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Establishing Social Norm through Increasing Visibility of Others' Vaccination and Health Status

We aim to change the social norm from “not vaccinating” to “vaccinating” by having caregivers compare their children's status with others.

Photo of Ryoko Sato

Written by

Describe what you intend to do and how you'll do it in one sentence (required 250 Characters)

We aim to provide caregivers the social comparison feedback on own and others’ vaccination status and health outcomes, using a smart phone app, in Nigeria. To do this, we will partner with the local tech company to design the appealing app.

Explain the idea (less than 2,000 characters)

Challenge: Almost 20 million children lack basic immunization worldwide, and 4 million of those children live in Nigeria (WHO, 2017). In northern states in Nigeria which is the site of the proposed study, 71 percent of children are not fully vaccinated (NICS, 2018). Lack of awareness is the reason for the incomplete vaccination among almost 40 percent of caregivers who did not have their children fully vaccinated. This lack of awareness might be attributed to the lack of social norms on vaccination; lack of the consensus that caregivers take children to health clinics for vaccination a certain amount of times at specific timing, in the community. Our Target Population: End users are caregivers of young children aged 12 months old or younger. Our target is caregivers who reside in urban setting where the mobile phone service is easily accessible. Caregivers can directly benefit from improved vaccination status among their children, which can even improve their health outcomes in later life. Solution: The first step is to establish trust and build a consensus (social norm) among community members through community meetings that caregivers should take children to clinic for vaccination multiple times to protect own as well as other children. The community meeting gathers influencers of the community including village head and decision makers of households (males) as well as caregivers of children for it to be impactful. Vaccination can indirectly protect other children due to herd immunity. We introduce this notion of herd immunity to promote the establishment of social norm through social pressure. The next step is to provide caregivers the monthly update of vaccination rate and health outcomes in own and in different communities through a smart phone app. We will show them the simple positive correlation between the vaccination and health outcomes and point where they are situated in the app, and compare their status with others' who live in Lagos.

Which part(s) of the world does this idea target?

  • Western Africa

Geographic Focus (less than 250 Characters)

Northern Nigeria

Who are your end users and how well do you know them? (750 characters)

We have conducted a research in the region for the past 5 years in the region. The vaccination rate is low, thus has potential to substantially increase the rate to improve their health status.

How is the idea unique? (750 Characters)

We are unique in attempting to actively generate the positive social norm on vaccination, using the power of social network. Social network is proven to influence people's behavior. However, our idea is unique because we are trying to change the social norm, through the community meeting and by making others’ vaccination behaviors and health status visible to the users.

Idea Proposal Stage (Select 1)

  • Blueprint: We are exploring the idea and gathering the inspiration and information we need to test it with real users.

How many months are required for the project idea? (140 characters)

It will take us 1.5 years to implement phase one and achieve a desire impact of our unique App intervention on full immunization rate.

Organization Name (less than 140 characters)

Harvard T.H.Chan School of Public Health

Type of Submitter

  • We are a formal part of a University or Research Institution

Organization Location (less than 140 Characters)

Boston, MA, USA

What is the current scale of your organization’s work?

  • Community (working within one or a few local communities within a region)

Tell us more about your organization/company (1-2 sentences)

Our organization is a research institute. Our idea fits into our organization goal as the goal is to create and advance knowledge and its translation into discoveries that lead to actions that improve health of people and populations.

Who will work alongside your organization in the project idea? (750 characters)

Our partner is the local tech company in Nigeria, the local university in Nigeria and local primary healthcare development agency. We have been collaborating with local primary healthcare development agency. They support us in providing necessary support such as informing clinics for the project, as well as ensuring the sufficient vaccine supplies in each health facility.

How many people are on your team?


