures

or illustrations on index cards,

users can sort processes they

experience or desire (a sequence

of events) or rank preferences

(their priorities for the week).*

For more on card sorting methods, see The Field

Guide to Human-Centred Design by Ideo.org.

Informal

interviews

This style of interview is

helpful to familiarize oneself

with the environment and build

rapport with users. These

conversations can be conducted

as an exploratory prerequisite

to structured interviews.

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KAP (knowledge, attitudes, and practices)

surveys are an attractive approach to

investigate health-related behaviours for a

number of understandable reasons: the

data are quantiﬁable and thus perceptively

rigorous; ﬁndings can be generalized to a

larger population beyond those surveyed;

and the methods for execution are well

known and so more easily implemented.

However, despite the comfort of obtaining

hard numbers, KAP surveys face considerable

limitations, especially when it comes

to obtaining nuanced understandings of

behaviours and the environments that

shape them. This page presents common

challenges to interpreting quantitative data.

Knowledge and Behaviour

An emphasis on assessing knowledge can

falsely presuppose a direct relationship

between knowledge and behaviour.37

For example, a KAP survey ﬁnding that

respondents generally have a low level

of knowledge regarding the link between

certain symptoms and a disease might

presuppose that this has a direct inﬂuence on

health-seeking behaviour — that insufﬁcient

knowledge will impair desirable outcomes.

However, this may not be the case; the

relationship between knowledge and

behaviour is often counterintuitive and indirect.

Measuring Attitudes

Here are some ways that survey responses

may fail to accurately measure attitudes:38

1) People tend to provide answers

they think are correct or which they

think the researcher wants to hear,

regardless of their true attitudes.

2) When people have no opinion they

may feel compelled to invent one.

3) Social norms may lead

respondents to modify responses

in order to appear acceptable.

4) Respondents tend to change their

responses to make contradictions

appear consistent.

We need to consider these constraints

before assuming that quantitative data

can accurately measure attitudes.

Past Practices

Asking respondents to report past events,

such as decisions they made or thoughts

they had in previous situations, can

assume an outsized ability among people

to accurately recall information.39 For

example, when asking a respondent about

the symptoms experienced during an

illness and the subsequent health-seeking

Research Methods:

Knowledge, Attitudes and Practices

Challenges to Interpreting Quantitative Data

37 Yoder (1997), ‘Negotiating Relevance: Belief, knowledge, and practice in international health projects’.

38 Podsakoff, et al. (2003), ‘Common Method Biases in Behavioural Research: A critical review of the literature and recommended remedies.’

39 Hassan (2005), ‘Recall Bias can be a Threat to Retrospective and Prospective Research Designs’.

40 Bernard et al (1984), ‘The Problem of Informant Accuracy: The validity of retrospective data’.

41 Pelto and Pelto (1997), ‘Studying knowledge, culture, and behaviour in applied medical anthropology’.

42 Launiala (2009), ‘How much can a KAP survey tell us about people’s knowledge, attitudes and practices? Some observations from

medical anthropology research on malaria in pregnancy in Malawi’.

43 Podsakoff, et al. (2003), ‘Common Method Biases in Behavioural Research: A critical review of the literature and recommended remedies.’

behaviour demonstrated, the responses

provided will likely be impaired by imperfect

informant accuracy.40 An over-reliance

on memory of past practices can lead

to compromised retrospective data.

Descriptive Data

Perhaps most critically, KAP surveys — as with

most survey instruments — can be helpful in

assessing people’s general understanding

of local practices, but are much less capable

of teasing out the logic behind respondents’

behaviours.41 In other words, KAP surveys

can give us lots of descriptive data, but

are less capable of providing explanatory

data. The implicit risk here is the use of KAP

surveys to determine the reasons behind

behaviours, rather than acknowledge the

limitations of such survey instruments.

Stated versus Actual

Surveys may reveal misalignment between

statements and facts. In one example, a

researcher recorded positive attitudes

towards an antenatal clinic’s services through

a KAP survey, and then vocal criticism of

that same clinic during in-depth interviews.42

The illustration is an example of courtesy

bias, where respondents produce answers

that they think the researchers want to

hear. Other issues, such as the difﬁculty of

obtaining veracious opinions on sensitive

topics, can also skew ﬁndings.43 Awareness

of potential misalignments will help to

interpret survey ﬁndings more accurately.

“The most important aspects of a situation are not necessarily those

which can be readily quantiﬁed… However, quite often the appeal

of quantiﬁcation derives from the unfounded belief that the process

of quantiﬁcation itself can promise or ensure precision, intelligibility,

reliability and concreteness. Of course, it does nothing of the sort;

quantiﬁcation often involves a large measure of abstraction.”

Bauer, P. T. (1972), Dissent on Development: Studies and debates in development economics

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ii Develop a Research Plan Research Plan Template

Observations

Where to Use

Choose a place where you can have an

experience that is relevant to your challenge.

Clinics, homes, transportation to and from

health centres, community centres, trusted

religious or spiritual centres are all potential

places for observation. Think about the daily

journey of your user — what places do they

touch along the way?

How to Use

Choose which activities will help you learn:

• Observing mothers and

families, experts, or clinics

• Shadowing mothers, caregivers, health-care

workers, or community health workers

• Co-create with the community, learning

from peer-to-peer observation

Interviews

Where to Use

Whenever possible, conduct interviews

in the home of the family, or a location

where health services are offered.

How to Use

• Describe the people you want to meet:

How are these people distinct? Who else

is part of their life that you can learn from?

• Select research participants: Talk with your

team, colleagues and partners to help locate

the contact the types of people you want to

speak with. Send an email describing what

you are looking for, post in a common area,

or reach out to a community leader for help.

• Develop a discussion guide but allow

for spontaneity (see page 78).

• Include interactive activities for

interviewees who may be reluctant to

share openly with open-ended questions.

How Many?

The difﬁcult question for research is: how

much is enough? We are not trying (at

least immediately) to ﬁnd a representative

group whose behaviours reliably can be

generalized to the entire population. We

are trying to solve for a distinct group

within a population — the prioritized user-

group — so the number we start with will

be small. We cannot give you an exact

number of interviews or observances,

but we can give some guidelines:

• Talk to more than one subgroup and

visit more than one location.

• Visit enough locations or speak to

enough people that you start to

recognise patterns — if you only see

or hear it once, it is anecdotal.

• There is no magical number, but talking

to seven people is a good rule to have

diversity of perspectives, but also

be able to draw commonalities.

Plan Your Interviews Plan Your Observations

Prioritized Users In the Home / Community

shadowing, peer-to-peer, ﬁrst-hand experience

Adjacent Users Type A

Adjacent Users Type B

At a Care Facility

shadowing, peer-to-peer, ﬁrst-hand experience

At a Religious/Inﬂuential Location

shadowing, peer-to-peer, ﬁrst-hand experience

1 1

4 4

2 2

5 5

3 3

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Express Gratitude!

Introduce Yourself

Start Speciﬁc

Go Broad

Concentrate on the Interest Areas:Try an Activity

Tell me a bit about yourself. Where do you

live? Where are you from? What do you do?

Can you show me how you...? Send me three

pictures of when you feel (x)... Sort these

cards in order of importance to (x)... Think

aloud as you perform (x) process or task

Tell me about a time when... What are

the best/worst parts about…? Can you

help me understand more about…?

Take me through a typical day... Where

do you get your information on...? What

work-arounds have you found for...?

Develop a Research Plan:

Discussion Guide

Having a good conversation with a stranger

is not always easy. You have to help the

person feel comfortable and build trust

while collecting relevant information. To

manage this delicate balance, prepare a

discussion guide to serve as an outline

for your conversation — a checklist to

ensure you have covered everything.

The exact order of the questions may change

to accommodate the natural ﬂow of each

conversation. All questions in the guide

should be followed up with probing questions

such as “Why?” or “How?” or “In what way?”

Identify topics

As a team, brainstorm themes you want

to learn about in your conversations

with research participants.

• What do you need to learn

about your challenge?

• What are you hoping to understand about

people’s motivations and frustrations?

• What do you want to learn about their

activities? Network? Habits? Beliefs?

Write questions

Write questions that are broad enough

to encompass the experience of many

perspectives. Frame them as open-

ended questions (avoid questions with

a “yes” or “no” answer) that invite

discussion of their experiences, such as:

• Tell me about a time when...

• What are the best/worst parts about…?

• Can you help me understand more about…?

• Take me through a typical day...

• Where do you get your information on...?

• What work-arounds have you found for...?

Include interactive activities

Activities are fun, interactive and can help

uncover the behavioural information you

are looking for when interviewees are

reluctant to share openly. Consider asking:

• Can you show me how you...?

• Send me three pictures of

when you feel (x)...

• Sort these cards in order of

importance to (x)...

• Think aloud as you perform

(x) process or task

Organise the order

• Introduce yourself: Explain what

you are doing, and reassure that you

are not here to judge the person.

• Start speciﬁc: Begin with questions your

participants are comfortable answering.

• Try an activity: Activities are a great

warm-up, so if they are part of your

plan, put them towards the beginning.

• Go broad: Ask more profound questions

about hopes, fears and objectives.

• Concentrate on the interest areas:

Explore your challenge or any interesting

theme you picked up on during the

conversation in more depth.

• Close the conversation: Always thank

the interviewee for his or her contribution.

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Conduct Field Research

Conducting

Interviews

• Interview in pairs (alone can be hard,

the entire team can be intimidating).

• Assign roles: one person leads the

conversation and reads the participants’

body language/facial expressions, the

other takes careful notes (get word-

for-word quotes where possible).

• If possible, take photographs. Remember

to ask permission before taking any photos.

• Hold the interview in a place with

minimal distractions or interruptions.

• Allow interviewees to share incorrect

answers, it does not matter who is

right, it matters what they believe.

• Do not make the interview about

you — even if you identify with stories

the interviewee is sharing. Build rapport

without dominating the conversation. Any

judgement, including positive or negative

reinforcement, can inﬂuence responses.

Exploring and

Observing

• Explore and take notes — try to blend in

with everyone else during your observation.

• Find a spot that is out of the way.

• Take notes and photos (ask

permission where appropriate).

• Capture interesting quotes (and the

context in which you hear them).

• Draw sketches, plans and layouts

(patient or health-care worker/

community health worker journeys).

• Look for interactions between people,

and between objects, instructions

and people (key experiences

and how they are created).

• Collect objects that facilitate activities,

experiences and interactions.

iii

Conducting research requires that we leave

our world behind, and become sponge-like

inside the environment, home, community

or health centre of our user. This acclimation

requires a few general preparations:

• Make sure you are not interested in a

particular outcome before you start. If we

know what we want to see or hear, we can

convince ourselves that we saw or heard

it. Be curious and inquisitive without an

agenda. If you feel you have an agenda or

expected outcome, share this with your

team when drawing-out your assumptions.

• Have your team meet somewhere

that is not where you will interview or

observe users. This ensures you are

prepared, gives you time to review

the most important questions you

have left to answer, and transitions

you into a research-ready mindset.

• We want to know about their lives.

Make sure you are aware of the social

expectations and customs in the region

where you are conducting research.

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After each day interview, quickly synthesize and record the information you have

gathered as an empathy map — what the interviewee is thinking, feeling, seeing,

doing and saying. This serves two key purposes: it ensures that important details

are not forgotten and helps guide what you are looking for during interviews.

Record Field Research: Interviews

Name

Date

Saying

5 memorable

quotes

Feeling

3 frustrations/

motivations they

were feeling:

Doing

4 recent actions

they took:

Thinking

2 things they might

have been thinking:

Describe setting Seeing: Describe setting

After each day of ﬁeld research, quickly synthesize and record the information

you have gathered — what you observed people seeing, doing and saying. This

serves two key purposes: it ensures that important details are not forgotten

and helps guide what you are looking for during additional research.

Record Field Research: Observations

4 Moments that stood out:

5 Observations

What are people doing in this situation? How are people

doing this? Why might they be doing it this way?

3 Things that were

new or surprising:

2 Things that felt familiar:

1 Way we could help our prioritized user-group:

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Our next task is to make sense of what we saw during

our observations and what we heard in the stories we

collected—in other words, to interpret our ﬁeld research.

If seeing and listening are about using a judgement-free

lens to take stock of environments and the ways in which

users behave within them, interpretation is about critically

analysing what we gathered.

The purpose of interpreting is to move from seeing “what

exists” to establishing “what this means.” This process will

lead us to articulate insights that capture the underlying

challenges facing users and what is standing in the way of

our programme objective.

Interpret Collected

Stories

Analyse key ﬁndings to hypothesize

why this is happening. Call-out patterns,

surprises and commonalities.

Choose the most important to consolidate

into prioritized pieces of information.

Hypothesize: Ask yourself why

this is happening, drawing from

research and educated guesses.

Debate: Can we prove ourselves

wrong? What might we have

overlooked? Misinterpreted?

Revisit and Finalize: Articulate ﬁnal

diagnosis succinctly to help teams make

sense of what was gathered in the ﬁeld.

Share information from the ﬁeld to help

everyone internalize what you observed.

Use creative presentation methods

that help close the empathy gap.

i: Share User Stories

ii: Identify Important Information

iii: Diagnose the Underlying Causes

Theme 1

Theme 2 Theme 3

There are three steps to interpreting the information we gathered from the ﬁeld:

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There are many methods for sharing what

you learned with your team members. The

presentation method allows colleagues

to passively receive information. The

interactive method walks colleagues

through a storyboard of events as recounted

by a user; asking them to view a wall of

pictures you snapped of a user’s lived

environment; inviting them to listen to an

audio recording of the crying babies and

shouting physicians in a clinic waiting room.

We prefer the latter method. While the

techniques for inviting team members into

the worlds of our intended users is vast,

what the effective ones share is a examples

of the concrete over the abstract.

For example, video clips of a chaotic

afternoon at a clinic can help team

members empathize with a mother who

was reluctant to bring her children there.

Rather than only share with colleagues

that “moms complain about the clinic

because it’s stressful,” this helps team

members to viscerally understand why.

Sharing should be a fun — and even

playful — team activity. Tell from the

user’s experience and viewpoint, not

judging from how you think they should

behave or what you want them to do.

Tool

Using notes from Record Field Research

along with material gathered from the

ﬁeld, transcribe what you have seen and

heard in the ﬁeld to your team members.

Sharing stories allows you to bring the

context of the user with you throughout

the rest of the process, ensuring you are

designing a solution that is addressed to

them. Rely as much on ‘sensory’ sharing

as possible—use visuals of the location or

person. Sample share back activities include:

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).

Gallery Walk: Place large printed

photographs taken in the ﬁeld around a

room. Each picture should communicate

something notable you / your team observed.

Storyboards: Draw simple storyboards to

walk your team through a story, a setting,

or a process you observed. 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.

Share User Stories

Sharing our material from the ﬁeld is an exercise in

transmission. As with any piece of communication,

information has the potential to be transmitted

eectively or ineectively.

Environment

What you noticed about their home,

community, or work place.

Connections and Relations

People and organizations

they are connected to.

Objects

Physical and digital objects they use.

Portrait / Images

Attach Photographs Here

Their Story

Who are they? What type of

user do they represent?

Quote

What was the most memorable

thing they said?

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It is possible that we’ll overlook important

pieces of information. Unfortunately,

sometimes those realizations come as

we implement and observe our ideas in

the ﬁeld (more on that in Question 5). But

we try our best to identify what matters

most. With the information you laid out

during ‘Share User Stories,’ you are in a

position to mark the information that is

surprising, familiar from other contexts, or

suggests a pattern. These themes are likely

to be the most important information.

