Community Theatre for Immunisation (CT4I)

Mama Koko is a 36-year-old rural fisherwoman, who lives in the heart of the Niger-delta region of Nigeria and who has just lost her 3-week-old baby. During the engagement, Mama Koko talked about her pain and her regrets, watching her baby suffer convulsions and eventually die from tetanus, a disease that vaccination could have prevented. Our encounter with Mama Koko occurred at one of our community surveys in her community.  Prior to her loss, she was unaware of immunizations, vaccines, or vaccine preventable diseases and about available immunization services in her community health centres.

In Nigeria, around one million such children die every year from Vaccine Preventable Diseases. “Mama Koko” explained that her greatest regret was not knowing about Tetanus and the Vaccination that should have prevented it. The challenges with demand for vaccinations in Nigeria are very well documented, with demand-related barriers contributing to around two-thirds of all cases of under-immunization and zero doses, according to reports in the 2016/2017 multiple indicator cluster survey and the draft reports of the 2019 National Nutrition and Health Survey. The extent of the challenge may however be under-estimated in the Niger-Delta region of Nigeria, a region that sits on one of the world’s largest deltas and is home to thousands of indigenous people and minority ethnic groups. Some sub-national program reports by UNICEF and WHO posit that the region may be home to half a million under-immunized children, with demand related issues accompanied by challenges of geographical accessibility. 42% of caregivers surveyed in a 2016 National survey in Nigeria indicated a lack of awareness as a key reason for not being fully immunized. 11% of them had no faith in immunisations

The Global Routine Immunisation Strategies and Practices (GRISP) 2016 report endorses “community involvement” as one of its nine transformative investments in achieving better immunisation outcomes. Community involvement here refers to “investments in the shared responsibility for immunisation delivery between communities and the immunisation program to reach uniformly high coverage through high demand and quality services.”

Our team uses a human-centred approach to develop a community theatre production that showcases real stories to educate community members on the value of immunisation and increase utilisation of available services. In unpacking the challenges of demand, our solution provides practical knowledge about diseases, about available health services for prevention and about where and when to access these services. Our focus is to use a human-centred design process of ideating, prototyping, collecting feedback and iterating, to deploy community theatre with different layers – focus-group discussions, training of the community members to perform, and the actual performances by community members in front of other community members.

The human-centred design approach of ideating, prototyping, collecting feedback and iterating our community theatre has allowed us to gain insights into different contributors to poor demand for vaccination in select communities in Niger-Delta region of Nigeria (e.g., not knowing about the pentavalent vaccine which prevents five child killer diseases including tetanus), and to work with community members to design messaging, co-create songs, create prompts for ad-lib dialogue and produce local theatre performances. The training, co-creation and actual performances provide a platform for us to familiarise caregivers with information on diseases that vaccines prevent, where and when routine and/or campaign services are provided, how many times a child should be vaccinated, the importance of timely vaccination, and to address common concerns especially around adverse events following immunisation (AEFI). The training and co-creation also mean that the handful of community members, usually around 10 in number per community, have their capacities built on multiple occasions and through different methods, to enable them to perform on stage and in arenas and pass the messages accurately. These handful of community members have been seen to become Champions for Immunisation in their local communities, with the potential to spur social change.

In conducting user research over the last 24 months of implementing the community theatre for health solution, we iterated our initial design for the community theatre and included a system that allowed it to additionally solve a problem of improving the convenience of services, e.g., setting up vaccination booths at the theatre performance and allowing children who are due to get their shots. We achieved this working with health workers at the facilities serving intervention communities by ensuring that necessary materials were commandeered from the health facility on an outreach service to the community centre or religious house where the theatre will be performed.

We intend to build on the successes and lessons of our initial implementation of community theatre where we largely prioritized vaccination and nutrition services, to scale our intervention to new communities and states and to increase the reach of community theatre through broadcast and digital dissemination of performances.

