Improving Health Workers' Immunization Performance: Using Behavior Integration to Improve Routine Immunization Services and the Client Experience in Western Kenya

"Behavior integration and co-creation can help ensure the needed focus on behaviors, learning from implementation, and adaptation based on what is learned."

This brief from MOMENTUM Routine Immunization Transformation and Equity presents a human-centred, behaviour-focused methodology used in two counties in Kenya to improve health worker (HW) performance on routine immunisation. The methodology - behaviour integration - was used to identify and address systemic barriers to better HW performance on immunisation, such as inadequate training, limited resources, and poor community engagement, to improve immunisation coverage. It emphasises co-creation, local ownership, and sustainability, enabling health workers and managers to adopt practices that enhance service quality and client experiences. The brief is intended for immunisation programme managers, implementers, and partners at multiple levels. 

As explained in the brief, "Poor staff attitudes and practices were most frequently reported in focus groups with caregivers in Western Kenya as reasons they do not vaccinate their children (Agócs 2021). Persistent challenges in Homa Bay include limited access to services; inadequate knowledge and skills among HWs due to infrequent training and supervision; and poor community linkages that compromise tracking children who miss appointments. Caregivers also cited HW lateness; lack of vaccines; poor communication; and no warning about adverse events following immunizations as reasons for non- or incomplete vaccination (Wanga 2018). Even in Nairobi, the capital, vaccine stockouts and inconvenient hours for working caregivers prevent children from getting fully vaccinated (Muathe 2020)." Immunisation programmes are also becoming increasingly complex, with additional vaccines given throughout life, and global immunisation goals that call for increased equity by reaching those historically underserved. For this reason, highly proficient and motivated HWs are crucial to reaching and sustaining global and national immunisation goals.

The behaviour integration methodology offers a way to put people and their behaviours at the centre of systemic change efforts. By leveraging social and behaviour change approaches, human-centred design, best practice design expertise, and systems strengthening insights, behaviour integration focuses on what people must do to adopt a behaviour and identifies interventions that link clearly to critical factors (barriers and motivators) that affect it. 

This focus allows projects to identify key behaviours that would improve outcomes and to design activities to enable the adoption of those behaviours. Learning and adaptation are integral to the process. As stated in the brief, changing people's behaviour requires understanding what they are doing and why, and what they might be willing to do and why - and closing the gap between the two. For optimum HW behaviour change, systemic elements including human resource (HR) management policies and practices, immunisation policies, accountability, financing, infrastructure, health information systems, communication, commodity availability, and behaviour-enabling technologies must also be addressed. 

The activity/methodology described in this brief seeks to identify and implement changes that can be made and sustained locally in the context of larger efforts toward systemic change that could improve HW performance. It follows an eight-step process as implemented in two counties (Homa Bay and Vihiga), providing an example that other counties within Kenya and beyond can adapt and implement. The steps are as follows: 

Step 1: Identify goal
In this case, it was defined as "Improved HW performance and leadership in reducing zero-dose and under-immunization".

Step 2: Analyse impediments to goal achievement
Examples of impediments included staffing shortages, inadequate or mis-matched capacity (skills, attitudes, knowledge), and inadequate or harsh supervision. 

Step 3: Prioritise behaviours to overcome impediments to the goal
This step involved brainstorming solutions that included, for example: supervisors providing or ensuring continuous learning; clinic managers providing feedback, encouragement, and skills-building; or district health management teams implementing quarterly calls with HWs to get input and feedback.

Step 4: Analyse the behaviours, creating pathways to change
This step involved (i) delineating the steps needed to practice the priority behaviour; and (ii) determining factors that can prevent (barriers) or support (motivators) the practice of this behaviour - looking at why the behaviour is or is not practiced. An example of a barrier was that county health managers have no control over staff function, reward, transfers, or deployment.  

Step 5: Using a co-creation process, validate the behaviours and profiles
The goal of the co-creation workshops was to identify and detail ways to facilitate the adoption of behaviours needed to improve HW immunisation performance. Participants included: HWs and facility in-charges; sub-county health managers, such as medical officers of health, public health, nurses (responsible for immunisation), and community health strategy focal persons; and county health managers, including the immunisation programme coordinators, HR and finance managers, health records and information officers, and county health directors.

Step 6: Prioritise solutions
In this step, workshop participants formed small groups according to their roles (HW, facility manager, etc.) to look across a subset of behaviours to identify and prioritise solutions and develop country plans. Examples of actions and solutions that emerged out of this process included: 
 

Homa Bay - to build capacity for quality immunisation services:
 

• Create award and recognition model.
• Conduct HW and community health promoter meetings at the facility.
• Assess service quality using quality assessment tools.
• Conduct regular supportive supervision to identify immunisation quality gaps and strengths.

Vihiga - to link and collaborate with the community:
 

• Conduct community dialogues.
• Conduct routine immunisation action days.
• Operationalise community health promoter performance monitoring chart. 
   

The final two steps do not form part of this brief, as the identified activities still require implementation:  
Step 7: Implement and monitor action plans
Step 8: Monitor progress toward behaviour change and adapt interventions as needed

As explained in the brief, the final year of this activity will focus on learning from implementation and sharing the process and findings with Kenyan health authorities at national and subnational levels, programme participants (e.g., HWs), and national, regional, and international audiences as appropriate. Learning will take place via regular monitoring and periodic pause and reflect sessions that also bring to the fore needed adaptation and new ideas.

In conclusion, the brief shares the following key insights on the process: 
 

• Recognition of the need for more immunisation funding and more and better-trained staff was universal, but workshop participants identified at least some things they could do with current resources. Spending even more time on "thinking outside of the box" might have resulted in additional small but important solutions on the pathway to greater and longer-term change.
• HWs' reliance almost exclusively on community health assistants to convey information (rather than leaving the facility to talk with communities themselves) creates social distance that compromises follow-up and caregivers' willingness to return for services.
• Behaviour integration supported a process for identifying behaviours, steps composing the behaviours, barriers, facilitators, supporting actors, and targeted interventions.
• Built-in flexibility and emphasis on local ownership of behaviours and solutions is expected to foster sustainability, as is partnership between the county, sub-county, and frontline HWs.
• Developing a behaviour-led strategy was new to and useful for workshop participants, in particular focusing on their own behaviours: Many arrived expecting to focus on caregiver behaviours. The process helped them see how their behaviour affects immunisation uptake and completion.
• It was important for HWs to determine which behaviours they want to work on, rather than having it determined for them. They also appreciated the acknowledgement of the range of obstacles to good performance and the shared responsibility for overcoming them.
• The co-creation workshops require much of participants. Management at each level embraced the process and the paradigm shift needed to improve the service experience for both HWs and caregivers.
• Improved HW performance requires behaviour change at multiple levels. The co-creation workshops demonstrated how HW behaviours depend heavily on management action. What managers at every level do affects what those under them can do. For example, sub-county and facility managers showing support, providing growth opportunities, and acknowledging performance rather than focusing almost solely on problems and corrective action can positively impact HW performance.