First, what surprises you should not be

relegated as ‘just’ an anomaly; it may be

tempting to disregard surprising information,

principally because it might not ﬁt with what

we think we know about the challenge.

Second, if you saw something in other

contexts, it is possible that you are seeing

a well-observed, common challenge of

immunization programmes. And lastly,

spotting a recurring theme — a pattern across

multiple observations and stories — suggests

a behaviour that is not an aberration, but

instead one that is being shaped by an

environment affecting many users.

As with ‘Share User Stories,’ the ‘Identify

Important Information’ process can take

many forms. We recommend following

a general principle: allow for both group

and individual analysis. Group analysis

can look something like this: after sharing

your ﬁeld observations and stories, ask

colleagues to write down on sticky notes

what surprised them, what reminded

them of past observations (in this or

other contexts), and what jumped out

as patterned. (These are the same three

criteria listed above.) Grouping the sticky

notes by common themes on a wall can

provide a quick visualization of what

collectively appeared to the group.

Group exercises like this can be preceded

by more individual reﬂection on the

information presented. Allowing colleagues

time to independently analyse what you

shared widens the scope of what the

team might ﬁnd important. It curtails our

tendency to focus too quickly and achieve

a group consensus on what is important.

After independent analysis, invite team

members to share their interpretations

of what seemed important and why.

The ‘Identify Important Information’ process

should conclude with a synthesized list of

surprises that stuck out, commonalities

from this or other contexts, and patterns

in the research. You will end this step

with the perspectives of an entire group

regarding what might be most important

from your user research. Rather than simply

reﬂecting on your own research, putting

the information you gathered in front of

others broadens the scope of inquiry.

It is now up to you to reﬂect on what

information has been prioritized and isolate

what you believe to be the most important

themes. For example, maybe a common

pattern identiﬁed by your team during an

‘Identify Important Information’ exercise

was the persistence of an intention-action

gap: that mothers consistently self-reported

their belief in the value of vaccines and

want to access them, but seem to defer

the action to an undeﬁned later date.

Place the most important

themes emerging from ﬁeld

research in your Field Notes

Map next to the learning goal

and assumptions they address.

During ‘Identify

Important Information’,

we face a key risk:

the tendency to assign too much

importance to the wrong information.

Consider, for example, research conducted

in Mozambique. In both surveys and focus

group discussions, researchers discovered

that a portion of the population held

misconceptions about vaccinations, or

a “general lack of accurate knowledge.”

Mothers stated that vaccines cure disease,

that it is dangerous to vaccinate a sick

child, and that receiving more than one

vaccine in a day can be dangerous.

If evaluating this information on its own,

it may be tempting to make an erroneous

conclusion: these misconceptions

negatively inﬂuence immunization

outcomes. However, the researchers

also found that in some areas, where

misconceptions were more prevalent,

immunization coverage was actually higher.

By contrasting these ﬁndings to other pieces

of information — for example, ﬁrst-hand

accounts that “virtually every mother”

wants to have her child “completely

vaccinated”— researchers were careful

to not give disproportionate value to an

observation’s importance. Instead, they

found that the “overwhelming barrier for

mothers who have never had their child

vaccinated was... distance to services.”44

44 Sheldon and Alons (2003), ‘A Study to Describe Barriers to

Childhood Vaccination in Mozambique’.

Identify Important Information in Stories

Mistaking

the Value

of Data

Identifying what matters asks that we prioritize what we just

shared. It requires that we make informed but nonetheless

subjective judgements about what information we think is

important and what we’ll choose to focus on.

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Source

Caregivers speak consistently

about both the source of the

vaccines and the sources of

information behind vaccines;

they are assigning importance

to where vaccines are

made and questioning the

veracity of what health-care

workers are telling them.

Familiarity

Most caregivers can recite

a similar rumour about a

new vaccination causing

illness, suggesting broad

familiarity with a repeated

story; at the same time,

caregivers deny the rumour’s

plausibility in interviews.

Deferral

Non-vaccinating caregivers

afﬁrm the importance

of immunization but are

continually pushing the task

into the future; they express

immunization’s beneﬁts in

abstract and general terms,

and the costs in speciﬁc

and concrete terms.

Independent Analysis

After (or during) ‘Share User Stories,’

individual team members should note

important information — one thought per

sticky note — according to the Criteria

for Important Information below.

Group Analysis

and Generation

Share Sticky notes from the Independent

Analysis in small groups. Use each other’s

sticky notes to generate additional notes

about what seemed important (refrain

from criticizing what others share).

Cluster Themes

Group the sticky notes by common

theme on a wall— what collectively

stood out to the group?

Example ThemesCriteria for Important Information

Add ﬁnal themes to your

Field Notes Map next to the

learning goal and assumption(s)

they respond to.

Identify Important Information in Stories

Isolate the most important pieces of

information from ‘Share User Stories’ and

cluster into themes. These themes will be

further investigated during ‘Diagnose the

Underlying Causes.’ Consider sharing user

stories and identifying important information

during the same team work session.

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?

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We shared what saw and heard in the ﬁeld — and forced

ourselves to identify the information that seems most

important. Diagnoses ask us to hypothesize why the

obstacles we identiﬁed exist.

Generating hypotheses is the most challenging step, prone

to assumptions and error. Moving through a rigorous process

will ensure we are fully and accurately investigating the

underlying causes.

Diagnosing requires that we develop viable hypotheses

about what is going on in the ﬁeld; referencing evidence

from user research that works to either help validate or

reconsider those hypotheses before we articulate them as

ﬁnal diagnoses.

Your Field Notes Map now includes

themes from ﬁeld research. You will

begin to speculate about the causes that

shape the obstacles you identiﬁed.

Example:

Suppose you learned in the ﬁeld that most

mothers really want to get their children

vaccinated. Nearly every mother you speak

with tells you exactly that and appears to

mean it. There is a strong stated intention.

When asked during a group discussion,

mothers could recite the general beneﬁts

of vaccines and deﬁnitively afﬁrm that

they want their children fully immunized.

During one-on-one interviews in mothers’

homes, you collected information about

their practical knowledge, such as where

the clinic is located and when their next

appointment is. A pattern soon emerged:

among mothers with under-vaccinated

children; most eagerly agreed that vaccines

were important, but could not accurately

recite when and where they were due

for their next appointment. By contrast,

mothers whose children were fully up to

date could recite that information, or they

were able to easily look it up in their personal

records. It would seem that this practical

piece of information separated those who

got immunized from those who did not.

Theme 1: Most mothers are aware

of immunization beneﬁts and intend

to vaccinate their children.

Theme 2: Mothers with under-vaccinated

children cannot remember when and

where the next appointment occurs.

Hypothesis #1: The intention-to-action gap

is widest with mothers who lack the mind

space to keep track of appointments.

Hypothesis #2: Lack of practical knowledge

around appointment times might be what

is keeping mothers from fully vaccinating.

Diagnose the Underlying Causes Hypothesize

Developing a hypothesis is a combination of using

evidence gathered from the ﬁeld along with educated

guesses about causal factors. There may be multiple causes

behind a single obstacle, and therefore multiple hypotheses.

Strong diagnoses are argu-

ably the most important —

and most challenging — phase

of interpretation. Determining the most

probable cause of challenges facing users

is the strongest link between research and

interventions. Without sufﬁcient diagno-

ses, interventions may rely on mistaken

speculation. Unfortunately, taking the time

to form thoughtful diagnoses is rare.

This is understandable. In much of the

day-to-day work of those involved with

immunization programmes, situations

arise and we are called upon to act quickly.

From an unexpected outbreak to the roll-

out of a new vaccine, we are sometimes

compelled to bypass considered diagnoses

in favour of speedy implementation.

We may also face administrative con-

straints. Programme planning may not

permit empathic user research. Too often,

conducting thorough analysis feels like

a luxury. However, ﬁnding the time and

permission to engage in the diagnostics

process will undoubtedly lead to more

effective (and less wasteful) interventions.

Finding

the Time

iii

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Debating is the process of stress-testing

our initial hypotheses by ﬁnding competing

and afﬁrming pieces of information

from our research. By the end of this

exercise, you should be able to (1) dismiss

initial hypotheses that do not hold up

to more scrutiny, and/or (2) reﬁne what

you have with additional evidence.

Continued Example:

Let us bring the previous hypothetical

diagnosis into question. What other

information might have been gathered

that could contradict — or at least

modify — the conclusion we came to?

Consider the fact that mothers were

asked about their beliefs and intentions

in a group setting: in front of their peers,

they collectively agreed that vaccinations

were good, and that they wanted to get

their children immunized. But perhaps they

would have given different answers out of

sight of their peers? Maybe some could

not remember when and where to go for

their child’s next vaccine because they had

already decided not to go, and so did not

bother with those unnecessary details?

Going back out into the ﬁeld, we set up

one-on-one, private conversations with

mothers. During our at-home visits, we ask

about any concerns they have regarding

vaccinations. A few mothers say that they

are a bit nervous about their child getting

too many vaccines, especially in the same

day. This is mentioned inconsistently among

them. We also follow up on the practical

information: we ask to look at their health

cards and ﬁnd that the information is right

there, but neither we nor the mothers can

read it. The date, time, and place scribbled

by the health-care worker is illegible.

We ask the mothers why this information

was not clariﬁed at the clinic. It becomes

clear that if they asked the health-care

workers for clearer information, they

might have been scolded. Or worse,

these proud mothers may have risked

seeming illiterate. During our interviews,

none seemed particularly willing to

follow up when information given to

them at the clinic was not clear.

Additional Factor 1: Answers about beliefs

and intentions were given in a group setting.

New Evidence (individual conversations):

Conversations only uncover additional

concerns about too many vaccinations; other

answers consistent with group responses.

Additional Factor 2: Inability to remember

appointment times may be the result of

not wanting to vaccinate, not the cause.

New Evidence (individual conversations):

Appointment information is present

but illegible and mothers are averse

to conﬁrming the information.

This last exercise should yield an improved

diagnosis for each of the themes we

placed in our Field Notes Map.

A stress-tested hypothesis has

allowed us to create a more

reﬁned and insightful diagnosis.

Capture each of your diagnoses

in the Field Notes Map.

Continued Example:

Our initial hypothesis seems to have been

on the right track; the additional evidence we

gathered now serves to make it stronger.

We acknowledge that other variables may

be at play, such as concerns regarding

multiple vaccinations. However, it seems

possible that such a strong social norm

contributing to immunization might mitigate

that concern; it appears unlikely that it

plays a signiﬁcant role in preventing full

immunization. What appears more likely

is that the key pattern separating the

fully from not fully immunized — a lack of

practical knowledge around appointment

times — is creating a signiﬁcant barrier

separating intention from action. We can

articulate a newly improved diagnosis.

Improved Diagnosis: Missing pieces of

practical knowledge about the when and

the where of a next appointment, created

by variables as minor as illegible health-

care worker handwriting and caregivers too

nervous to clarify, is preventing mothers

from following through on their intentions.

RevisitDebate

With this new information, we have a dierent perspective.

We revisit our initial hypotheses to rethink and rewrite as

ﬁnal diagnoses.

Debating our diagnosis is not about arguing among team

members. Instead, debating is about trying to prove

ourselves wrong. What might we have overlooked?

Misinterpreted? Neglected to ask about entirely?

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Hypothesis are iterative,

and may require additional

research to validate.

Suppose we observed ‘refusal’ by a group of

users — caregivers who were not engaging

with immunization services. Through

interviews, we gathered stories about how

mothers were not getting their children

vaccinated because the vaccines, they

heard, were coming from a non-Western

country. A possible hypothesis might be

that a lack of trust in producers of vaccines

(‘performance trust’) was leading to refusal.

To stress-test that hypothesis we went

back out into the ﬁeld. Instead of just

interviewing users this time, we also spoke

to nurses and doctors, all of whom shared

that mothers were indeed coming to the

clinic. In fact, many were asking lots of

questions about the source of vaccines.

When the clinicians strongly afﬁrmed that

the vaccines were effective, some mothers

acquiesced and some mothers did not.

In this case, it would be appropriate to reﬁne

our hypothesis. Mothers trekking to the

clinic, asking lots of questions, and some

making a new decision — such observations

suggest that these potential users are not

really hard-line ‘refusers’ at all. In fact, it

would seem there is quite a lot of room

for persuasion. By all accounts, they are

demonstrating normal information-seeking

behaviours. As opposed to pinpointing ‘lack

of trust’ as the singular hypothesis, it is

more likely that conﬂicting information is

causing a form of decision-making paralysis.

Ambiguity and conﬂicting information

have the tendency to incline people

toward inaction: it is much easier to avoid

a decision when the information you have

gathered seems unclear or inconclusive.

Had we kept the initial hypothesis, we

may have been careful not to ﬂood the

community with vaccine efﬁcacy messages.

With hardline refusers, we would risk

a ‘backﬁre effect’. But now that our

hypothesis suggests a slightly different

scenario, we could very well test out a

communications campaign that makes the

efﬁcacy of vaccines the dominant piece

of information mothers’ receive. Iterative

hypotheses will yield improved solutions.

Sometimes, additional research will

reﬁne a hypothesis, as with the situation

above. In other instances, new research

might reverse our hypothesis. Either

way, hypotheses should be considered

iterative. Making observations is one

thing — they are empirical. But inferring

the underlying causes of what we are

observing leaves open ample room for

reconsidering and improving our hypotheses.

Diagnoses should be mindful of over-

reliance on past research and events.

In the Democratic Republic of the Congo,

past research has highlighted the prevalence

of “rumours and false religious beliefs”

as a reason for “mothers’ resistance”

to vaccinations, particularly among

hard-to-reach populations. For example,

one piece of research found that:

• “[A] a pastor wrongly told his community

that the cases of polio… were caused by

the poor quality of the anti-polio vaccine.”

• “For some religious followers… the

‘vaccine is a spirit of the devil and only God

can immunize with the blood of Christ.’”

• “For others, AFP [acute ﬂaccid

paralysis] are caused by witchcraft

and not by disease.”45

These ﬁndings may still hold true; they

also may be outdated, or perhaps not

as relevant to decision-making as they

once were among community members.

When engaging in a fresh diagnostics

exercise, including past research can be

helpful. However, it is critically important

that such knowledge (1) is not outdated:

perhaps these beliefs are no longer

widespread; and (2) if still relevant, is not

over-emphasized: perhaps these beliefs

still persist, but have little bearing on user

behaviour (see ‘Challenges to Interpreting

Qualitative Data’ on pages 74-75).

In many cases, teams working in a certain

context have been working there for a

long time. There is deep knowledge, a

history of past projects, and many lessons

learned. Separating what is helpful from

existing knowledge from what might

put the current diagnoses at risk is a key

challenge. It may be helpful to return to

your Assumption Catalogue (page 51).

A diagnosis focuses on a why a

user is or is not acting, not on the

presence or absence of an action.

Effective diagnoses suggest a reason for

the persistence of a problem, not simply the

absence of a solution. This may sound like

splitting hairs, but the distinction matters.

For example, we might know that clinics in a

given district have less well-trained health-

care workers than in others. A tempting

diagnosis could be “a lack of well-trained

health-care workers impedes vaccination

rates.” But this ‘absence’ says nothing

about a persistent problem as it relates to

users; moreover, it also presupposes an

appropriate solution (health-care training).

Consider this alternative based on

hypothetical information: “When caregivers

become frustrated because their questions

are not answered by health-care workers,

they do not return to complete their

immunization course.” This diagnosis does

not jump to an absent solution (trained

health-care workers). Instead, its emphasis

is exclusively on the challenge facing the

user and the possible reason behind it.