The plays will also be taped for possible future broadcast in local theatres, television, radio, social media and other traditional forms of media as well as modern media alternatives. We intend to work with subnational expanded immunization teams, Community Health Committees, Women's Groups, and Traditional and Religious Leaders in the target communities to put this strategy into action. These parties will be involved in the development, implementation, and oversight of the plan. This will ensure that the strategy is included in existing sub-national initiatives to boost immunization rates in specific locations. Our idea is to see if caregivers will demand immunization services as a right if they are involved in a human-centred process of creating trust, education, and social support. Our approach is likely to be successful since it is based on well-established statistics and best practices in community participation and demand growth, as well as a unique design concept.

Stakeholders

Value/Offering

Incentives

Health system decision makers

Strategy to improve child survival through vaccines, Increased community involvement in health services, political advantage

Increased resource efficiency, improved reputation for their achievement in improving child survival

Mid-level immunisation managers

Strategy to increase demand for vaccination, strategy to increase vaccination coverage

Increased trust in immunisation programs, increased immunisation coverages

Health care workers

Capacity improvement in identifying and resolving issues in demand for vaccination, strategy for seamless community engagement

Increased community involvement in immunisation and other health programs, increased trust from the caregivers, increased in immunisation uptake

Community

Increased well-being of families and community members

Herd immunity, healthier communities, reduced outbreaks

Caregivers and children

Increased knowledge on vaccine preventable diseases, increased knowledge on routine immunisation schedule, service availability, reduced suffering and emotional stress due to child illness and increased productivity

Educational entertainment, improved convenience to access RI services,

Corona Management Systems (CMS) is a Social Enterprise operating with the belief that committed individuals who have a passion for solving problems, can with the right tools change the world. CMS specializes in providing technical and management support to programs, and implementing innovative projects in Health, Education and Social Development. CMS succeeds by leveraging Community assets, institutionalizing Data use for action and deploying Information and Communications Technology (ICT).

The theory of change of our Health Division is centered on the third Sustainable Development Goal, although our work cuts across a number of other goals. The mission of our health division is to champion the delivery of country-owned high impact Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) services, through Advocacy, Community engagement and Technical Support for policy development and for the use of data for action in improving Governance and Service Delivery.

To achieve our mission, we work at the critical nexus of five pillars: Resource Mobilization, Community Engagement, Policy Development, Innovation and ICT for development. Through our work, we have seen the direct effect that progress in these pillars can have on human health and sustainable development. Our work leverages program expertise from more than a decade of work in the Niger Delta and over half a decade of work across the rest of Nigeria, even as we look to venture into new countries and new terrains.

Corona Management Systems also maintains Education Division and Social Development Divisions, where the focus is on leveraging Community Structures (CS), Data use for action, and Information and Communications Technology (ICT) towards causing incremental change across the social determinants of health and driving progress towards the Sustainable Development Goals. Our team currently has an administrative office in Abuja and State offices in Bayelsa and Imo States. Our health division team totals 16 full time staff and 12 contract staff and consultants, available when needed. This is in line with our organizational strategy of maintaining lean operations.

Corona Management Systems (CMS) is experienced in the implementation of advocacy, communications and social mobilization strategies. Our team has many years of experience in providing technical support to Government at sub-national level, on Communications for Development, cutting across Reproductive, Maternal, Newborn, Child and Adolescent Health. We currently implement this Communications for Immunisation intervention – Community Theatre for Immunisation – at sub-national level, that leverages design thinking and social and behavior change communication to increase demand for vaccination.

We also currently provide strategic communications support for the Nigeria Centre for Disease Control on the COVID-19 risk communications and community engagement (RCCE), and this has included support for the development of a strategy and monitoring and evaluation framework, support to strengthen research and knowledge management capacity, and support for a transition from a Social Cognitive Theory (SCT) for RCCE to an Extended Parallel Process Model (EPPM) theory for the implementation of RCCE. We are also providing Strategic Communications support for the planned roll out of the Resiliency through Azithromycin for Children (REACH) campaign in 4 States in Nigeria (Kebbi, Jigawa, Sokoto and Yobe States), building on the back of the outcomes of the MORDOR trials in Niger, Malawi and Tanzania.