Overview of How Your Concept Has Evolved (5-6 sentences):

1. We learned that endusers find it easy& intuitive to understand the importance of vaccines through the comparison between their status and others' in Lagos. The picture of healthy baby ALONG WITH the vaccine picture encouraged endusers too. 2. Sustainability is the key! The engagement of national/local governments is the key to the success for the widespread use of the app. 3. Webinars (esp the Gates foundation) provided us the inspiration: the process of improving the idea/design is important. We aim to improve further by interacting more with the potential endusers. 4. Our prototyper provided useful thoughts, especially on things we did not think of. Based on our prototypers' feedback, we tested and improved some ideas in the f

Viability (3-4 sentences and activity upload):

Feasibility (3-4 sentences):

- Our prototyper gave us a great insight on the potential importance of the community meeting: we can introduce our solution in the community meeting -- this can be very effective and have a sustainable effect! - From our prototype we tested during this phase, we learned that 1) endusers really like the visual information, 2) they understand the information better if the picture of health baby is attached to the picture of vaccines, and 3) the comparison between two different cities seem effective in making them feel envious and imitate what others from other city is doing and doing good!

Desirability (3-4 sentences and activity upload):

- The problem is that women in endusers' community do not take children for vaccination much (low social norm) - Because of the limited access to information, the social norm in Lagos doesn't spread to their community. BUT women in the community are curious to know what other women do in a "good" place (like Lagos). - Our potential endusers in the field were very happy to gain the information on the importance of vaccine in general (importance of awareness). - They were particularly happy to observe the link between vaccination and happy baby - They also seemed to be inspired that other women in other city (Lagos) were doing good, and seemed encouraged to do the same.

Community Focus (2-3 sentences):

- Northern Nigeria suffers from extremely limited vaccination rate. - From our interviews with potential endusuers, we learned that the lack of awareness can be a primary barriers to the vaccination. - If we can change the social norm from "not vaccinating" to "vaccinating", we can significantly improve their health by reducing the risk of contracting diseases. - This social norm on vaccination can spread to other health behaviors, and to other cities as well.

Community Impact (2-3 sentences):

- The knowledge level among caregivers will improve, and it can lead to the increase in the vaccination rate in the town. - We might be able to observe the potential positive spillover effects to other neighboring towns in term of the usage of App, improvement of the knowledge & vaccination rate. - If successful in Jada town, we aim to engage the local/national government for a larger-scaled implementation of the App. - It can take 1 year to see if the full immunization rate among children improve in the town. It will take longer (up to 5 years) to see if the effect of App is sustainable


Join the conversation:

Photo of Shahed Alam

Ryoko Sato UX map looks good. Did you explore to show the comparison within the city itself? What if Aisha learns the status of how other kids are doing in her own city?

Photo of Ryoko Sato

Thank you for your comment Shahed!
Yes indeed! Originally we were thinking to do promote the information sharing within the neighborhood. However one concern is that if no one does it, other people wouldn't do it either (Aisha does not do it because her friends do not do it.). We hypothesize that we need some external push to move the social norm within the neighborhood from "not vaccination" to "vaccination".
There is evidence that peer can positively influence within the community, but our hope is that if they compare with others from other "better" places, maybe we can encourage them even further?

Photo of Shahed Alam

Make sense, good luck with your submission.

Photo of Ryoko Sato

Thank you Shahed!

Photo of Estela Kennen

Had some additional comments and questions after reviewing your business model.
1. It seems that there are some key activities on the part of your group that need to happen so that the key activities listed can happen.... and also evaluation, since you listed that as a resource.
2. As far as cost structure, what to do you envision supporting community meetings looks like? And should evaluation costs be in that list too?
3. Any cost or activities involved in getting national vaccine data? (Also, how will individual data be obtained? Does the user submit that themselves?)
4. Customer feedback 2 does not seem entirely human-centered. (Getting feedback from users during testing is a must, but asking for feedback from all users after operations is a drag to a lot if not most of them.)

Hope these comments help!

Photo of Ryoko Sato

Thank you again for your comments Estela. Very useful as always.
1. I completely skipped the App design phase -- now added. I also added evaluation.
2. The community meetings should be supported by the national/local government as they are part of the agenda proposed by the government. We should ensure that the government maintain the regular meeting in communities. Evaluation costs added!
3. We plan to use the publicly available vaccination data with GPS coordinates (DHS data). DHS has information on vaccination status for women across the country with the location. The available data is from the last survey in 2013, but the most recent data was collected in 2018 and we are waiting for the data to be publicly available. For the individual data, we will need to link the app with patient portal.
4. Agreed -- we deleted this part.