Tips for Diagnoses

45 Communication for Immunization and Polio Eradication in the Democratic Republic of the Congo: A joint case study by BASICS,

WHO and UNICEF (1999).

iii

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iii Diagnostics Worksheet

For each theme isolated by you/your team, create

hypotheses by responding to each of the following:

Hypothesize

Ask yourself why this is happening. On

sticky notes, write three or more causes

that help to explain or make sense of

the prioritized piece of information.

Debate

Can we prove ourselves wrong?

What might we have overlooked?

What might we have neglected

to inquire more about? What

might we have misinterpreted?

Themes from ‘Identify Important

Information in Stories’

What theme are we about to examine?

Revisit

Reﬁne hypotheses to delete,

modify, or rewrite to reﬂect

any new information that has

emerged during the debate.

Rewrite as Final Diagnoses

Articulate a ‘ﬁnal’ diagnosis

for each theme.

Add ﬁnal diagnoses to your

Field Notes Map in line with

the theme(s) it refers to.

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Theme Examples

Indecision

Ambiguity and uncertainty

foster inaction.

The perception of missing

information, conﬂicting

information, or unknown

probabilities can incline people

toward inaction. When the risks

and beneﬁts of vaccination are

unclear, caregivers are more likely

to opt for inaction — or non-

vaccination — as the safer choice.

It is 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…”51

51 Betsch, et al. (2015), ‘Using Behavioural

Insights to Increase Vaccination Policy

Effectiveness’.

“I’m being told

dierent things

by dierent people,

so it’s better that I

just avoid this.”

Deferral

Bias towards the present.

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 aggravated by poverty,

which requires the poor to

address pressing concerns at

the cost of dedicating mental

resources towards the long

term. This can lead people to

‘defer’ health-seeking behaviour,

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.”50

50 Sturm, et al. (2005), ‘Parental Beliefs

and Decision Making About Child and

Adolescent Immunization: From polio to

sexually transmitted infections’.

“I needed to focus

on this week’s

harvest; I can think

about vaccines later.”

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

behaviour in a given situation

rather than considering the

situation’s external factors.

In the context of health-care,

especially among health-care

workers, this misattribution man-

ifests itself as a “tendency to be

judgemental and blame patients

for their illnesses (dispositional

causes) rather than examine

the circumstances (situational

factors) that might have been

responsible. In particular, psy-

chiatric patients, minorities and

other marginalized groups tend

to suffer from this CDR [cogni-

tive disposition to respond].”52

This might result, for example,

in pegging a caregiver’s deci-

sion-making to inherent ‘laziness’

rather than to contexts of poverty,

potentially affecting the equitable

rendering of services by HCWs.

52 Croskerry (2003), ‘The Importance

of Cognitive Errors in Diagnosis and

Strategies to Minimize Them’.

“She must be a

neglectful mother;

she should be

ashamed of herself for

not getting her child

immunized.”

These examples offer some recurring themes of challenges that impede the ability of users to successfully use

immunization services. They are not exhaustive. In fact, we hope that many of the themes you may be familiar

with are not here, and that at least some of the themes 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.

Omission

Action can be scarier

than inaction.

People tend to favour harmful

omissions over equally or

more harmful commissions.

In the context of vaccinations,

caregivers 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).46

46 Ritov and Baron (1992), ‘Status-quo and

Omission Biases’.

Social Norms

Perceived group rules

regulate behaviour.

People tend to behave in

ways that conform to how

they perceive others would be

behaving. Vaccination-related

behaviour can be affected

by whether such behaviour

is seen as normal or deviant

in a given 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.”49

49 Streeﬂand, et al. (1999), ‘Patterns of

Vaccination Acceptance’.

Hidden Costs

Free is not 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, caregivers usually pay

a small amount for a health card

that is needed for the recording

of vaccinations and other health

status information.”47 In Nigeria,

caregivers were required to show

that they 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.”48

47 Holte, et al. (2012), The decision to vaccinate

a child: An economic perspective from

southern Malawi.

48 Oluwadare (2009), ‘The Social

Determinants of Immunisation 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.”

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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 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 non-vaccination, not

less.”54 Another study witnessed

a similar effect, ﬁnding that

corrective information designed

to reduce misperceptions around

vaccines actually “decreased

intent to vaccinate among

parents with the least favourable

attitudes towards vaccines.”55

54 Meszaros, et al. (1992), Cognitive processes

and the decisions of some parents to forego

pertussis vaccination for their children.

55 Nyhan, et al. (2014), ‘Effective Messages in

Vaccine Promotion: A randomized trial’.

Status Quo

Past behaviour predicts

future behaviour.

When given the choice between

continuing in the current state

or making a change, the current

state often wins. People tend

not to change an established

behaviour unless the incentive

to do so is compelling. Therefore,

past experience with vaccinations

is a very strong predictor of

future behaviour; for those not

vaccinated previously, it is 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.

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.”56 In fact,

among those who had been

vaccinated in the past, this

bias towards the status quo

was more Inﬂuential than what

might otherwise be problematic

beliefs, such as their subjective

probability of getting sick.

56 Tsutsui, et al. (2010), ‘A Policy to Promote

Inﬂuenza Vaccination: A behavioural

economic approach’.

Availability

The easier to recall, the

more Inﬂuential.

People tend to rely on immediate

examples that come to mind

when making 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 regard 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,”53 rather

than as a choice between a

low-risk and high-risk decision.

53 Cappelen, et al. (2010), ‘Demand for

Childhood Vaccination: Insights from

behavioural economics’.

“A new vaccination?

I’ll just do whatever

I did last year.”

“I recently heard

about a child that

got very sick from the

vaccine, so I think I’ll

avoid that one.”

“Seeing that

information from the

health-care workers just

makes me even more

sceptical of it.”

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 caregivers 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.”57 While it may not be

surprising that “[a]ttitudes and

behaviour of health staff… are

frequently cited as discouraging

children’s vaccination”58 in many

contexts, the disproportionate

power of negative incidences

adds a challenging element

to service experiences.

57 Streeﬂand, et al. (1999), ‘Patterns of

Vaccination Acceptance’.

58 Favin, et al. (2012), ‘Why Children Are Not

Vaccinated: A review of the grey literature’.

Practical Knowledge

Missing information

leads to inaction.

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 behaviour.

In studying barriers to childhood

immunization in Mozambique,

researchers found that two thirds

of mothers at various ‘mobile

brigades’ did not 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.59 Another study on

inﬂuenza vaccination in the US

found that even though logistical

information such as the location

of a clinic was technically available

to participants, vaccination rates

decreased when it was not made

immediately and easily available.60

59 Sheldon, et al. (2003), A study to describe

barriers to childhood vaccination in

Mozambique.

60 Ross, et al. (2013), Using Behavioural

Economics for Postsecondary Success.

Optimism

It will not 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.61

61 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.”

“I was rushed,

my child cried a lot,

and I didn’t have any

time to ask questions.

That’s what I

remember most.”

Theme Examples

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Q3: WHAT STANDS IN OUR WAY? 3A: INTERPRET COLLECTED STORIES

This step creates a bridge between research and solutions.

During this step we translate the ﬁnal diagnoses into

prompts: actionable questions that prepare your team to

generate solutions. Prompts are a way of presenting the

problems from user research as opportunities for inventive

solutions. They help our teams begin to answer the

overarching question: what is to be done?

Propose Opportunities for Design

To help us write prompts that respond to

the people we’re trying to reach we create

Persona Proﬁles, and to help us write

prompts that respond to the challenges

we identiﬁed during ﬁeld research we

create a Relationship Map, or system

map. Together, these activities allow us to

look at the problem from multiple angles

and pivot from problem to possibility.

Each prompt prepares your team to

brainstorm different categories of solutions,

all of which could respond to the challenges

identiﬁed in the insight. By generating

multiple prompts against the same insight,

we enlarge the scope of possibilities.

After forming diagnoses

and articulating prompts,

your Field Notes

should be complete.

Take time to reﬂect on each row. Are

there additional assumptions worth jotting

down? Are the challenges diagnosed

in some instances likely to be more

important or weighty than others?

A completed wall of Field Notes will help

us to link user research (Question 3)

to the creative process of generating

solutions (Question 4). Next you will

conceptualise, design, and prototype

solutions that respond to each row.

Final

Field Notes

Example Personas for this Diagnosis:

1. Higher-income caregivers

(the prioritized user)

2. Health worker (service provider)

3. Community leader (role who most

inﬂuences the caregivers)

Relationship Map Example:

The example diagnosis showcases a

tension between public and private

beliefs and behaviours, highlighting social

norms and inﬂuential identities affecting

these caregivers. The relationship map

shows these barriers and inﬂuences.

Prompt Examples (multiple

prompts for each diagnosis):

• How might we deliver immunization

out of sight from the perceived

judgement of peers?

• How might we ﬂip the association

between vaccines and poverty, to

vaccines and success/well-being?

• How might we make these caregivers’

identities as good mothers more important

than their identities as ‘not poor’?

To help analyse and make sense of

the diagnoses, map the relationships

between your personas, their needs,

and the people responsible.

For each diagnosis, articulate multiple “How

might we?” questions that will prompt

teams to think about creative solutions.

Identify all users and describe them

in more detail, including the service

recipient and service provider.

Diagnosis Example: While they may

privately value vaccinations, higher-income

caregivers publicly decline immunization

for their children because of an association

between vaccines and being poor.

i: Create Persona Proﬁles

ii: Draw the Relationship Map

iii: Articulate Creative Prompts

There are three steps to move from diagnoses (why something is

happening) to prompts (redeﬁning challenges as opportunities):

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Q3: WHAT STANDS IN OUR WAY? 3A: PROPOSE OPPORTUNITIES FOR DESIGN

Personas are ﬁctional characters that are

used to understand the needs, values,

aspirations, abilities, limitations and character

traits of different users, along with the

challenges they face and their desires for

potential solutions. They will help your

team consider designs and plans from

a point of view that is not their own.

Determine realistic combinations of

characteristics that together could form

a single person. A persona is developed

from a range of different sources, pulling

together common characteristics of

similar people into an “archetype” through

which a group can be understood.

If possible, validate the persona.

Get feedback from stakeholders

who understand the real people that

these personas represent, or go back

and review with interviewees.

Finally, create multiple personas. In addition

to your prioritized user-group, represent your

caregiver’s interactions with community

leaders, other mothers, health-care workers,

community health workers and other key

players. You will present these personas

along with prompts during Question 4.

User Type (priority population, health-care worker, community health worker, caregiver, technician, community advocate, volunteer)

What they do now

(current behaviour)

What they should do

(ideal state)

Place photo / drawing

Inﬂuences

Think about single behaviours that result from external

pressures (rather than regular habits). Who or what are

the inﬂuential stakeholders in their life?

Environment

What is the geography and conditions where they live?

Role/Responsibilities

Describe what his/her job is, or what role her or she plays

in the community.

Time

What does a typical day look like? How do they divide

their time? What do they spend time worrying about or

celebrating?

morning

mid-day

afternoon

evening

Background

What important life experiences or events have

contributed to this person’s current situation? What social

determinants of health inﬂuence his/her current situation?

Needs

What frustrations do they have? What limitations do they

encounter? Write as a quote — how would they say this?

Persona Proﬁles Name:

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Q3: WHAT STANDS IN OUR WAY?

Often, we blame the moral character of

caregivers or human error of health workers

for what are really system failures. We draw

the false conclusion that the people who

made mistakes need to be reprimanded,

retrained, or more closely monitored.

Looking at the systems allows us to see

beyond the symptoms (mistakes) to uncover

the complex network of root causes.

Two main insights emerge from mapping

the relationships — or system. First,

we can identify what emerges from

the interconnected relationships. For

example, looking at the responsibilities

of a volunteer in isolation may seem

overwhelming. Considering the social

inﬂuence they receive from the local leader

may change this view. We can never

understand these traits without seeing

the societal, technological, and economic

ecosystem in which they operate.

The second thing we look for is opportunities

for incremental change. Remembering

our “Small is Big” principle, we can

look for small changes that can lead to

signiﬁcant improvement instead of, or in

partnership with, designing a new solution.

Now, armed with a better understanding of

the people we are trying to serve and the

diagnosis of the challenges we face, we can

map the relationships. During this exercise,

we will organise the different pieces of

the system and show how they connect

to and communicate with one another.

Relationship Map

Local

International NGOs / Global governing bodies

National ministries / NGO headquarters

Regional governments / Health facilities / NGO ofﬁces

Child or Individual / Religous leader / Health centre Front-

line health worker / Community leader / Marginalized

group / School / Community volunteer / Service provider

Regional

National

International

• Chains of command

• Decision-making

inputs

• Funding

• Social links

• Familial links

• Patient-provider

relationships

Draw Connections

Draw lines between all the users and

institutions that are formally or informally

connected in some way. Use two different

colors: one for social relationships and

one for service relationships. Examples:

• Infrastructure

solutions/gaps

• Communication

solutions/gaps

• Funding/Lack

of funding

• People who can/

cannot fulﬁll their

responsibilities

• User knowledge

about services

• Societal norms

Mark Barriers + Positive Inﬂuences

Note where barriers that impede our goals

and inﬂuences that support our goals exist.

What technologies or tools exist at these

intersections? What makes it harder for

users to get what they need? What points

of leverage make it easier? Examples:

List Everything

Identify all the users and institutions

that are in some way connected to the

issue you identiﬁed. Start with your ﬁnal

personas, and include additional roles

that relate to your challenge. Examples:

• Front-line worker

• Health worker

• Family

• Health centre

• Child or Individual

• Service provider

• School

• Community

volunteer

• Religious leader

• Community leader

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Q3: WHAT STANDS IN OUR WAY?

Diagnosis #1:

Poorer mothers feel anxious about

going to clinics because they receive

derisive judgement from health-care

workers, many of whom attribute under-

immunization to mothers’ laziness.

Not-so-Good Prompt:

How might we improve

interactions between

health-care workers and

patients?

This prompt is too vague. A too-general

prompt that does not respond to the

important details in the insight fails to

give your team clear enough direction

on how to address the challenge.

Better Prompt:

How might we sensitize

health-care workers to the

tough challenges facing

poorer patients so that they

demonstrate empathy?

Use the prompt formula to build

on each of your diagnoses. Follow

these tips and examples.

Be Open-Ended vs. Prescriptive

Prompts inspire and guide your team to

generate a lot of solutions (more on that

in Question 4). Open-ended prompts do

not assume solutions but allow teams to

consider as many solutions as possible.

To ‘check’ if your prompt is sufﬁciently

open-ended, ask yourself: can I immediately

think of more than a single solution to the

problem? If not, you may have been too

prescriptive. The opposite can also be a

problem: prompts that are too general feel

overwhelming and difﬁcult to comprehend.

Prompt-writing is a balancing act.

Respond to the Diagnosis

If a prompt is crafted just right — not too

general, and not too prescriptive — it must

also directly address the problem we

identiﬁed as our ﬁnal diagnosis. A prompt

that is not risks leading your team down a

wrong path that yields ineffective solutions.

Incite Inspiration

Feeling inspired matters. The best solutions

come from prompts that excite you and your

team members. Does the prompt feel like

a call to action? Is it a mandate to explore

interesting ideas? Does it immediately

make you start thinking of solutions?

Diagnosis #2:

Confronted by immediate challenges, parents

are deferring their visits to the clinic while

thinking that they will go soon enough.

Not-so-Good Prompt:

How might we use non-

ﬁnancial, micro-incentives

to motivate mothers to get

their children vaccinated?