Officially registered with the Nigerian Corporate Affairs Commission in 2012, as an organization working to foster the production and integration of data and technology, towards sustainable development, Corona Management Systems is rapidly growing into a key stakeholder providing our unique range of community interventions, using data for action and deploying information and communication technology for development. Many years since we were first founded, and little has changed in our mandate. We continue to believe that appropriate technology and innovation can change the world and advance development, and we work every day to help realize this potential.

Core Implementation team

S/N

Name of staff

Role

Dr. Chijioke Kaduru

Project Director

Ms. Ganiyat Eshikhena

Project manager

Dr. Woyengitari Sampou

Senior M & E manager

Dr. Tosin Akande

Immunization specialist

Ms. Adaeze Eche-George

Community Engagement officer

Chimezie Anueyiagu

Associate communication

Aliyu Umar

IT specialist

Mr. Ken

Theatre consultant

Sabenus Timiebiere

Theatre specialist

Koko Aadum

Innovation specialist

Mrs. Tombari Duruzor                             

Project Advisor

Dr. Ejike Oji

Project Advisor

Our idea is built to test the hypothesis that community members will utilize available immunization services as a right, if they are engaged through a human-centered process of trust building, education, and social support. We expect our solution to succeed because it builds on documented evidence and best practices of community engagement and demand generation, whilst innovatively introducing a different design model. We hope that through the  challenge, we will be able to test our hypothesis and to demonstrate proof of concept on the role of theatre and emotions in stimulating learning and mobilizing social change.

We also look forward to the financial and networking support that we anticipate will be available through the accelerator programme

Community theatre has the potential to reach hundreds of thousands of people on a larger scale, engaging them on practical issues such as vaccines and vaccination services through a human-centered process of trust building, education, and social support, enabling these people to demand vaccination services as a right among other fundamental human rights, which can be achieved with the support and collaboration of MIT SOLVE.

The innovative nature of our solution is underpinned by how it fosters creative confidence among end users, strengthening the ability of beneficiaries to develop their own solutions for local issues, because the complexity of generating demand for vaccination does not allow for the luxury of time, and benefits from different and sometimes new ideas and tactics. The solution engages people early and throughout the process of developing solutions for them and rapidly moves from insights gathered from user research and from collecting feedback, to action by translating learnings into tangible concepts that can be tested, adapted, and improved, working with the end users. Our idea is different because it builds on a history of Africa that is steeped in storytelling and the use of theatre. It draws on lessons from the use of theatre in increasing awareness of HIV/AIDS, increasing awareness of gender-based violence, and advancing justice and restitution following conflicts. It also taps into lessons learnt from the use of magnet theatre to address social issues. Our solution brings all of these together, and then adds an additional layer through our use of a human-centered design and by having community members work as an amateur cast to present key issues on vaccines and vaccination services.

In implementing our idea for 12 months, we have successfully identified, trained and co-created with 119 Immunisation champions across 18 communities. We have successfully performed for audiences of over 1,200 adults, and more than 200 eligible children have received vaccination shots at the end of our performances. We have been able to achieve this despite a 3-month delay as a result of the COVID-19 pandemic and with only around 65% of our planned performances completed, whilst working to ensure that all activities are safe and adhere to COVID-19 guidelines.

The adaptable nature of community theatre is reflected in the incorporation of functional and aesthetic demands based on the needs and behavior of the users, as well as peculiarities in the broader systems within which our users live and thrive. Through a creative, effective and rigorous process of ideation, co-creation and performing theatre, we bring people's needs to the forefront when decisions are made about the design and implementation of interventions within the vaccination program.

