Strengthening Capacity for Tailored Immunization Programs Using Adult Learning Principles: A Case Study from Nigeria

"Policymakers should create policies to integrate behavioral science into immunization programs to address the behavioral and social drivers of vaccine uptake and incorporate HCD [human-centred design] approaches when engaging with communities to enhance people-centered, participatory, and data-driven interventions for equitable immunization coverage."

Nigeria has one of the highest numbers of zero-dose children (2.2 million) in Africa and globally. In response, immunisation programme managers (PMs) and healthcare workers (HCWs) have been urged to develop tailored strategies to improve vaccine uptake, given their understanding of the context. However, there are competency gaps among immunisation PMs and HCWs in Nigeria in tailoring immunisation programmes (TIP), contributing to suboptimal vaccine uptake and coverage. This article discusses the use of adult learning principles (ALPs) to strengthen the capacity of PMs and HCWs to use the human-centred design (HCD) approach for tailored immunisation strategies, illustrated through the Strengthening Capacity for Immunization Data Use (SCID) pilot intervention in Northern Nigeria. 

The National Primary Health Care Development Agency (NPHCDA) trains PMs and HCWs to deliver quality routine immunisation services at the state and local government area (LGA) levels. The training is delivered through the cascade or "training of trainers" (TOT) model. SCID applied ALPs to the TOT model because it is a participatory, self-directed, problem-based, and experiential approach to learning. It recognises that adults learn by actively participating in the learning process through discussions, problem-solving/brainstorming, and other interactive activities such as role-play and group exercise and can apply knowledge gained to real-life situations.

As part of SCID, ALPs were used to design and deliver the TOT for PMs and HCWs on HCD for TIP (HCD-TIP, which is described in detail at Related Summaries, below). Incorporating evidence on vaccination behaviours and recognising population diversity, HCD-TIP provides "hands-on" tools and participatory approaches to working with communities to (i) understand reasons for low vaccine uptake among the un/undervaccinated and underserved populations, (ii) co-design tailored solutions to address the identified challenge, and (iii) implement and evaluate the solution with continued community engagement. Co-designing tailored immunisation strategies is thought to be crucial for overcoming vaccine uptake and equity barriers.

Specifically, SCID is a capacity-building intervention that (i) used ALPs to train immunisation PMs and HCWs on the HCD-TIP iterative stepwise process for understanding and addressing barriers in immunisation, in partnership with communities and health facilities; (ii) provided templates to support the systematic use of data for diagnosis, intervention design, implementation, and evaluation; and (iii) introduced incorporating the principle of "good enough", which refers to critical and easy-to-take actions to be taken at each stage of the HCD-TIP process. The goal is to help PMs and HCWs generate simple, people-centred, culturally appropriate, feasible, and low-cost solutions to address the identified challenge.

The SCID intervention was implemented in 3 LGAs of the Federal Capital Territory (FCT), North-Central Nigeria, in collaboration with the FCT Primary Health Care Development Board. The approach to the intervention was participatory and targeted to the needs of the stakeholders at all levels. Four key activities were implemented between May and September 2023: (i) stakeholder engagement; (ii) desk review and training needs assessment; (iii) curriculum development and template adaptation; and (iv) training sessions, with the delivery approach guided by participatory, experimental, and reflective ALPs and supported using the teach-back method for effective information delivery and reception.

First, the study team and the FCT Training Working Group (FCT-TWG) trained 10 state and 30 LGA PMs from the selected LGAs on the HCD-TIP steps, its templates, and the ALPs to apply, enabling them to train HCWs. Between July 24 and August 27 2023, the study team, FCT-TWG members, and state and LGA PMs observed the 42 trained HCWs use their immunisation data and HCD-TIP approaches and tools to conduct 2 distinct HCD sessions in 12 communities with 240 community members, including vulnerable groups and missed communities. Together, they co-designed 24 targeted and tailored prototype solutions, testing 12 of them for 4 weeks. One example: To reach unvaccinated Fulani settlement households in Dagiri, the prototype solution involved engaging community Imams to sensitise followers on vaccine safety and debunk misinformation. The design objective was for hesitant husbands to change to being receptive to vaccines by addressing the cultural misconception about vaccines and infertility.

The study team evaluated the effectiveness of the SCID intervention at 3 time periods using a mixed-methods approach. Key findings:

• The training content and the participatory delivery approach reportedly met the participants' expectations, were relevant to their job, and motivated them to apply and prioritise what they had learned in their daily job tasks. There was a high level of satisfaction with the training among LGA PMs (100%), state PMs (91%), and HCWs (85%).
• The pre-and post-test mean scores showed a statistically significant improvement in the knowledge and competence of the PMs by 21% in the post-training evaluation (P<.001), as well as a statistically significant (P<.001) increase in HCWs' knowledge and competence scores from pre-training (mean of 9.97) to post-training (mean of 15.88).
• Three months post-training, data revealed increased vaccine uptake and behaviour change in work practices. For example, 75% of LGA PMs, 72% of HCWs, and 67% of state PMs reported an improved understanding of HCD approaches due to the training. Most LGA PMs (81%), HCWs (75%), and state PMs (50%) strongly agreed that the workshop positively influenced their approach to immunisation programmes by enhancing collaboration with communities, communication skills, and data-driven approaches. There were increases in PMs' and HCWs' capacity to engage undervaccinated communities to address barriers to vaccination and to co-design people-centred, culturally appropriate, practical, and low-cost solutions to improve vaccination uptake and service delivery.
• Results showed increased coverage of the pentavalent vaccine first dose (54%) and third dose (188%) across 12 participating communities.

Based on this experience, the study team presents policy recommendations to improve capacity-building interventions for immunisation and other primary healthcare interventions. For instance, they note that "HCD-TIP requires continued community engagement....Although HCWs engage with community members, continuous capacity-building, a platform for peer learning, and mentorship are needed to promote HCD-TIP approaches during community engagement activities. Countries can use adult learning methods like data review meetings to promote peer learning and mentoring on HCD-TIP approaches and strengthen capacity for data reporting and quality....Lastly, policies must incorporate behavioral science in immunization data and programs to better understand behavioral and social drivers of vaccine acceptance and hesitancy for targeted interventions."

In conclusion: "The application of ALPs in training, use of HCD-TIP approaches and tools, and supportive supervision enhanced PMs' and HCWs' capacity for tailored interventions. Countries should consider adopting a holistic approach that focuses on using these approaches in immunization programs to strengthen the health system for equitable vaccine coverage."

Full list of authors, with institutional affiliations: Chisom Obi-Jeff, Brooks Insights and London School of Hygiene and Tropical Medicine; Funmilayo Oguntimehin, Brooks Insights; Abduljaleel Adejumo, Brooks Insights; Abdulrahman Ibrahim; Brooks Insights; Olympus Ade-Banjo, Brooks Insights; Dan Gadzama, Federal Capital Territory Primary Health Care Board; Nicholas Okoli; Federal Capital Territory Primary Health Care Board; Chidera Obi, Brooks Insights; Rachael Olorupo, Brooks Insights; Ifeyinwa Martins, Brooks Insights; Amina Usman, Federal Capital Territory Primary Health Care Board; Audu Joy, Federal Capital Territory Primary Health Care Board; Tanko Chadwafwa; Federal Capital Territory Primary Health Care Board; Anthony Onimisi, Brooks Insights