This prompt is too speciﬁc. Rather than

guide your team’s problem-solving, this

prompt prescribes a solution. Non-ﬁnancial,

micro-incentives might very well be a strong

idea, but it is certainly not the only one.

Better Prompt:

How might we give mothers

reasons to act today rather

than wait to return to the

clinic?

Diagnosis #3:

Despite a recent campaign promoting

immunization as a public good that

helps everyone, most parents think

that their neighbours do not get

their children vaccinated and so they

do not feel compelled to act.

Not-so-Good Prompt:

How might we convince

parents that getting

vaccinated will protect the

entire community?

This prompt fails to correctly respond

to the diagnosis. It ignores the

information that as long as parents don’t

perceive their neighbours accessing

vaccinations, they will not bother getting

their own children immunized.

Better Prompt:

How might we reveal to

parents the actual volume

of community members

accessing vaccinations,

demonstrating a widespread

social behaviour?

Prompt Formula Add ﬁnal prompts to your

Field Notes Map next to the

diagnosis they respond to.

FN How Might We + Verb + Response to Diagnosis = Prompt

iii

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Q3: WHAT STANDS IN OUR WAY? 3A: PROPOSE OPPORTUNITIES FOR DESIGN

How Could

We Respond?

Introduction: Experimental Solutions

This phase outlines a three-step creative process to respond

to user challenges, facilitating your team’s ability to generate

solutions and test their ecacy. It will encourage divergent

thinking: generating many ideas before converging on the

most desirable, viable and feasible. Top ideas will be rapidly

prototyped so that early, promising solutions can be modiﬁed

and improved, and less promising solutions can be cut prior

to investing too many resources.

The creative process of generating and evaluating solutions

is experimental. The exercises of conceptualising ideas and

getting feedback from the ﬁeld will be iterative. Some ideas

might prove problematic, and we will drop them; others might

prove promising, and we will work to improve them. Only

through experimentation can we design optimal solutions.

These phases should not involve undue time and resources.

Months of planning are not necessary. These phases and their

associated exercises are intended to enable rapid ideation

and the gathering of imperfect but critical experimental

evidence in little time. By the end of this question, we will

have a set of solutions ready for initial implementation in

the ﬁeld.

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DEMAND FOR HEALTH SERVICES

While these phases are linear, they are also iterative. It is likely

that prototyping will generate feedback that forces changes to

the design of an idea, or in some cases, will require that teams

go back to conceptualising new ideas entirely.

4Methodology

Make ideas concrete through initial

outlines, models or rough sketches

of ways to implement promising

concepts.

Design Examples

With an extended team, quickly

generate many possible solutions for

each prompt. Assess the solutions

to identify 2-3 promising ideas per

prompt.

Assess Concepts

Concept Examples

Deﬁne learning goals for each design,

then select activities that will test

(prototype) the design in the ﬁeld.

Take draft ideas into the ﬁeld to test

with, and get feedback from, users.

Prototype Planning

Prototype Evaluation

Photos / materials to

visualize the challenge

Concepts

Prototype Revised

Prototype

HMW

Question Revised

Question

Prompt

Visualizations

Models

Sequences

User Feedback User Feedback

4a: Conceptualise Solutions 4c: Prototype Design with Users4b: Design Quick Examples Final Output: Tested Designs

At the end of this phase, you have

designs that respond to initial user

research and have been tested

with the user in their environment.

Initial prototypes have been evaluated

and necessary adjustments have

been made.

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Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE 4B: DESIGN 4C: PROTOTYPE

This ﬁrst step is built on the premise that good ideas are

born from a lot of ideas. Conceptualising is the exercise of

generating as many solutions as possible that might help to

solve the challenges presented in your prompts.

Conceptualising is centred around team brainstorms, which

require thoughtful preparation and disciplined facilitation.

Conceptualising ends with a short evaluative exercise

to categorize the solutions coming out of a brainstorm,

highlighting top contenders.

Conceptualise

Solutions

Many, Many Solutions

Some programmes have a familiar and well-

practised set of solutions. Behaviour change

communications might be an example. It

is possible that this creative process will

suggest a communications solution to a

given challenge — but it is not a given. We

will aim to push ourselves to think differently

about what constitutes a potential solution.

We may discover that a creative

solution does not require printing a

single poster, or spending a single dime.

From changing the timing of outreach

services, to communicating a message

differently; from simplifying the steps a

user is required to go through to access

services, to offering SMS reminders;

from activating a latent social norm, to

increasing the importance of a positive

identity — both familiar and less familiar

ideas should emerge during this process.

What is a creative process?

To illustrate the idea of a creative process,

consider the example of a public health

organization in Zambia that recruits and

trains hairstylists (‘agents’) to educate

their clients on HIV prevention and to

distribute condoms. The organization, in

collaboration with researchers, sought to

address issues of agent motivation in an

effort to increase condom sales. One idea

aimed to do so by incentivising agents

with ﬁnancial rewards. Another idea

imagined a type of non-ﬁnancial reward:

“[A]gents are provided with a thermometer

display, akin to those used in charitable

fund-raisers. Each sale is rewarded with a

star stamped on the thermometer, which is

labelled as measuring the stylist’s contribution

to the health of their community.... In addition,

stylists were told that all those who sell

more than 216 packs over a year would be

awarded a certiﬁcate at a ceremony.”62

These ideas were then piloted and evaluated.

Agents were either given a 90 per cent

margin on condom sales or a 10 per cent

margin on condom sales (two very different

levels of ﬁnancial rewards), were given

the “stars”, or were given nothing at all.

Agents receiving the public recognition

scheme sold, on average, over twice as

many condoms as those in any other group.

A creative process is one that liberally

experiments with different ideas until the

best ones materialize. It generates multiple

(and often competing) ideas and tests

them out — even if on a small scale for the

purposes of improving some ideas while

discarding others. And it does not take a

specialist. What it does take is a commitment

to open-mindedness and experimentation.

62 Ashraf, et al. (2014), ‘No Margin, No Mission? A ﬁeld

experiment on incentives for public service delivery’.

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Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

Facilitating a productive brainstorm can be challenging —

too often, brainstorms become undisciplined conversations.

To get the most out of a brainstorm, clearly communicate

the purpose and enforce the rules (e.g. time).

Materials matter:

have plenty of

sticky notes,

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

collaboration,

and group sharing

Separate prompts

and brainstorm

solutions around

each separately

To start, schedule an uninterrupted period

of time and invite additional participants.

Divide the available time between each

prompt, usually ﬁve minutes of generating

ideas followed by ﬁve minutes of sharing

ideas. Sometimes this is repeated for

the same prompt so participants can

improve upon each other’s ideas.

Each Field Notes row ends with a

diagnosis, which describes a challenge,

and a prompt, which suggests a way

to approach the challenge. Creative

brainstorming gives us dedicated space to

think big and broadly about each prompt. In

preparation for brainstorming solutions:

• Freshly transcribe each prompt; print

it out to ﬁll an entire piece of paper.

• Gather supporting material relevant

to each prompt; for example, a few

pictures to help team members

during brainstorming visualize the

challenge embodied in the prompt.

Both of these — prompts and visuals —will

serve as the reference points during

your team’s brainstorming. The last

thing to do is to collect materials for

participants to write and draw on.

Prepare for a Brainstorm Session

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Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

iii Converge

With a large volume of ideas on the table,

coalesce around recurring themes — what

“categories” of ideas are surfacing among

us? You can also use voting dots (3

stickers each) to let participants select the

concepts they ﬁnd most compelling.

i Share User Stories

and Scenarios

A great idea is driven by the collective expertise

and knowledge available in the room. Immerse

the room in the ﬁeld research by sharing

back user stories, photographs and quotes.

ii 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.

Brainstorm Concepts

The initial objective of conceptualising

is to generate a substantial volume of

ideas, not only good ideas. Disciplined

brainstorming can work to quickly and

efﬁciently generate that volume. We will

work to design good ideas later; but a

necessary prerequisite to good ideas is a

large enough amount of them to work with.

Brainstorming creative solutions can be done

over the course of many days; but it can

also successfully be done in an afternoon

of dedicated and uninterrupted time. Either

way, brainstorming should be an intentional

and well-deﬁned period of time. At the

end of a team brainstorm, you will have

a collection of ideas and solutions that

respond to each of the prompts from the

Field Notes in the previous phase of work.

Tool

Generate a large quantity of possible

solutions to each of the prompts

drawn from your Field Notes.

Rules of Brainstorming:

• Build off each others’ ideas — do not be

afraid to suggest alternatives or additions

• Aim for quantity over quality

• Turn off phones! Concentrate on the

ideas for short, intense spurts

• Draw what you can — a picture

is worth 1,000 words

• Go for ideal, wild ideas!

• Do not eliminate or critique ideas (save

for the next step: Assess Concepts)

The process of generating a large volume of ideas

(brainstorming) happens best in groups, with team members

building o of one another.

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Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

Unsuccessful Tries

These ideas are neither responsive

to the prompt nor easy to

make happen. Discard them!

Building Blocks

While it is possible that your programme

could feasibly implement these ideas,

they need work. Adapt these to

make them more responsive to the

challenge captured in the prompt.

Innovative possibilities

Ideas that are clearly responsive to the

prompt, but may be difﬁcult to implement.

Obvious Wins

Ideas that are relatively

easy to make happen, and directly

respond to the prompt.

Very Responsive to Prompt

Unresponsive to Prompt

Safe Unrealistic

Assess Concepts

Effective brainstorming should generate a

broad spectrum of ideas, from the obvious

and low risk to the unconventional. Ideas

that veer towards the latter can be the

most important because they can often

be made more feasible. An idea that is

not quite plausible may still have elements

that are worth exploring. The process

of selecting candidate ideas to move

forward is not just about selecting the top

ones from your brainstorming; it is about

editing imperfect ideas with promise.

To that end, the following tool Assess

Concepts is meant to aid in the process

of both selecting ‘top’ ideas along with

identifying imperfect but interesting ideas that

may require further thinking. The objective of

this step is to ﬁnalize a group of ideas from

your brainstorming to be designed for the

purpose of learning more. Ideas here are far

from ﬁnal. Instead, they are ones that seem

to respond well to your prompts, and that

deserve to be explored through prototyping.

At the minimum, you should aim to

select at least 2-3 ideas per prompt. If

you only land on a single idea at this

step for a particular prompt, you may

risk coming up empty-handed if that sole

idea later becomes ineligible. Multiple

ideas for each prompt increase the

likelihood of ﬁnding one that works.

Tool

After brainstorming, use this chart to

organise ideas for each prompt you

used. You will need to create multiple

charts — one for each prompt.

Place a sticky note (containing one idea each)

into the quadrant that seems appropriate.

Select 2-3 ideas from the ‘Obvious

Wins’ and ‘Innovative Possibilities’

that are interesting and show promise.

After you have a large volume of ideas responsive to each of

your prompts, you are in a position to make decisions about

which ideas deserve to move forward.

iii

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Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

The following stories are meant to instigate your team’s creativity, drawing inspiration from various

ways that other immunization programmes 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 stimulate your team’s own brainstorming efforts.

Sometimes, however, a norm is

not obvious. There is little visible

‘proof’ that a group is collectively

practising some behaviour, which

reduces the power of positive

group norms.64 In some cases,

vaccinations ﬁt this phenomenon:

caregivers who do not access

vaccinations may simply not

know that their peers are doing

so, and therefore are not being

motivated by a perception that

getting vaccinated is the norm

in their community. The idea of

providing ‘social proof’ aims to

harness the power of norms by

making them publicly visible.

Experiments in India and Timor

Leste demonstrate the power of

social proof. In the project, known

as “My Village is My Home”

(MVMH), a large poster was

displayed in a public space.65 On

the poster, clinic staff recorded

the birth dates of all infants and

made note of every immunization

along a timeline. The poster turned

normally private information

(dates of birth and vaccination

status) into a visible record.

This simple public tracking

scheme not only made it easier for

outreach workers to notify families

of a child’s next vaccination date,

but also broadcast a positive

behaviour exhibited by a majority

of the community. It visualized

previously ‘unseen’ behaviours

(one’s peers getting their children

vaccinated). By making others’

behaviours visible in a safe

context, the posters tapped into

subtle social pressures to mobilize

those with under-vaccinated

children; caregivers were dually

accountable to the infants and

to the community as a whole.

The intervention proved motivating.

In India, pilot MVMH communities

achieved immunization rates of 80

per cent, considerably higher than

comparable districts’ rates, which

ranged from 49 per cent to 69 per

cent. As a World Bank report noted,

social proof ideas are especially

potent in contexts where “the

difﬁculty of observing a behaviour

makes it difﬁcult to correctly

estimate how common it is.”66

Previously, community members

may have assumed accessing

vaccines was uncommon; a

public visualization changed that.

Social Proof

As social beings, we modify our behaviour by conforming to perceptions of group

norms and expectations. For example, people are generally more likely to follow

health advice when it is presented in groups of peers, rather than individually.63

63 Bertrand, Mullainathan and Shaﬁr (2006), ‘Behavioural Economics and Marketing in Aid of Decision Making Among the Poor’.

64 For example, the general public in the US signiﬁcantly underestimates childhood immunization coverage. When asked to estimate the proportion of

children who receive no vaccinations, only 9 per cent currently estimate “1 per cent or less,” whereas over onethird estimate the ﬁgure to be somewhere

between 21 per cent and 30 per cent. (Kahan (2004), ‘Vaccine Risk Perceptions and Ad Hoc Risk Communication: An empirical assessment’.

65 Jain, et al. (2015), ‘Engaging communities with a simple tool to help increase immunization coverage’.

66 World Bank (2015), Mind, Society and Behaviour.

One key to isolating practical

information is understanding

precisely the gaps in information

that currently prevent a user

from completing an action. For

instance, a landmark 1965 study

on tetanus shots on US college

campuses compared the efﬁcacy

of merely “warning” students

of the dangers of tetanus with

an intervention that provided

critical pieces of information to

practically assist students with

accessing the vaccination.

When only verbally warned

about tetanus and encouraged

to get the shot, coverage was

3 per cent. Meanwhile, another

group of students received key

pieces of practical information: a

campus map with the location

of the inﬁrmary circled, a list of

times when immunization were

available, and a prompt to schedule

an appointment immediately.

Twenty-eight per cent of these

students ended up getting

vaccinated — a ninefold increase.

The experiment demonstrated how

practical information can help to

overcome small inconveniences

that might otherwise stand in the

way of a user taking action. Noting

the value of the map, for instance,

a review of the study suggested

that “these [students] may have

already known how to get to the

inﬁrmary or had access to the

same campus map. However,

having the map at the right time

made the information salient,

reduced the hassle of looking for

its exact location, or reduced the

thinking required to get there.”67

Practical information seeks to

remove any ‘friction’ in a decision-

making and action-taking process.

From simple visualizations (like

maps) to tactile actions (like

writing down an appointment

time), making the most important

pieces of information salient

helps to remove obstacles to

accessing a health service.

Practical Information

Practical information enables users to locate and process only the most critical

details about a programme. 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.

67 Ross, et al. (2013), Using Behavioural Economics for Postsecondary Success.

Solution Examples

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Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

Visible:

To account for challenges like

forgetfulness, in contexts where

people’s attention is spread thin,

action cues bring only the most

important information to the user’s

attention, making it easier to see.

For instance, in Peru, mothers

are typically given a handwritten

paper reminder at clinics that is

easily lost or misinterpreted. One

organization is piloting a solution:

the Alma Sana bracelet — a durable,

customizable and colourful

bracelet that records a child’s

immunization schedule. Infants

wear the bracelets on their wrists

as a physical and always visible

reminder to the caregiver (and

community). In a pilot study, 91

per cent of mothers reported that

the bracelets helped to remind

them of their next appointment,

and 90 per cent said they

plan to keep using them. The

bracelets cost US$0.10 each.73

Timely:

Action cues work best when

they can prompt users with

information on a timely, repeated

basis through channels that

they consistently access.