Photo of Estela Kennen

Hi Ryoto, I'm so glad user testing and prototying went well. Seeing your update made me think of a couple of things:

1) Sometimes comparison has the opposite from the intended effect. What can you do to make sure people don't get a fatalistic view from the comparison? ("I'm so late/far behind, what's the point?")

2) I didn't realize earlier that your intervention was app-based. Nigeria has a high mobile penetration, but a majority of that is feature phones, not smartphones, and phones are more likely to be owned by men, not women. Will the app work on feature phones? How will immunization information be updated? Will people get feedback only when they open the app or will it send push reminders?

3) It seems that multi-factor inteventions work best to increase vaccine demand. Could your app do double-duty by addressing some of the other barriers, for instance practical information about where/when to vaccinate or other little nudges like that?

Photo of Ryoko Sato

Hi Estela, Thank you for your inputs! Here are my responses;
1) You have another very good point! Yes, this information can discourage some people. To avoid that as much as possible, we organize the community meeting to create the sense of integrity and make the community members feel that they can do it! Also, it is important to inform the members that it is never too late to take their children for vaccination (except some type of vaccines..)
2) Yes - I am looking into the possibility of using the app. I am thinking to do the project in the urban area, but not as big city as Lagos. In Yola, the capital of Adamawa state (northeast), the utilization of smartphone is pretty good. However, please note that this is still a initial stage; I would like to look into the possibility of alternative ways to convey the same message, not using the smartphone app, if it turns out unrealistic. For example, we can show the same information using tablet, whenever women visit clinics for antenatal care (as most of women visit health clinics for ANC). Hmm, probably this is more realistic and more affordable than App in smartphone.
Within App, the information will be linked with the patient portal in health facility.

3) If we push for App, yes we can definitely design other features such as reminders.

Photo of Isaac Jumba

Hi Ryoko Sato 

Great to see updates and progress on your idea.
We wanted to check in and see how far you have gone with getting feedback from some potential end users for your concept. Were there insights or surprises that came out? What aspects of the concepts did you test out?

As the refinement phase nears the end, it will be great to update your submission with the needed additional information(answers to the questions, the user experience map after user feedback and the business model)
Feel free to reach out to me or Manisha Laroia  or the community for specific feedback.


Photo of Ryoko Sato

Hi Isaac, thank you so much for following up!
Indeed, with great help of a prototyper (Joyanne Muthee), we tested out our idea with the end-users.
We tested whether women with young children (end-users) can be motivated to take their children for vaccination once we show the visual information which convey the following message: 1. vaccine is good, and 2. other people from other places, where one might envy their life style, are doing it more than she does.

As Estela Kennen pointed out in her comments, we needed to be careful about the causality and potential backfire effect of the information (please see below).

Thus we tested 1) if end-users can be motivated simply by showing the comparison of vaccination status between their children's and others' from different places (after we introduce that the vaccine is good), and 2) if we can motivate end-users' vaccination by introducing the difference in health outcomes between children from their community and children from other places to motivate their vaccination WITHOUT making them misunderstand about the correlation with the causation.

We have reached out to some potential end-users with several options of pictorial information described above. Then, we found out that women love the picture of happy baby, attached to the number of vaccination received. We found that it was easier for women to relate "vaccine=good" if the vaccine picture comes along with the picture of a happy baby.

We also found that with the pictorial information, it is easier for women to understand that children in other part of Nigeria (Lagos) receives more vaccination and that children in Lagos are also healthier. Women express their willingness to take their children for vaccination, just as other women do in Lagos.

We were pleasantly surprised by the powerfulness of the picture of a happy baby. While we should be careful in using this pictorical information not to cause any misunderstanding (that if vaccinated, the baby never gets sick etc), we definitely think that using the picture of a happy baby is a powerful message for women.

We will start updating our submission soon!
Thanks so much!

Photo of Ashley Tillman

Hi Ryoko Sato great to have you in the challenge, can you share a little more info about your background (and include a link to your bio)?