Implementing our community theatre involves a systematic approach, facilitating deep collaboration across stakeholders at the different levels of the health system and community. It ensures co-creation with stakeholders and beneficiaries. Building our performances on the back of user research amplifies core principles of global health, by actively engaging target audiences to uncover root causes, generate ideas, and ultimately, to test prototypes. Our rapid prototyping allows us to be curious, to defer judgment, to be reflective, and to embrace collaboration, with an implementation model that emphasises testing and iteration, helping us quickly eliminate bad ideas and prioritise effective, desirable, and sustainable concepts.

Over the next few years, we intend to achieve the following goals and objectives

• To decrease the proportion of caregivers who express lack of information, lack of trust or lack of motivation as a reason for their child's incomplete vaccination in the Niger-Delta region of Nigeria, by May 2023;
• To increase the number of communities in the Niger-Delta region of Nigeria with community theatre for immunization performances to 200 communities, by May 2023;
• To increase the capacity of health workers in the Niger-Delta region of Nigeria on identifying and resolving challenges affecting demand for vaccination services, by May 2023;
• To increase the global reach of community theatre for immunization through broadcast and digital dissemination of performances, by May 2023.

The first three objectives are intricately linked to the current model of the Community theatre for immunization, which we intend to test at scale. Increasing the number of communities in the Niger-Delta region of Nigeria with community theatre for immunization performances, will require that we work harder at designing with health workers and this provides a platform to transfer capacity on problem diagnosis and problem solving, including developing capacities on issues like defaulter tracking, and on inter-personal communication skills. In turn, Phase I experiments have shown that attending performances have a direct effect on decreasing the proportion of caregivers who express lack of information, lack of trust or lack of motivation as a reason for their child's incomplete vaccination. The focus then is quite significantly on proving that this is possible at scale

We measure progress and impact through pre and post implementation survey in the intervention communities, collecting experiential feedback from the audience at the theatre using a technology-based app designed specifically for our project. Some of the indicators we measure are stated below;

• Proportion of caregivers who express lack of information as reason for child’s incomplete vaccination
• Proportion of caregivers who express lack of trust as reasons for child incomplete vaccination
• Proportion of caregivers who express lack of motivation as reason for child’s incomplete vaccination
• Percentage of fully immunized children in the community
• Percentage of under-immunized children in the community
• Percentage of zero-dose children in the community
• Percentage of caregivers who are satisfied with our performance
• Percentage of caregivers who receive information about immunization from community theatre
• Percentage of caregivers who trust the health workers a source of health information
• Penta 3 coverage in the communities
• Penta 3 dropout rates in the communities

The Community Theatre for Immunisation intervention was built to test the hypothesis that caregivers will demand immunization services as a right, if they are engaged through a human-centered process of trust building, education and social support. We expect our solution to succeed because it builds on documented evidence and best practices of community engagement and demand generation, whilst innovatively introducing a different design model. Overall, our application of design thinking across our community theatre intervention has really allowed for deeper learning through a more nuanced understanding of people’s needs and behavior - User Research + Time spent training actors + turning insights into tangible solutions that can be tested. It has also allowed us more latitude to operationalize findings from traditional research approaches like the pre-implementation survey and the FGDs, by ensuring that performances not only incorporate their results, but also that the insights gleaned are used to support designing for local contexts.