SMS reminders have proven

effective in several settings. In

Kadoma City, Zimbabwe, one study

found that 95 per cent of children

in a group that received SMS

reminders were fully immunized

at 14 weeks, compared to 75

per cent of children in a similar

group that did not receive the

reminders. Those who received

reminders —sent 7 days, 3 days,

and 1 day before a scheduled

visit — were also 75 per cent less

likely to delay.74 A majority of the

intervention group preferred to

receive a reminder the day before

their appointment: a time-sensitive

feature made possible by SMS.

Actionable:

Action cues should result in

just that — action. Rather than

assume that people will ﬁgure

out the requisite steps to take

on their own, action cues can

help people to follow through on

their intentions by guiding them.

Research shows that encouraging

people to take an action with a

generic reminder letter often is

not enough. In one experiment

regarding inﬂuenza vaccination,

letters that included speciﬁc

information about where and when

to get the vaccination resulted in

a 28.2 per cent vaccination rate,

compared to 19.2 per cent among

users who only received general

encouragement to get the shot.75

As the researchers hypothesized,

lack of action cues — missing

information about when and where

to access the vaccination — was

a more important obstacle to

overcoming the gap between

intentions and actions than

people’s attitudes about

receiving the vaccination.

Action Cues

Action cues are reminders built into a programme’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

present critical information to the user in visible, timely and actionable ways.

73 <www.indiegogo.com/projects/alma-sana-vaccine-reminder-bracelets-for-moms>

74 Bangure, et al. (2015), ‘Effectiveness of Short Message Services reminder on Childhood Immunization Programme in Kadoma, Zimbabwe: A randomized

controlled trial’.

75 McCaul and Johnson (2002), ‘The Effects of Framing and Action Instructions on Whether Older Adults Obtain Inﬂuenza Shots’.

For this type of intervention to

succeed, programme designers

must have a clear understanding of

which incentive(s) would work to

sufﬁciently push a group of users

towards the desired behaviour.

Research has shown that both

small ﬁnancial and non-ﬁnancial

incentives can be effective — but

the appropriate incentive is

different in different contexts and

with different groups of users.

Financial:

In one experiment, college

students in the US were twice as

likely to get an inﬂuenza shot when

offered a $20 reward (19 per cent

vs. 9 per cent). Researchers found

that many students had a strong

intention to get vaccinated, but

perpetually postponed taking the

necessary actions. (As the authors

explained, “individuals postpone

getting vaccinated, because the

cost is immediate and the beneﬁts

accrue only in the future.”)68

Why cash?: Researchers

observed that extra money was

highly motivating for college

students. Even this (relatively)

small incentive was enough to

motivate twice as many students

to take the time to vaccinate.

Non-ﬁnancial:

In India, an organization provided

families whose children completed

a full vaccination course with

a small bag of raw lentils. The

actual monetary value of the

bag was less than US$1. A

concurrent programme to increase

reliable access to vaccinations

pushed immunization rates from

6 per cent to 18 per cent in

participating villages — but when

the additional incentive of lentils

was added, the ﬁgure jumped

to 39 per cent, representing a

more than sixfold increase. The

researchers hypothesized that

a minor incentive helped to

overcome small but powerful

barriers, like procrastination

among people juggling many

competing priorities.69, 70

Why lentils? In this resource-

poor environment, the bag of

lentils offered an immediate and

tangible beneﬁt to users. The

long-term beneﬁt of vaccinating

was harder to visualize — but the

lentils provided a compelling-

enough reason to act today.

Various other forms of micro-

incentives have been studied

across contexts. In Pakistan,

DTP coverage at 18 weeks

of age increased twofold

compared to a control group

when food and medicine

vouchers were introduced.71 In

rural Nicaragua, a food incentive

increased turnout at mobile

clinics by over 60 per cent.72

As the authors of that study

suggested, food in Nicaragua

(rather than vaccines alone)

proved an effective motivator

because it “directly inﬂuence[d]

a family’s economic welfare.” It

turned caregivers’ focus from

something abstract in the future to

something tangible in the present.

Micro-incentives

Micro-incentives are small, motivating bonuses given to users that increase adoption of a desired

behaviour. 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.

68 Bronchetti, Huffman and Magenheim (2015), ‘Attention, Intentions and Follow-through in Preventive Health Behaviour: Field experimental evidence on

inﬂuenza vaccination’.

69 Banerjee, et al. (2010), Improving Immunisation Coverage in Rural India: Clustered randomised controlled evaluation of immunisation campaigns with and

without incentives.

70 UNICEF (2011), ‘Child Poverty Insights, A new look at an old problem: Why do so many poor children miss out on essential immunization?’.

71 Chandir, et al. (2009), ‘Effect of Food Coupon Incentives on Timely Completion of DPT Immunization in Children from a Low-income area in Karachi,

Pakistan: A longitudinal intervention study’.

72 Loevinsohn and Loevinsohn (1986), ‘Improvement in coverage of primary health care in a developing country through use of food incentives’.

Solution Examples

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DEMAND FOR HEALTH SERVICES

Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

Implementation Intentions

Follow-through can be increased

by implementation intentions —

for instance, by asking patients

or caregivers to describe or

write down in detail their plan

to vaccinate.81 These plans ask

users to specify when, where

and how to carry out an action,

forcing the ‘present self’ to prepare

the ‘future self’ for following

through. Rather than relying on

open-ended intentions (“I want

to get my child immunized”),

implementation intentions

prompt users to link that positive

intention to a plan for action.

In one study of workplace

vaccination, employees that

received a postcard about available

workplace inﬂuenza shots were

more likely to vaccinate if they

were prompted to write down

when they planned to come for

the vaccination. Moreover, when

they were prompted to write down

both a date and a time, vaccination

rates were even higher.82

Commitment Devices

Follow-through can also be

deployed through commitment

devices, which help bind users

to a future action — say, by

adding a penalty if they do not

follow through.83 This approach

helps to ‘lock in’ an action that

the future self takes based on a

decision made in the present.

In one (non-vaccine-related)

study, grocery store shoppers

were asked to commit in advance

to buying healthier foods. They

received a discount if they

increased their healthy purchases

by a speciﬁed percentage, and

agreed to relinquish the savings

if they didn’t meet the threshold.

The shoppers who made a

binding agreement increased

their healthy food spending

relative to a control group.84

As some researchers observed,

if applied to immunization, a

parent “could be asked to

pre-commit to approving the

scheduled vaccines for the child

and to put down a deposit that

would only be returned (perhaps

with a bonus) once the vaccine

had been administered.”85

—

Making a decision and following

through takes effort, which we

can always put off until tomorrow,

again and again. Follow-through

helps us to overcome our

inclination to delay, forget

or ignore our positive

intentions — whether by making

plans concrete, or by incurring a

cost or relinquishing a reward.

Consider the following three

methods of structuring choices

relevant to immunization:

defaults, presumptive language

and enhanced active choices.

Defaults

Defaults capitalize on our tendency

to stick with the status quo, or

‘go with the ﬂow’. We are usually

content to continue with the

option that we are automatically

given, and are much less likely

to opt out of a decision that is

suggested for us, especially if

suggested by a perceived authority

ﬁgure or someone whom we trust.

One study on inﬂuenza

vaccinations found that people

‘pre-scheduled’ for a inﬂuenza

shot were far more likely to get

vaccinated than those who had

to make an appointment on their

own. (In the former group, people

could ‘opt out’ of the appointment;

in the latter, people were forced to

‘opt-in’ by making an appointment

independently.) The study found

a 36 per cent relative increase

for the pre-scheduled group.26

Presumptive Language

Presumptive Language refers to

the way in which a conversation

is started during a provider-patient

interaction, suggesting that how

providers initiate a vaccination

recommendation matters.

In one study, paediatric providers

either used presumptive or

participatory language with

parents. The presumptive language

(e.g. “Well, we have to do some

shots”) signiﬁcantly outperformed

participatory language (e.g. “What

do you want to do about shots?”)

among all parents, even vaccine-

hesitant ones. When the provider

used participatory language, 89

per cent of the vaccine-hesitant

parents resisted compared to

30 per cent when the provider

used presumptive language.77

Enhanced Active Choices

Enhanced Active Choices ask

people to make a deliberate

choice between multiple

options presented to them. The

preferred choice is framed

in positive, encouraging

language, and the undesirable

choice in dissuasive language.

In another series of inﬂuenza

vaccination experiments,

researchers structured choices so

one group “had to actively select

whether they would get a inﬂuenza

shot to reduce their risk of getting

the inﬂuenza, or would choose

not get a inﬂuenza shot, even if

it meant increasing their risk.”78

Seventy-ﬁve per cent of this group

said that they would get the shot,

compared to 42 per cent of a

control group that saw a standard

message79 about the shot.80

—

In each of these three instances,

caregivers maintain the ability to

make a non-vaccination decision.

However, most people (even

many vaccine-hesitant ones) tend

to stick with options that are

presented favourably or as the

default. The deliberate structuring

of choices can encourage desired

behaviours among users in ways

that afﬁrm their inclination to do

what is easier and beneﬁcial.

Follow-through

Follow-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 behaviour.

Structuring Choices

Ways of structuring choices can have a powerful inﬂuence on an individual’s decision-

making. The same information presented in dierent ways can result in dierent outcomes.

Thoughtfully designing how choices are presented can shape the choices that are made.

81 Gollwitzer and Sheeran (2006), ‘Implementation Intentions and Goal Achievement: A meta-analysis of effects and processes’.

82 Milkman, et al. (2011), ‘Using Implementation Intentions Prompts to Enhance Inﬂuenza Vaccination Rates’.

83 Rogers, et al. (2014), ‘Commitment Devices: Using initiatives to change behaviour’.

84 Schwartz, et al. (2014), ‘Healthier by Precommitment’.

85 Betsch, et al. (2015), ‘Using Behavioural Insights to Increase Vaccination Policy Effectiveness’.

76 Chapman, et al’ (2010), ‘Opting In vs. Opting Out of Inﬂuenza Vaccination’.

77 Opel, et al. (2013), ‘The Architecture of Provider-Patient Vaccine Discussions at Health Supervision Visits’.

78 Participants facing an enhancd active choice were asked to check one of two boxes: “I will get a Inﬂuenza Shot this Fall to reduce my risk of getting the

inﬂuenza and I want to save $50 or, I will not get a Inﬂuenza Shot this Fall even if it means I may increase my risk of getting the inﬂuenza and I don’t want to

save $50.”

79 The standard message read: “Place a check in the box if you will get a Inﬂuenza shot this Fall.”

80 Keller, et al. (2011), ‘Enhanced Active Choice: A new method to promote behaviour change’.

Solution Examples

128 129

DEMAND FOR HEALTH SERVICES

Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

In a ﬁeld experiment in Zambia,

four groups of hairstylists were

recruited to sell female condoms.

One group received no additional

reward beyond the proceeds

of sales, two additional groups

received ﬁnancial rewards (90 per

cent and 10 per cent margins on

sales, respectively), and a ﬁnal

group received symbolic social

rewards in the form of stars

stamped on a publicly displayed

chart to represent each sale.

After one year, members of the

‘star treatment’ group had sold

twice as many condoms, on

average, as any other group.90

Public recognition proved far

more powerful than ﬁnancial

incentives in driving performance.

Recognizing HCWs with small,

non-monetary gifts can likewise

improve outcomes. An experiment

in the United Republic of Tanzania

promised a biographical book

about a doctor to HCWs at a future

date; it was also inscribed with

a thank you message from the

research team. The gift “triggered

an immediate response at the

time of the promise.” After 10

weeks, adherence to protocol

remained consistently high.91

Small material rewards can work

to trigger reciprocity: a social

behaviour by which we respond to

another’s action with an equal, and

sometimes more signiﬁcant, action.

Non-ﬁnancial rewards can be

particularly appealing given that

they cost so little to implement.

As the World Bank noted, “[social]

rewards are free to give and carry

no immediate material beneﬁts

but have a substantial effect

on productivity and may play a

key role in sustaining... effort

over time.”92 While non-ﬁnancial

rewards will not substitute as

solutions to more fundamental

problems, like inconsistent or

inadequate salary disbursements,

examples show that ideas like

reciprocity and recognition can

be implemented in ways that

move HCW motivation and

performance in a positive direction.

Community Feedback

Community Feedback creates

mechanisms for dialogue

between service providers

and the people they serve—

and can go well beyond the

‘transaction’ of immunization

at the point of service.

In one study in Uganda,

researchers established a

“community monitoring scheme.”

Service providers and community

members met regularly to discuss

how to improve services and

created a shared action plan. A

year later, health facilities in these

villages were 36 per cent more

likely to have suggestion boxes

and 20 per cent more likely to have

numbered waiting cards; waiting

times decreased on average

by 12 minutes, absenteeism

decreased by 13 per cent, and

the facilities were cleaner. Overall

immunization rates increased

for all age groups, though

especially among newborns.86, 87

Peer Feedback

Peer Feedback has proved to be

an effective means of improving

the quality of care administered

by HCWs. Studies have shown

that simply reminding HCWs

of the social expectations of

their performance can make

a positive difference.88

A study in urban United Republic

of Tanzania showed that clinicians

increased their performance

when a visiting peer recited a

short ‘encouragement script’

and mentioned ﬁve speciﬁc and

important protocol items (which

most clinicians knew but did not

regularly perform). There were no

additional changes to the incentive

structure for clinicians (i.e. no

pay-for-performance schemes

or rewards were introduced),

and yet the researchers found

a “large increase in quality

with a simple and seemingly

inconsequential intervention.”89

—

Community Feedback strengthens

local relationships by giving

users a voice and a stake in the

success of a programme, fostering

mutual accountability between

users and HCWs. Peer Feedback

leverages social pressure by

reminding those delivering care of

their professional responsibilities

and building their self-esteem.

These strategies place a

premium on dialogue—moving

immunization from a technical

transaction to part of a mutual

effort towards a common goal.

HCW Incentives

Rewards are an age-old mechanism to modify behaviour. Importantly, rewards

may take many forms. While salary increases and opportunities for career

advancement can be instrumental to improve HCW performance, so too can public

recognition, symbolic armations of social status, and feelings of reciprocity.

Feedback

Systems of regular feedback can help to encourage positive behaviours 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.

90 Ashraf, et al. (2014), ‘No Margin, No Mission? A ﬁeld experiment on incentives for public service delivery’.

91 World Bank (2015), Mind, Society and Behaviour.

92 Ibid.

86 Bjorkman, et al. (2009), ‘Power to the People: Evidence from a randomized ﬁeld experiment on community-based monitoring in Uganda’.

87 Speciﬁcally, 46 per cent and 42 per cent more newborns received the ﬁrst doses of BCG and polio vaccines, respectively, compared to the control group.

88 Jamtvedt, et al. (2007), ‘Audit and Feedback: Effects on professional practice and health care outcomes (Review)’.

89 Brock, et al. (2012), ‘Generosity Norms and Intrinsic Motivation in Health Care Provision: Evidence from the laboratory and the ﬁeld’.

Solution Examples

130 131

DEMAND FOR HEALTH SERVICES

Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

Health communications have

sometimes sought to appeal

to caregivers’ identities as key

members of a community with

messages emphasizing shared

responsibility. Activating certain

identities — making them more

salient in a given situation — can

inﬂuence behavioural outcomes.