Additionally, can you expand upon how the way you propose actively generate the positive social norms on vaccination is different from other projects in the space?

Photo of Ryoko Sato

Hi Ashely, thank you for your comments.
I am a research associate at Harvard T.H. Chan School of Public Health. My research has been around improving health behaviors. I have conducted several field experiments to evaluate the barriers to and incentives for vaccination among women in northern Nigeria.

For the project design, the following is what I think how the proposed program can generate the positive social norms;
1) we will bring influential community members (village head, health personnel, caregivers, and husbands) together in the community meeting and share the importance of vaccination completion. We will also inform them about the vaccine schedule. The goal of this community meeting is to have consensus about benefits of vaccine completion and schedule within the community.

2) Then, we provide the smartphone app to caregivers and husbands.
Through this app, they receive the monthly feedback. The app shows 1) positive correlation between the vaccination completion rate and health outcomes/educational outcomes (weight for age, height for age, educational attainment), using the actual data. For example, we can use the data from DHS (Demographic and Health Survey) and create the figure that shows the positive correlation. Then, within the figure, it shows where the caregiver's children are at, in terms of the vaccine completion, as compared to other people within the same community.
Through this app, caregivers can compare their children's vaccination status with others, and see how their children can be doing (good/bad) in terms of health/educational attainments.
In Nigeria, the social division is prevalent geographically but it is often difficult for people in the north (which has the low vaccination coverage) to have information on people in the south (where the vaccination coverage is high) . Through this app, people in the community which did not establish the positive social norm about vaccination can easily compare their children's status with others within their and other communities. If they see that children in other communities have higher vaccination rate and are better off in terms of health/educational outcomes, it can generate the positive social norm toward vaccination among them, which can encourage them to bring their children for vaccination.

This project is unique in the sense that we propose to utilize the app, which can promote the information spread to enhance the establishment of the positive social norms in a easy way.

Photo of Estela Kennen

Hi Ryoko. What an interesting idea. Do you have any concerns regarding potential users of your intervention confusing correlation with causation, and what second-order effects that might have?

Photo of Ryoko Sato

Thank you for your feedback, Kennen.
Indeed, our design might wrongfully lead caregivers to think that the positive relationship is causal (although it COULD be causal, it is difficult to prove it is..).
This perception of causality might result in the distrust of vaccination at later stage, if they do not observe what they are "promised" (ex. even if their children receive full immunization, they are not as tall as other children --> we tell them a lie about the "causal effect" of vaccination --> they distrust vaccination then) [serious second-order effects]

Thank you for pointing this out!
We need to be more careful about how to convey the message.
Definitely we would like to convey these 2 messages; 1. vaccine is good, and 2. other people from other places, where one might envy their life style, are doing it more than she does.
Now the question is whether we want to introduce the 3rd message; 3. Other children from from other places, where one might envy their life style, are healthier.
And if we introduce this information, how do we convey this message, in relation to the first 2 messages?

We would like to propose the following;
- We will introduce the third message about the health status of other children from other places
- But we will not directly link the vaccination and the health status in one graph as we originally design

In this refinement stage, we will test 1) if end-users might be motivated simply by showing the comparison of vaccination status between their children's and others' from different places (after we introduce that the vaccine is good), and 2) if we can motivate end-users' vaccination by introducing the difference in health outcomes between children from their community and children from other places to motivate their vaccination WITHOUT making them misunderstand about the correlation with the causation.

We will test this by asking some end-users about the concept during the refinement stage, but we plan to do more investigation before we finalize the design.

What do you think?

Photo of Estela Kennen

Your plan sounds solid to me. Just the information about vaccination rates in enviable places might be enough to create a halo effect -- "I want for my kid what those kids get," so it's definitely worth testing, as is the effect of seeing more general information about others' health status. I really appreciate how this project leverages the idea of positive social contagion. I will also be interested to see what you learn about communicating the concept of herd immunity and how it is interpreted. Best of luck!

Photo of Ryoko Sato

Thank you Estela!
Yes! I will also ask around on the herd immunity.