Input

Activities

Output

Outcome

Personnel, finances, 

Advocacy engagements with states

Additional states where implementation is commenced

Decrease in the proportion of caregivers who express lack of information, lack of trust or lack of motivation as a reason for their child's incomplete vaccination in the Niger-Delta region of Nigeria, by May 2023;

 Personnel, finances, theatre props

Planning and review meetings with states, LGA and health facilities

More localized insights on barriers for vaccination services

Increase in the number of communities in the Niger-Delta region of Nigeria with community theatre for immunization performances to 200 communities, by May 2023

 Personnel, finances,

Pre-implementation surveys

Availability of baseline data

 Personnel, finances,

Engagement with community leaders

Additional communities where implementation is commenced

 Personnel, finances,

FGD with community members

More localized insights on barriers for vaccination services

 Personnel, finances,

Problem solving meetings with health facilities

Increased capacity of health workers for problem solving

Increased capacity of health workers in the Niger-Delta region of Nigeria on identifying and resolving challenges affecting demand for vaccination services, by May 2023

 Personnel, finances,

Trainings and co-creation with champions

Increased constituency of community champions trained on immunization and theatre performance

 Personnel, finances, theatre props

Community meetings with theatre performances

Increased number of community theatre performances

 Decrease in the proportion of caregivers who express lack of information, lack of trust or lack of motivation as a reason for their child's incomplete vaccination in the Niger-Delta region of Nigeria, by May 2023;

 Personnel, finances,

Post-implementation survey

Data on progress of implementation

Audio visual equipment, personnel, finances, subscription for broadcast and digital channels

Specialized training meetings with champions for recording, studio meetings with recording of performances and audio perception surveys

Recorded series of short films (audio and video), digital channels disseminating short films and reports on the reach of community theatre for immunization outside the Niger Delta region of Nigeria

Increase in global reach of community theatre for immunization

We deploy the use of technology primarily in monitoring the process and outcome of our solution

• We developed a mobile app to collect experiential data after each performance. The app is built to be user friendly using emojis and icons to depict different emotions that can be elicited through our performance. The experiential data collects feedback from each individual audience that watched our play. The data is synchronized in our secured server. The data is then downloaded subsequently for our analysis.
• We also deploy the use of Open Data Kit (ODK) to conduct pre- and post-implementation surveys. The survey questions are designed and coded into the ODK app. The data is also sent to our secured server and can be downloaded for data analysis.
• We also use GIS for geo-tracking of data collectors 

Our organization is women-led, with over half of our supervisory board identified as women. Additionally, our organization maintains a gender equity policy. Our solution targets the most vulnerable groups in these communities. Our approach to implementing our solution is 100% inclusive of groups, including people living with disabilities. We employ various mechanisms to ensure all people who are the primary beneficiaries of our solution are reached, including audio for people with visual impairments. We prioritize women's, children's, and men's involvement in rolling out our solution. 

Corona Management Systems is a social enterprise that specializes in providing technical and management support to programmes, and implementing innovative projects in Health, Education and Social Development. CMS succeeds by leveraging community assets, institutionalizing data use for action, and deploying Information and Communications Technology (ICT).

Our organization has a revenue canvas that encompasses a broad range of programmes, donors, and partners. Over the last decade, we have received funding from the Government of Nigeria at Federal, State and Local Government levels, indirectly accessed funding from the World Bank via International Development Assistance credits provided to Government and funding from the Bill and Melinda Gates Foundation, through their Grand Challenges Explorations’ initiative. We have received funding from Shell and GE, through the Oloibiri Health Program. We have received funding from the Advance Family Planning programme of the Bill and Melinda Gates Foundation, through the in-country implementing partner in Nigeria – Pathfinder International. We have received funding from FP2020, a partnership of the United Nations’ Foundation. We currently maintain direct and indirect funding from the Africa CDC, GAVI, UNICEF and the World Health Organization for a range of projects and technical assistance interventions. We are also currently accessing funding from the Bill and Melinda Gates Foundation supported Safety and Antimicrobial Resistance of Mass Administration of Azithromycin in Nigeria (SARMAAN) project, through our partnership with SpeakUp Africa.