Appealing to certain identities

not only requires isolating the

identity most likely to yield a

corresponding desired behaviour,

but also requires using an effective

cue. In other words, how would

we make salient, for example, a

woman’s identity as a responsible

member of a community?

In a series of randomized

experiments, researchers used

different linguistic phrases to

evaluate which yielded stronger

voter turnout. Researchers

embedded linguistic cues within

a survey delivered to participants,

and found that cues phrased

as a noun (“be a voter”) led to

higher voter turnout than those

phrased as a verb (“go vote”). By

framing voting as an issue of

identity rather than simply as

a behaviour, the distinction in

phrasing resulted in an 11 per cent

difference in actual turnout.88

It so happens that nouns tend to

do a much better job of priming

identities and prompting desired

behaviours than verbs — whether

with turning out to vote, or turning

out to access vaccines. That is

principally because “[v]erbs are

harder to remember, more broadly

deﬁned, more prone to be altered

in meaning when conﬂict of

meaning occurs, [and] less stable

in translation between languages...

than nouns.”89 For example, a

message could encourage a parent

to “be a protector” by getting

her child immunized, rather than

instruct her to “protect your child.”

Nouns help to activate particular

identities, subtly tapping into

a person’s sense of self.

Consider, for example, the

proposals made by a design

ﬁrm to change the standard

home-based record in an

effort to increase immunization

coverage.93 The ﬁrm observed

that a home-based record — as

the name might suggest — should

be designed for the home, not

just a clinical environment.

In that case, what function

should it serve in the home?

“In the home the most critical

role of the record is to indicate

when the child needs to return

for a follow-up visit. The record

may, however, be put away for

safe-keeping, reducing it to a

static record rather than a present

reminder for action. Conversely,

the record may be kept out and

be subject to general wear and

tear or unintentional misuse.”

In response, the improved design

featured four essential elements:

Prompt:

The principal design form features

a yellow sleeve inside which

records are kept. Each time a HCW

writes the date of the next visit and

inserts the record into the sleeve,

the date ‘sticks out’ visibly from

the sleeve for the family to see.

Materials:

The record used by HCWs

and put into the yellow sleeve

is printed on a low-cost type

of paper that is resistant to

wear and moisture. The sleeve

itself is made from Tyvek, a

durable and low-cost material.

Photo:

A HCW takes a photo of the

immunized child, displayed

on the yellow sleeve’s cover,

“transform[ing] the record into a

keepsake that may be proudly

displayed in the home.” This

functions to not only ensure the

record’s continued visibility, but

also motivates the family to keep

the records out of harm’s way.

Visuals:

The visual design “emulates a

government document, like a

passport, to ensure it is kept

safe and not discarded.”

—

When modifying objects such as a

home-based record, small changes

can yield large consequences.

However, especially with objects,

we should be mindful of only

modifying materials — for example,

only making home-based records

more durable with elements

like water-resistant paper. While

helpful, “[t]he durability of a record

is as much about its materials

as it is about ensuring that the

record is prized and visible in

the home and not damaged or

discarded unintentionally.” In

addition to making physical

changes, considering how an

object will emotionally impact a

user — such as motivating a sense

of pride — is equally important.

Identity Saliency

Identity is fundamental to behaviour. Individuals 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 dierent contexts.

Modiﬁed Objects

Small details in the design of objects, such as a user’s home immunization records, can have

an outsized impact on an object’s intended function. Attributes like physical design, content,

and the way information is presented can all aect whether an object serves its purpose.

88 Bryan, et al. (2011), ‘Motivating Voter Turnout by Invoking the Self’.

89 Gentner, Dedre (1981), ‘Some Interesting Differences Between Verbs and Nouns.’93 <www.gravitytank.com/pdfs/RFL/gravitytank_RFL_Final_v5.pdf>

Solution Examples

132 133

DEMAND FOR HEALTH SERVICES

Q4: HOW COULD WE RESPOND? 4A: CONCEPTUALISE SOLUTIONS

For a piece of communication, like a radio

spot, maybe a draft script would be helpful;

if the idea involves an SMS reminder, a

storyboard could lay out how sequential

SMS messages lead to a clinic visit; an idea

related to a new clinic intake experience

could be visualized as a diagram.

Where possible, consider creating

multiple designs of the same idea.

Sometimes, users may be reluctant to

give feedback when only a single design is

presented. However, having multiple options

may help to open up conversation, as well as

allow you to compare key variables of an idea.

While you should aim to design each idea,

it is equally important not to over-design.

A design is just a physical approximation

of your idea. It may be tempting to give a

certain idea more love and attention than

others — to dedicate more effort to a certain

design. Hard as it may be, refrain from

investing too much in any one idea at this

stage. Keeping designs ‘low-ﬁdelity’ (or

simple) will allow your team to explore

many different ideas without feeling

committed to any single one too early.

Remember: design is not about

perfection. Design is about making ideas

concrete enough to gather feedback

from the ﬁeld during prototyping.

Design Quick

Examples

The process of design forces us to think in concrete terms

about how an idea would work. For each of the candidate

ideas that made it through your Assess Concepts step,

consider how the idea might be made more real.

Know that designing does not require designers. Ideas can

be designed quickly, easily and cheaply by anyone with basic

materials.

Common Categories of

Idea Designs:

Visualizations

Visualizing an idea involves putting pen

to paper. What does an idea look like?

How does it work? Visualizing is the most

direct way to move from an abstract to

a concrete idea. Ideas that would likely

be two-dimensional in reality — from a

sticker to a poster — are best visualized.

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 will not require ‘making’

anything, but instead require changing 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.

135

DEMAND FOR HEALTH SERVICES

134

Q4: HOW COULD WE RESPOND? 4B: DESIGN QUICK EXAMPLES

Visualization

Example:

Personal

Pledge

Model Example:

Health Card Sequence

Example: Clinic

Experience

Model Example:

Health Card

An idea to reorganise the information on users’ health

cards might be sufﬁciently communicated through

a visualization. But perhaps the idea goes beyond

health card information to include new aspects like a

plastic cover, a string to hang it inside the home, and

so on. Rather than leave these to the imagination,

use rough materials to further bring the idea to life.

Sequence Example:

Clinic Experience

An idea to redesign elements of a clinic experience

for users is hard to capture with just words. Instead,

a storyboard of events — from the beginning

of a user’s experience to the end — helps to

communicate the idea more fully. It also makes

clear to others what exactly needs to change,

at what point, involving whom, and so on.

Visualization Example:

Personal Pledge

An idea like a ‘personal pledge’ is intended

to help users follow through on their

intentions — a speciﬁc plan a user makes

to carry out an action. Visualizing this idea

could require sketching out the different

elements of a pledge card: perhaps a

piece of paper with sections about what a

user is pledging to do, when and how.

Design Examples

136 137

DEMAND FOR HEALTH SERVICES

Q4: HOW COULD WE RESPOND? 4B: DESIGN QUICK EXAMPLES

Prototype Designs

with Users

Prototyping is the exercise of testing low-ﬁdelity designs

with real users. This method allows users to experience and

react to simulated solutions within their environment (the

home, the clinic, the community).

The purpose is not to rigorously measure performance (that

comes later). Instead, we are interested in determining

elements of an idea that are working well and elements

that require rethinking. This step precedes full-scale

implementation to optimize ideas prior to investing

resources in their roll-out.

By the end of this phase, your team will have a ﬁnal set of

ideas that have been tested, reassessed, and redesigned.

Investigating the Challenge, Again

In creating prototypes that users can interact

with, we have the opportunity to not only

examine the strengths and weaknesses of

our ideas, but also to further examine our

conclusions about the challenges. Putting

solutions in context further conﬁrms

or questions our initial diagnoses.

For example, perhaps we concluded

that users were not completing a full

immunization course because of the length

and cost of travel. Existing quantitative data

showed that clinic transport costs require a

signiﬁcant portion of monthly income, and

narrative data from users conﬁrmed that

caregivers’ perceptions of costs matched

this reality; many told us that transport

costs were just too high. In response, we

designed a voucher programme to mitigate

costs and incentivize follow-through.

To prototype our idea, we set up a mini-

version of the voucher programme. We

distributed our low-ﬁdelity vouchers to

groups of new mothers. We then tracked

voucher collection at a local clinic and

found that few mothers used them. In

our follow-up interviews, we asked why

they were not used and found that costs

are indeed perceived as high; but that is

not the only problem. Additionally, many

mothers shared a common negative

experience: the last time they went to

the clinic, it had run out of the vaccine.

Taking another day off work and paying

transport costs again when the availability

of vaccine is uncertain was an additional

challenge, and a different diagnosis.

Prototype Tools

Successful prototyping is predicated

on successful planning and evaluation:

deﬁning when, where, and with whom

to prototype each idea; selecting the

prototyping activities to assign for each

idea; recording key lessons as they emerge

during and after prototyping exercises; and

articulating and reﬁning your evaluations

of each idea’s performance in the ﬁeld.

The tools in this section — Prototype

Planning and Prototype Evaluation

Worksheets — are intended to assist

you and your team when planning

and evaluating the prototyping of your

various designs. Each idea requires its

own set of Prototype Worksheets.

The Prototype Worksheets help you

and your team to make decisions

about which ideas to implement and

what to improve prior to doing so.

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Establish Learning Goals

Each design should have a clear goal or set

of goals associated with its prototyping.

While prototyping will likely uncover

unexpected ﬁndings about the strengths and

weaknesses of an idea, an overall learning

goal should help to guide in-ﬁeld exercises.

For example, if you are prototyping a

voucher programme, your primary concern

could be whether or not the vouchers

are actually used. Prototyping exercises,

such as a mini-pilot combined with post-

pilot interviews, should be in service of

learning whether vouchers are leading

to clinic visits, and why or why not.

For each design ask yourself: what

do we want to learn from putting

this idea out into the ﬁeld?

Enable Real Use-Cases

If prototyping is limited to asking users

their opinions on a solution, what we

learn will be limited. As far as possible,

prototyping exercises should be designed

to simulate real use-cases. This allows

for observing people’s responses and

behaviours — a more reliable predictor of

an idea’s efﬁcacy than self-reported data.

For example, if you are prototyping a

redesigned health card, your primary

concern might be to ascertain whether

it facilitates timely return visits to the

clinic. Simply handing a redesigned card

to a person on the street and asking

for feedback will not usually yield data

in service of that learning goal.

While a mini-pilot might not always be

feasible if you are rapidly prototyping, you

could instead distribute cards to users

and evaluate through exercises whether

the new cards overcome some of the

challenges associated with the old cards,

like poor comprehension. Such data

would be an imperfect but still helpful

indicator of the new card’s ability to

facilitate return visits by addressing key

challenges discovered in user research.

For each prototyping exercise ask

yourself: how can we quickly create

the idea in context with real users?

Iterate as You Go

As your prototyping exercises unfold

in the ﬁeld, making small, iterative

changes as you go is one of the surest

ways to gain deeper insights.

For example, if during an exercise you learn

about a shortcoming, improving the design

prior to the next exercise will help you to

learn more. Did the design change yield

new feedback from users? Iterating as

you go is especially valuable when certain

elements are distracting from the core idea.

Maybe a particular color is throwing users

off, preventing you from getting deeper

feedback? Best to correct this early on.

After each prototyping exercise

ask yourself: what could we

adjust prior to the next one?

Filter Feedback

Not all feedback has equal value.

Key to processing feedback after prototyping

exercises is ﬁltering the helpful from the

unhelpful. Often, ‘unhelpful’ feedback

is generated in response to low-ﬁdelity

designs — feedback from users that touches

on the low quality of a particular solution.

In other instances, users may express

stated preferences that do not align with

observed behaviour. For example, maybe

some users say they prefer cash over

food as a reward for getting their child

immunized; however, your prototyping

shows little difference in the impact of

the ﬁnancial versus non-ﬁnancial reward.

After prototyping ask yourself:

how much weight should be given

to each piece of feedback?

Invite User Co-Creation

The best form of feedback can come in the

form of direct contributions from users.

Often, users will have questions about

the solution you are introducing. Suppose

you are prototyping a public recognition

scheme to motivate HCW performance. A

HCW asks you if this recognition is only

among her HCW peers, or among the wider

community. Rather than provide an answer,

invite her to share an opinion: should it

only be among peers, or among the wider

community? What would that look like?

Throughout prototyping ask

yourself: where are there

opportunities to directly involve

users in developing an idea?

Prototype Principles

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Activity:

Suppose we designed this idea in response

to an intention-action gap observed during

user research; we found that forgetfulness96

causes users with an intention to

vaccinate not to do so (or not to do so on

time). The personal pledge is designed

to narrow that gap by helping users to

concretely establish a plan of action.

According to our learning goals, we

are concerned about whether the

pledge supports increased action-

taking, and whether it does so simply.

To those ends, we could design a

mini-pilot like the example below.

The gathered data will be far from perfect.

Nothing about prototyping is or should be

rigorous by usual standards. We will not

be able to conﬁdently assess the idea’s

impact one way or the other. However, what

it should enable us to do is identify some

initial strengths and weaknesses for the

purpose of developing the idea further.

For example, if most mothers return for

their next appointment late, we know that

we have more work to do, prompting us

to investigate why (say, through more

follow-up interviews). If some mothers

return on time, we will not be able to

veritably attribute it to our idea; however,

we might get valuable feedback when

interviewing mothers who return on time

versus those who return late or not at

all. We might also learn that HCWs do

not administer the pledge as we had

anticipated, causing complications that

we can address in our next iteration.

96 Issues with memory are now widely studied phenomena; for a helpful survey on “how and why memory can get us into trouble,”

see: Schacter (1999), The Seven Sins of Memory: Insights from Psychology and Cognitive Neuroscience.

Prototype Activities, as suggested in the

Prototype Principles, should get as close

to a real scenario as possible. The more

similar to a real use-case we can get, the

more valuable our learnings will be.

However, prototyping should also be

rapid, allowing us to learn and improve our

ideas quickly. Finding a balance between

polishing enough for real-world users to

understand the idea, and working rapidly,

is important. Activities that require too

much investment are less desirable than

ones that can be pulled off quickly.

To illustrate prototyping activities that

are both in context and rapid, here is

an example using the personal pledge

from ‘Design Quick Examples’.

Example: Personal Pledge

Prototype:

We designed a ‘personal pledge’ using

a piece of laminated paper that asks a

user to articulate what she is pledging to

do (get her child fully vaccinated), when

she is planning to undertake certain

actions (the dates, times and location

of future clinic visits), and how she

plans to make those actions happen (for

example, her exact transport plans).

Learning Goals:

• Does the prototype help users to follow

through on an existing intention to get

their children fully vaccinated on time?

• Is the pledge easily administered by HCWs

and easily comprehended by users?

Location

Choose a location and

communicate the process to

administration for support.

Team

Station a team member on

site throughout the day in

case questions emerge or

unexpected challenges arise.

Partners

Find HCWs or partners

that will help administer

the prototype. Conduct a

short training on what you

would like them to do.

Measurement

Create a simple

tracking system to

measure outcomes.

Users

Ensure that the desired

user-group participates.

Follow-up

To evaluate ease of use,

directly observe the activity

and conduct follow-up

interviews with users.

Prototype Activities

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For each idea, use this worksheet to develop a prototype

plan in preparation for gathering in-ﬁeld feedback.

When

Decide upon precise times, such as when a prototyping activity begins and when

interviews will be conducted. Include the duration — hours or days — for the activity.

With Whom

Conﬁrm that you are engaging the intended user-group as deﬁned in

your Objective. Remember that selecting a variety of people — both non-

vaccinators and vaccinators — can generate more helpful feedback.

Where

Select the precise location(s) where you will introduce the prototype, such as a group

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

Learning Goals

What do we want to learn

from ﬁeld-testing this idea?

Prototype Planning

Demonstrate the Idea

How will you demonstrate the idea? Examples include: paper

sketch, cardboard sign, SMS text(s), radio spot script, etc.

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Desirability

Desirability is the evaluation of an idea from

the perspective of intended users. It helps

ﬁt our ideas to actual people. Consider

whether an idea is asking a little or a lot

of users’ time and energy, whether or

not it is easy to process or engage with,

and whether or not it is being correctly

used. Focusing on elements such as these

(burden, comprehension and use) ensures

that ideas are being designed for the user.

Feasibility

Feasibility is the evaluation of an idea

in the context of your programme’s

organizational and technical capacities. It

requires identifying the range of capabilities

necessary for effectively executing an idea

and sustaining it over time. Imagine what

might be needed to implement, distribute

and sustain an idea. If moving from a

prototype to full-scale implementation seems

difﬁcult because of programmatic limitations,

this means you have challenges of feasibility.

Viability

Viability is about evaluating the ﬁnancial

resources required to sustain an idea.

Consider whether or not an idea has a

sufﬁcient initial programmatic budget

for implementation and whether

possible savings will help to make

the case for sustaining and scaling the

idea over time. Low-cost ideas, or ideas

that save programmes money in the

long run, are often the most viable.

Biggest strengths

Do the user responsibilities

seem realistic?

Observed weaknesses

Is this idea desirable?

• 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 understood

and correctly used?

• Is it inviting or complicated?

Is this idea feasible?

• Is the technology required of

the idea easily available?

• Is the technology easily

sustained over time?

• Can your programme actually

make it happen?

• How long will the idea take to

move beyond a prototype?

Is this idea viable?

• What can be projected

about possible costs?

• Is the idea honouring the

programme’s budget?

• Might the idea actually save

the programme money?

• How near-term versus long-

term are potential savings?

What do we still need to know?

Not yet?

Return to

the design

phase and

reﬁne.

Not yet?

Return to

the design

phase and

reﬁne.

All yes?

Move on!

All yes?

Move on!

Not yet?

Return to

the design

phase and

reﬁne.

All yes?

Move on!

Prototype Evaluation

Use these three dimensions that focus on an idea’s potential

to evaluate the simulated solution’s future success.

For each idea, use this page to evaluate the idea post-prototyping.

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How Could

We Improve?

Introduction: Continuous Learning

We established what we want to achieve, investigated

what might be preventing our desired outcomes and

generated potential solutions to those challenges. Now it

is time to scale and implement our ideas.

But this is not the end. As we bring these ideas to the

ﬁeld, how can we continually improve them throughout

their implementation?

Improving immunization programmes requires a continual

process of discovery, experimentation and learning. Many

variables shape the success of a programme; some may be

identiﬁed before implementing new ideas, but some will be

identiﬁed during implementation. This calls for iteration.

Implementation is an opportunity for further learning and

improvement. While disappointing, it is possible (and even

likely) that our initial diagnoses were incorrect, or partially

correct, and that our evaluations of prototyping were

insucient. Only by scaling and implementing our ideas can

we see what works and what does not in the real world.

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One way to think about methods of iterative

implementation is ongoing user research.

This implies that we always have more to

learn and more to improve upon. These

methods promote the concept of ‘phasing’:

rather than approach implementation

as a one-time task, it advocates phased

steps to implementing an idea. This

cyclical approach to planning, assessing

strengths and weaknesses, and making

adjustments before scaling a programme

initiative (and repeating that process) gives

us the opportunity to properly iterate.

For many programmes, this principle — that

implementation is iterative — will be easier

in theory than in practice. Those who fund

programmes are not often interested in

imperfect results, and those who execute

programmes are sometimes wary of

acknowledging them. But by candidly

recognizing that implementation will reveal

both shortcomings and opportunities

for our ideas, programmes can work to

improve initiatives over time, increasing

impact and decreasing waste.

Iterative implementation requires that

programmes think ahead about behaviours

that will either facilitate or handicap the

ability to adapt ideas over time. Consider the

following three ways in which programmes

can set themselves up to embrace adaptation.

Eective Programme Management

A lot goes into successfully bringing an idea

to the ﬁeld during its iterative implementation:

building capacity to implement programme

initiatives, logistical planning, staff training

and ensuring ﬁnancial resources. Distinct

from those concerns, this section is

exclusively focused on methods to ensure

we learn about and improve ideas over

time. This does not negate the importance

of effective programme management.

Resources for Adaptation

Plan to budget resources — time, money

and effort — for the explicit purpose

of learning and making changes

throughout implementation.

Resources tend to be tied to particular,

pre-decided activities, and also tend to

stay static. This can prove challenging. If

an idea calls for introducing new clinic

procedures, implementation might require

creating and deploying new materials,

conducting HCW trainings on how to use

them, and so on. But perhaps in the course

of implementing we ﬁnd that a change to our

planned activities is appropriate. Maybe an

adjustment to an activity becomes necessary,

or an additional activity is required?

Ensuring up front that budgets

enable adaptation of planned efforts

in the ﬁeld allows for responding to

the realities of implementation.

Permission for Adaptation

Do not avoid change simply because an

initial investment in the idea has been made.

Too often, programmes feel compelled to

continue a project as is despite evidence

of ineffectiveness, or identiﬁcation of

new opportunities for improvement.

This may come from a fear that if a project is

put on hold, or a part must be redesigned, it

will appear that the programme has wasted

resources.97 But by letting ineffectiveness

continue, we will waste even more

resources. This tendency is prevalent

when we have already invested a lot of

time, energy and money, and therefore do

not feel we have permission to adapt.

Iterative implementation calls for

giving programmes permission to

honestly evaluate, adjust and improve

ideas throughout their execution.

97 Arkes and Blumer (1985), ‘The Psychology of Sunk Cost’.

Standards for Adaptation

Iterative implementation is dependent

upon knowing exactly what should be

improved. This requires knowing what to

measure — which standards to apply.

Indicators are tools; some are helpful for

certain tasks and some are not. Selecting

the appropriate indicators for the purpose

of adapting ideas over time is often a

tension between indicators that will help

us to make effective adaptations, and

ones that will please a programme’s

stakeholders. They are not always the same.

The methodology that follows is

dedicated to selecting the most useful

techniques to evaluate ideas and

support their continual improvement.

Iterative Implementation

Phasing Model:

Learn to scale, and scale to learn

Time

Scale

5A: PLAN 5B: EVALUATE 5C: IMPROVE

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The approach is divided into three parts. At the end of the

process, we will return to our initial implementation planning

and make adjustments prior to repeating the process and

further scaling an idea.

Methodology

Revisit the initial Adaptation Plan

to reﬂect what we are learning,

adjust what we are measuring, and

continue to improve the execution

of our ideas. Implement adaptive

changes that respond to ﬁndings as

you scale the improved idea.

If the idea is working, the ﬁnal output

is a revised Adaptation Plan and

proven ideas that can be scaled. If the

idea is not working, step back into the

creative conceptualising and design

exercises laid out in Question 4,

then redeploy.

Devise an Adaptation Plan for

each draft initiative. Deﬁne the

key evaluative questions, possible

risks, measurable criteria and

corresponding indicators to track

progress over time. We will return

to the Adaptation Plan after each

phase of implementation and make

adjustments.

Assess each revised idea in the ﬁeld

using the Adaptation Plan as a guide.

Evaluate the accuracy of diagnoses

and determine what we still do not

know much about.

Revised

Adaptation Plan

Revised

Idea

5a: Plan for Iteration 5c: Improve Initiatives5b: Evaluate Eectiveness Final Output: Revised Adaptation

Plan and Proven Ideas

5A: PLAN 5B: EVALUATE 5C: IMPROVE

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Plan for Iteration

Separate Plans for Separate Ideas

Each initiative requires its own iterative

implementation process. For every

prototyped idea your team should devise

an Adaptation Plan, evaluate the idea’s

performance in the ﬁeld and make

adjustments prior to scaling it further.

While some ideas may be implemented

together (for example, perhaps you plan

to introduce both new health cards and

a new intake process at neonatal clinics),

devising separate planning, evaluation

and improvement processes ensures that

each idea gets the attention it deserves.

Adaptation Plan: Making Ideas Better

What do we hope to learn during programme

implementation? What are we going to measure? How will

we measure it?

An Adaptation Plan contains questions that we will return

to during the iterative implementation of our ideas. These

questions determine what we learn and what we change.

Adaptation Plans are ‘living’ documents. They should

change from phase to phase. For example, we might identify

unforeseen obstacles to success and we might change what

we choose to measure.

Questions

What are we hoping to

learn more about?

Choosing what to measure is predicated

on what we want to learn.

Suppose we are implementing an SMS

reminder programme responding to user

research indicating forgetfulness as a

chief reason for under-immunization. We

want to know whether or not reminders

actually increase coverage—articulated

in our Objective Statement (Question 1).

However, that will require long-term tracking.

For the Adaptation Plan, we are only

concerned with what we can learn about

and improve during iterative implementation.

To learn whether reminders help decrease

forgetfulness we could ask: Does the

SMS reminder programme make it

easier for caregivers to follow through

on their intentions to vaccinate?

We might also evaluate details of the

programme such as the frequency and

the timing of reminder messages.

To generate valuable questions, ﬁrst return

to the diagnosis behind the idea. In the

short-term, it is more realistic to evaluate

whether an idea is effectively responding

to its insight than to evaluate overall impact.

Second, consider elements of the idea that

would improve its performance (in this case,

perhaps the volume or timing of messages).

Indicators

What are we going to measure?

Now that we know what we want to learn,

we can determine how we want to measure

progress towards our learning goals. We

choose indicators that can be reliably

followed over time, and that reveal how an

idea is working through change or stagnation.

To continue our example, if we want to know

whether SMS reminders make it easier for

caregivers to follow through on their positive

intentions, an increase in clinic visits is a

strong indication that the idea is working.

Therefore, we could select “percent change

in clinic visits” as a corresponding indicator.

We could also select more than one

indicator to help answer a question. Having

multiple indicators gives us multiple

perspectives on the same question.

Components of an Adaptation Plan

5A: PLAN FOR ITERATION

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iii

Veriﬁcation

How are we measuring?

Now that we established what we are

measuring, we need to devise how to

measure. What methods will we employ

to track the indicators we laid out?

There are many ways to measure the

effectiveness of SMS reminders to increase

clinic visits. One approach could rely on

clinics’ administrative data: evaluating

the aggregate change in visit volumes over

some period of time. However, total visits

could increase for various reasons, and it

could prove difﬁcult to conﬁdently attribute

our SMS reminders to this outcome.

Another approach could rely on an

individual tracking system: enrolling

a sample of caregivers into the SMS

reminder programme whom we track

throughout the duration of the programme.

While this method may be more veriﬁable,

it is also potentially more effortful to

administer. Each means of veriﬁcation

will have distinct pros and cons.

Finally, quantitative approaches are not

the only (or necessarily the best) way

to gather information that improves the

effectiveness of an idea. The data we gather

for iterative implementation do not need

to be deﬁnitive; they need to be enough

to inform incremental improvements.

Because an Adaptation Plan is intended

to help improve an initiative, re-engaging

with qualitative user research is a useful

veriﬁcation tool. Consider the value of

follow-up interviews with caregivers after

experiencing the SMS reminder programme.

In addition to the data of change in clinic

visits, we can learn about why the SMS

reminders helped some caregivers

and not others. As with user research

(Question 3), qualitative approaches can

help to uncover motivations that would

not likely emerge in quantitative data.

Justiﬁcations

Why are we measuring this way?

Why have we selected a particular

indicator, and why have we chosen

to track it in a particular way?

In the previous parts of the Adaptation Plan,

we chose indicators, methods to measure

and means to verify. The Justiﬁcation

component exists to track why we made

these decisions and communicate the

reasoning to a broader team. Articulating

justiﬁcations will also instigate critical

reﬂection on those decisions to help us

avoid selecting inappropriate measurements.

Justiﬁcations should be given speciﬁcally

for each means of veriﬁcation (you may

have multiple methods for verifying a single

indicator). For example, perhaps we chose

to measure the percentage increase in

clinic visits to see if forgetfulness is the

biggest obstacle. In addition, we chose

to measure changes in timeliness to see

if follow-up is the biggest obstacle.

To track those indicators, our chosen

means of veriﬁcation is administrative

data provided by participating clinics.

Our justiﬁcation acknowledges the

attribution issues with the approach, but

explains that given a short timeframe and

limited budget, it is an optimal option.

Like recognizing assumptions we

may have (Question 2), identifying

external variables helps us design

for the existing system and

users, rather than for an ideal

system and generalized users.

There may be a lot that does not go according

to plan throughout implementation — some

within a programme’s control, and much

outside of it. While effective programme

management should help to account for

those variables within a programme’s

control, identifying external ones that

might jeopardize an idea is another way to

adapt our ideas to be more risk-resilient.

For example, the effectiveness of an SMS

reminder programme might rely on the

assumption that throughout the duration

of the programme, a caregiver is reliably

accessing the same mobile phone. In

reality, the phone may be shared within

the family and therefore reminders may

not reliably reach the caregiver at the right

time. The idea might also require that

caregivers can consistently pay for mobile

service, which may not be realistic. From

internet connectivity, to the performance of

programme agents like HCWs, to vaccine

supply itself, many external variables

pose as risks to an idea’s success.

Taking these risks into account is critical

for three reasons. First, we must recognise

possible external variables in order to

address them by adapting our ideas.

Second, knowing external variables that

stand in our way helps identify which

measurements are reliable within the

Adaptation Plan. It is unlikely that all risks

will be taken into account up front during

the development of an Adaptation Plan. It

is more likely that key risks are discovered

during implementation. This is why the

Adaptation Plan must be ‘live’— we

should be able to return to it and adjust

as an idea is tested in the real world.

Third, external variables help explain why the

idea did not perform the way we thought it

would. Shortcomings in the SMS reminder

programme that show up in the data may not

indicate shortcomings of the idea’s concept.

Instead, they might suggest that the idea’s

design and distribution should be better

adapted to mitigate these external variables.

External Variables

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Deﬁne Implementation Questions

Deﬁne what you want to learn about and improve

from phase to phase during iterative implementation.

Remember the Objective

Locate the Objective from Question 1 for reference—

this is what our continuous learning should support.

External Variables

Recognise external variables that may

jeopardize an idea or interfere with indicators.

Sample External Variables:

! Caregivers may not have reliable access to the

same mobile phone—it could be shared.

! Caregivers may not consistently pay for mobile

phone service.

! Caregivers may not have regular access to Internet.

! Clinics may not regularly stock all vaccines.

iii iii iv

For each idea, use this worksheet to develop an Adaptation Plan. Adjust the plan throughout

implementation. Add additional rows as needed for additional implementation questions.

Select Indicators

Based on your questions, determine

what you need to measure.

Articulate Justiﬁcation

Document why each indicator and its associated

means of veriﬁcation were selected.

Determine Means of Veriﬁcation

Determine which methods to use for tracking

the indicators and improving the idea (not

for deﬁnitively evaluating its impact).

Question Examples:

? Does the SMS reminder programme make it easier for

caregivers to follow through on their intentions to vaccinate?

? Are more messages better than fewer?

? How important is timing?