To achieve our mission, we work at the critical nexus of five pillars: Resource mobilization; Communications and community engagement; Policy development, implementation, and evaluation; Innovations for health systems strengthening; and information and communications technology for development (ICT4D). Based on these pillars, our client canvas cuts across four main groups:

• Government
• Multilateral Agencies
• Private Foundations and non-profits
• Private for-profit organizations

Our revenue model cuts across three main streams:

• Fees for Consulting Services – We provide management consulting services to Government agencies, as technical assistance for the design, implementation, monitoring, and evaluation of health programmes at national and sub-national levels in Nigeria. This also includes technical assistance for health planning, research, and statistics, as well as to strengthen healthcare delivery. We provide consulting services to multi-lateral agencies, private foundations, and non-profit entities to conduct health systems situational analysis, project and programme evaluation, and mixed-method studies that provide insights and intelligence to guide or support their work in Nigeria. We also provide strategic planning, strategic communications, and knowledge management consulting services for these groups of organizations both in Nigeria and in the wider global health community. We provide consulting services on strategic planning and programme evaluation for private for-profit organizations, with special focus on private for-profit organizations working in the Niger-Delta Region of Nigeria.
• Grants – Our team is a grantee to the UN Foundation and the Bill and Melinda Gates Foundation, allowing us to implement projects and strategies for charitable purposes that advance health and development. We have previously been grantees for private for-profit organizations, supporting the corporate social responsibility mandates of these organizations and implementing innovative strategies that increase health outcomes and contribute towards achieving equity.
• International Development Assistance Credits – Our team implements international development assistance credits provided by the World Bank, the Africa Development Bank, or the Islamic Development Bank to the Government of Nigeria at national and sub-national levels. Our implementation of these credits are as non-state actors (NSAs) selected by the Government of Nigeria at the relevant level, with oversight from the task team leaders from the relevant institutions. Our implementation of these credits has cut across Reproductive, Maternal, Newborn and Child Health (RMNCH), polio eradication, disease surveillance enhancement, Malaria elimination, and improving child and adolescent nutrition.

A key element of sustainability for community theatre is aligned with testing willingness to pay to watch a performance. Performances during the Phase II award will also provide an opportunity to test the assumption that people will pay to watch community theatre performances. Phase I experiments show an overwhelming proportion of attendees reporting a willingness to pay the price of a Coca-Cola bottle to watch a performance. Testing this assumption potentially provides results and insights that are key to sustainability, as a low-cost pay-per-view system for community theatre could potentially chart a path for sustainability.

An additional pathway for sustainability that has been entrenched within Phase I experiments and which we intend to continue and strengthen in Phase II, is the community ownership of community theatre. During Phase I, communities provided town halls, provided furnishings and local materials to complement props, and in some cases, provided their own costumes to add color to theatre performances. Communities conducted town announcements about planned theatre performances, including using community radio to remind caregivers to bring the copies of their home-based vaccination records (child health cards) when coming to attend the performances. This was intended at making sure that when eligible children receive vaccination at the end of theatre performances, their records are reconciled by the health workers from the health facility that serve that community. These demonstrations of community buy-in and ownership have been critical to ensure program-focused resource efficiency and the implementation of community theatre for immunization activities and performances. This level of community ownership will therefore be a critical component of sustainability, and if complemented by pay-per-view performances, could position the theatre as a routine part of the community.

The three potential pathways to scale that we currently see following experiments in Phase I, include:

- Government uptake of community theatre as a routine intervention for generating demand for services;

- Additional pathways that facilitate expansion of community theatre to generate demand for other services or shape behavior including around issues like water, sanitation and hygiene; and

- Expansion to include mass dissemination of community theatre episodes through broadcast and digital channels. 

Community ownership: We have tested the assumption of community ownership to offset some financial expenses. Community buy-in in our intervention communities resulted in communities taking responsibility of some components of rolling out a performance such as donating townhalls for the performances, taking on town announcements using their community radio and town announcer, caregivers willingness to act out the plays offsetting the cost of hiring professional actors, leveraging on community dance groups and their musical instruments as well as community members donating their materials to be used as props.