Indicator Examples:

+ percentage change in clinic visits

+ percentage increase in on-time visits

Method Examples:

» Use clinics’ administrative data (aggregate change in visits)

» Enrol a sample of caregivers into the SMS reminder

programme and track this controlled set

» Conduct individual interviews with caregivers after

experiencing the SMS reminder programme

Justiﬁcation Examples:

» The two indicators address two related issues (forgetfulness

leading to non-access or late-access)

» Administration data from clinics is a more suitable means of

veriﬁcation given short time frame and limited budget

Tool #1 Adaptation Plan

5A: PLAN FOR ITERATION

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Whereas Planning happens on paper, Evaluation happens

in the ﬁeld. This step is comprised of two sequential

parts: executing the means of veriﬁcation chosen in the

Adaptation Plan and analysing information as it is collated.

The methods used to execute the means of veriﬁcation and

analyse ﬁndings will vary signiﬁcantly depending upon the

chosen initiatives chosen for implementation.

Evaluate Eectiveness

5b Incomplete Diagnoses

Our user research (Question 3)

did its best to identify and explain issues

impacting the intended users of immu-

nization programmes. Our diagnoses

captured why these issues exist.

However, no amount of research will

produce deﬁnitive diagnoses. One of

the beneﬁts of iterative implementation

is the opportunity to use the real world

to test our ﬁndings: are the solutions

we developed actually responsive to

the challenges articulated in our diag-

noses? If not, what did we miss?

Consider two different scenarios; one

of them reveals an incomplete diag-

nosis, and one of them does not.

In the ﬁrst example, a box of tea is used

as a non-ﬁnancial reward for completing

an immunization course. Our evaluations

reveal that clinic visits did not meaningfully

change with this new reward system in

place. Through individual interviews, we

learn that the reward itself is of little interest:

tea is not especially desired, and the idea

miscalculated its relevance. This example

does not point to an incomplete diagnosis,

but to the shortcoming of the idea itself.

In a second scenario, tea was very much of

interest to this user-group: non-users of the

rewards programme discussed how much

they would have liked to have received the

reward. But these non-users also communi-

cated that because of high transport costs,

they still could not dependably visit the

clinic, despite wanting to. In this instance,

the diagnosis was incomplete: forgetfulness

is a problem, but so too are travel costs.

Our idea only addressed the former.

When we recognise evidence of incomplete

diagnoses, we must reﬁne them, adjust

their corresponding prompts and revisit idea

generation and design. This iterative loop

ties our implementation (Question 5)

back to our research outputs (Question 3)

and creative efforts (Question 4).

Unknowns

Finally, one of the most important aspects

of an honest evaluation is acknowl-

edging what we still do not know.

One example of a predictable unknown

is the degree to which an idea effectively

supports a programme’s objective. Is the

idea actually increasing coverage among

the user-group? Is it decreasing inequities?

This measurement of impact will come from

rigorous evaluation over a longer time.

Our evaluations will be incomplete in many

other ways. Data will be imperfect, or

inconclusive — and explicitly identifying

those ‘unknowns’ at the end of an imple-

mentation phase will help us to adjust an

Adaptation Plan for a subsequent phase. For

example, continuing with our hypothetical

rewards programme, perhaps data from

an initial phase suggest that a particular

sub-segment of users (young caregivers) are

using the programme less than others. At

this point, we have an outstanding unknown:

why are these particular caregivers tending

to use the rewards programme less?

Identifying unknowns will help to complete

our measurement activities— and, subse-

quently, improve the ideas themselves.

In addition to the tracking and analysis

activities your team chooses, the following

three categories will help improve an

idea from one phase to the next.

External Variables

The Adaptation Plan lays out the potential

external variables (risks) beyond the

immediate control of your team that can

jeopardize the effectiveness of an idea

once implemented. For example, a reward

given to a user for seeing an immunization

course through will not be useful if upon

the last visit, the vaccine was not available.

If you cannot resolve them (e.g. vaccine

supply) you must adapt ideas to be more

risk-resilient. Consider the same example

of a reward for a user that is not very useful

if a vaccine is not in supply. After visiting

a clinic twice, motivated by the promise

of a reward upon the third and last visit, a

user is likely to be upset by the absence

of a vaccine — and moreover, by the

absence of a promised reward. Following

the adaptation option, the reward system

is modiﬁed: users who encounter this

situation are offered an increased reward

for returning for a fourth clinic visit, when

the vaccine stock is scheduled to be

replenished. This may not work perfectly

(especially in the unpredictable context of

a failing vaccine supply system); but it may

improve an idea’s chances of success.

It may not be possible to fully address

the external variables facing an initiative.

Evaluating those risks is still critical to

any measurement exercise, as it helps to

explain how an initiative’s effectiveness

will continue to be mitigated.

5B: EVALUATE EFFECTIVENESS

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DEMAND FOR HEALTH SERVICES

160

Q5: HOW COULD WE IMPROVE?

There are two ways that ﬁndings from ‘Evaluate

Eectiveness’ help teams to improve an initiative.

The ﬁrst involves eorts to improve the idea itself. Discovering

that a particular risk is impeding an idea’s potential, or

that the idea is not being received by users in the way we

anticipated, requires returning to concept creation and

design (Question 4). Once we have a new idea, we redeploy

in a new phase of implementation and re-evaluate its

performance. We can call this Idea Improvements.

The second involves making adjustments to how we measure

and learn. Before we continue scaling up, we should revisit

the initial Adaptation Plan: have we been asking the right

questions? Are the indicators we chose proving helpful, or

too challenging to meaningfully track? Are there others we

should consider? What additional risks emerged that we did

not anticipate? What risks did we anticipate that had no

impact? We can call this Planning Improvements.

Improve Initiatives

Checking Ourselves

Throughout this problem-solving process we risk viewing

ourselves as the experts and users as the people who

require help. This is not the case. A human-centred

methodology treats users as the ultimate experts and

ourselves as learners intent on better understanding what

is preventing better immunization outcomes. While you

may be the one holding this Field Guide, it is unlikely

that you also know the problems facing immunization

programmes as well as those aected by them.

Intended users are not alone in facing the

challenges presented here. Our cognitive

abilities are a relatively poor predictor of how

susceptible we are to cognitive biases.98

Educated, high-income people are just as

susceptible to forgetting important tasks

or exaggerating probabilities as the less

well-educated and poor. As Jim Yong Kim,

President of the World Bank, commented,

“development professionals and policy

makers are, like all human beings, subject

to psychological biases.”99 On the next

page are three reminders to help us be

self-critical of biases and assumptions we

might inadvertently bring into this work.

5C: IMPROVE INITIATIVES

98 Stanovich and West (2008), ‘On the Relative Independence of Thinking Biases and Cognitive Ability.’

99 World Bank (2015), Mind, Society and Behaviour.

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DEMAND FOR HEALTH SERVICES

162

Q5: HOW COULD WE IMPROVE?

Hearing What We Want

Consider two uncontroversial observations.

First, it is unlikely that health professionals

approach a problem without any pre-

existing experience or knowledge. To

the contrary, most engage with a

challenge having the distinct advantage

of a career’s worth of expertise.

Second, it is usually easier for us

to get behind familiar ideas than

unfamiliar ones. Familiar information is

comfortable, and unfamiliar information

is less so. And we usually do our

best — even if unconsciously — to

avoid feeling uncomfortable.

Taken together, these two phenomena

can handicap our work: the more we

know, and the more uncomfortable it is to

process unfamiliar information, the more

likely it is that we will be selective in what

we hear. From conducting ﬁeld research

to analysing research ﬁndings, we exhibit

the tendency to ﬁt what we see and hear

to pre-existing models of how we think

things work. We bypass information that

goes against those mental models.100

For example, consider the researcher who

developed the following hypothesis: a

particular user-group is rejecting vaccinations

because of a dearth of proper education. For

years, across many contexts, this researcher

observed the correlation between low levels

of education around vaccines and low uptake.

In the present context, the researcher

takes special note of these observations:

there is no discussion of vaccines in

schools and little education at clinics.

The researcher may have also heard during

interviews that vaccines are not safe. This

seems to further support the researcher’s

hypothesis: people are not properly educated

given that they think vaccines are dangerous.

But that is not the whole story. Suppose

the researcher is in a country with a

history of forced sterilization. Users

may have reason to believe vaccines are

dangerous. ‘Rumours’ of sterilization may

not be accurate in the present, but they

are meaningful historical events.101 The

problem is a distrust of public services

rather than misconceptions about vaccines.

Had the researcher stuck with the initial

hypothesis regarding under-education,

the solutions developed would not be

effective. By selectively emphasizing certain

observations and bypassing others based

on previous knowledge and experience, we

risk misdiagnosis and ineffective solutions.

Having an Answer

Health systems and the various ways

that populations engage with them

are complex. Despite that evident

complexity, health professionals are

sometimes more comfortable with

deﬁnitive answers than with ambiguity.

At their best, human-centred methods

avoid overstated precision by surfacing

our assumptions, by questioning the

perfection of any diagnosis or idea, and

by mandating continual investigation

and improvement. Being unsure is far

better than falsely conﬁdent. In any arena

where practitioners are tasked with

better understanding and responding

to the subtle and complex elements of

human behaviour, overconﬁdence can

be debilitating. Having no answer is

better than having the wrong answer.

For example, take a programme that has

invested signiﬁcant amounts of time, money

and effort into communication assets

that used positive framing to motivate

caregivers: it used messages like “getting

fully vaccinated can save your child’s

life.” Assessments during the prototyping

of the communication assets were not

conclusive; the initial evaluations did not

strongly suggest success or failure.

Before implementation, the programme

decided to additionally prototype negative

messages to better compare and contrast

the idea (for example: “your children

will be more likely to contract a serious

disease if you don’t get them fully

vaccinated”). The ﬁndings did not reveal

anything conclusive. So the programme

brought both negative and positive

messages through to implementation,

piloting them over time and evaluating

their potential affect on clinic visits.

Rather than defaulting to an answer for

the sake of conclusivity, the programme

maintained humility in its assessments

and, as a consequence, opened itself up

to further experimentation by bringing the

negative messages into its prototyping

and iterative implementation.102

We do not have all the answers. Humility

helps us remain open to new insights.

Letting Go

Lastly, human-centred methodologies

require that practitioners let go of certainty.

In the course of the work presented in

this Field Guide, teams will likely articulate

an insight, discover a ﬁnding or devise a

solution that needs to be changed — or

discarded altogether. However, when

we invest signiﬁcant energy in an

effort, or are especially satisﬁed with

our work, making changes or discarding

that work can prove challenging. We

have a tendency to resist change.

For example, during the prototyping of

creative ideas, it is unlikely that any later

ideas will bear a strong resemblance to

the concepts initially developed during

creative brainstorming. However, the

more we hold onto our ideas as they are,

the less we are able to objectively listen

to users and adapt our ideas based on

the valuable feedback they provide.

Resisting overcommitment opens our work

to more possibilities for experimentation

and effectiveness in the long run.

100 Nickerson (1998), ‘Conﬁrmation Bias: A ubiquitous phenomenon in many guises’.

101 Generalized example based on empirical evidence: ‘Social Mobilisation and Communication for

Polio Eradication: Documentation in Nigeria, India and Pakistan (2002-2003)’.

102 Gallagher and Updegraff (2012), ‘Health Message Framing Effects on Attitudes, Intentions, and

Behaviour: A Meta-Analytic Review’.

“As it happens, research has largely been inconclusive on framing effects as they relate to

vaccination-related behaviours; loss-framed messages generally tend to perform better with

health-related behaviours overall, but their strength is less certain in regards to immunization.”

A human-centred approach to problem-solving is

accepting that our pre-existing knowledge is incomplete,

that deﬁnitive answers can be dangerous, and that better

ﬁndings and new solutions await our discovery.

5C: IMPROVE INITIATIVES

164 165

DEMAND FOR HEALTH SERVICES

Q5: HOW COULD WE IMPROVE?

For additional details, or to download a

digital version of the full Field Guide, visit

HCD4I.org. Additional components to

accompany the full ﬁeld guide include:

For examples of how UNICEF’s

Innovation Team is using a human-centred

approach: unicef.org/innovation

Take Acumen Courses in Human-Centred

Design: plusacumen.org/courses

For more information on interviewing

users and creating a discussion guide, read

Rosenfeld’s Interviewing Users:

rosenfeldmedia.com/books/

interviewing-users

For an overview of human-centred

design and a complete kit of methods to

apply throughout the process, visit the

IDEO.org Design Kit: designkit.org

View tools for collaboration and

brainstorming in the HyperIsland

Toolkit: toolbox.hyperisland.com

frog’s Collective Action Toolkit puts

design-thinking tools into the hands of

local change agents: frogdesign.com/

work/frog-collective-action-toolkit.html

Find practical tools to trigger and

support social innovation in the

DIY Toolkit: diytoolkit.org

For tools focused on improving the

conditions and experiences of vulnerable

populations visit the Social Innovation

Lab Guide: socialinnovationtoolkit.com

Additional

Resources About This

Guide

1 2 3

Principles & Process Poster

This 6-page, fold-out poster provides a short

introduction to the project, an overview

of the process, and the six behavioural

principles to keep in mind during the process

(which can be posted your workspace).

Workbook

This fold-out workbook provides an summary

of each step of the process and its associated

tools. The form encourages immediate trial

for new users and provides helpful reminders

for users familiar with the process.

If you are interested in thinking about

innovation at an organizational (not project or

service) level, visit Capacity

to Innovate: capacitytoinnovate.org

For ready-to-use workshop agendas and

guidance bringing together groups, download

the Social Innovation Lab Guide:

rockefellerfoundation.org/report/

social-innovation-lab-guide/

About This Guide

In 2015, the SAGE Decade of Vaccines

(DoV) Working Group tasked UNICEF

and WHO to establish a working group

related to GVAP Strategic Objective

2 (GVAP SO2). This Field Kit builds on

the ﬁndings and recommendations of

the “GVAP SO2 Working Group.”

The SO2 ﬁndings disrupt a simple distinction

between “supply” and “demand.” They push

for increased EPI capacity to understand

and respond to challenges, whether

they are related to care-giver KAPs, HW

skills, or issues of service quality.

This resource was created by the

Communication for Development (C4D)

team in the Immunization Unit of the Health

Section, UNICEF PD, to help colleagues

apply “human-centred design” approaches

informed by emerging insights from the

behavioural sciences to do just that.

Share Feedback and Ask Questions

To share your successes and stories

from the ﬁeld, or to ask any questions

you have regarding this guide email

HCDimmunization@gmail.com.

166

CONCLUSION

Some terms used in this guide may be foreign in health

programming ﬁelds, but their meaning is probably not as

foreign. Terms common to human-centred design are listed

below. The language is also meant to be human-centred:

simple terms that can be understood outside technical

jargon and specialized acronyms.

Diagnosis – the identiﬁcation of the root cause of a

behaviour, perception, or other challenge by examination

of the symptoms

Hypothesis – initial or proposed explanations, made

on the basis of available evidence, as a starting point

for further investigation

Lexicon

168 169

DEMAND FOR HEALTH SERVICES

CONCLUSION

User – the person who will be using or interacting with

our solution: the child we are trying to reach, the caregiver

we are trying to help and health-care workers

Brainstorming – a group activity for generating ideas collectively

Prototype – a mini-pilot that acts as the a ﬁrst

preliminary model of an idea

Low ﬁdelity – a draft plan, sketch, or rough drawing

that serves to quickly to make an idea real

High ﬁdelity – a reﬁned plan, sketch, or rough drawing

that serves to more closely approximate the ﬁnal version

of the idea

Adaptation Plan – an implementation plan that

will continually change during the implementation

process to become better suited for the initiative

and its changing environment

UNICEF Demand For Health Services Field Guide V1 2016 PDF

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