Problem Pathways

Routine immunization · Domains 6, 7, 2

Signal. Settlements with births but no Penta1 doses recorded. A zero-dose child has no first dose of a DTP-containing vaccine. Nigeria had an estimated 2.1 million zero-dose children in 2024, the highest number of any country (WHO and UNICEF estimates). Immunization Agenda 2030 aims to halve the number of zero-dose children from the 2019 baseline by 2030.

1. Identify and understand. Conduct a local needs assessment (ERIC): map settlements, births and doses. Diagnose access with Levesque's access framework and caregiver drivers with BeSD. Use CFIR outer-setting constructs for local conditions, critical incidents and financing.
2. Improve: select strategies. Use TIP research with caregivers in low-uptake settlements to design tailored solutions. Then use Implementation Mapping or a simple barrier-to-strategy matrix. Typical strategies: change service sites, tailor strategies, inform local opinion leaders, involve Ward Development Committees.
3. Deliver and log changes. Track fidelity of outreach plans. Record adaptations with FRAME and strategy changes with FRAME-IS.
4. Assess. RE-AIM reach disaggregated by settlement. Proctor penetration and cost per child reached. Plan ongoing fit with the Dynamic Sustainability Framework.

Pitfall: reporting doses given without a settlement-level denominator hides who is still missed.

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Routine immunization · Domains 2, 6, 3

Signal. Dropout of 10 per cent or more, which WHO's Immunization in Practice guide rates as poor use of services.

1. Understand. CFIR scan of the facility. BeSD questions with caregivers. Check practical issues before labelling anyone hesitant.
2. Understand the behaviours. COM-B for caregiver return. TDF for staff defaulter tracing.
3. Improve. Behaviour Change Wheel functions, then ERIC strategies: audit and provide feedback, remind clinicians, intervene with caregivers to enhance uptake. Describe each on the seven points from Lesson 5.
4. Assess. Fidelity of weekly defaulter review, acceptability of reminders, cost per outreach. Report effectiveness on its own line: the dropout trend.

See the worked example in Lesson 8.

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New vaccine introduction · Domains 1, 2, 5

Nigerian anchors. Nigeria introduced the single-dose HPV vaccine for girls aged 9 to 14 in October 2023, aiming at 7.7 million girls in 16 states and the FCT in phase 1. The R21 malaria vaccine followed in December 2024, starting in Kebbi and Bayelsa. A 25 to 28 March 2024 outbreak campaign was the world's first rollout of MenFive (Men5CV).

1. Understand. Organise the whole effort with EPIS phases. Use CFIR innovation constructs (complexity, design, cost) and policies and laws (regulatory approval).
2. Prepare and improve. Check host-setting readiness with the QIF and team readiness with ORIC. Strategies: stage implementation scale-up, conduct educational meetings, inform local opinion leaders, change service sites.
3. Assess during delivery. Track adoption, fidelity and acceptability (Proctor). Log modifications with FRAME and strategy changes with FRAME-IS.
4. Assess impact. RE-AIM across all five dimensions, with effectiveness reported apart from the implementation results. Report studies with StaRI.

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Quality improvement · Domains 2, 3

Nigerian anchor. A CFIR study in five Kano PHC facilities assessed a quality improvement programme on missed opportunities. Barriers included stock-outs, faulty cold chain, lack of incentives and socio-cultural beliefs.

1. Understand context and behaviour. CFIR for facility context. TDF or COM-B for the screening behaviour.
2. Improve. Remind clinicians, revise professional roles, audit and provide feedback. Test changes with the Model for Improvement and PDSA cycles.
3. Assess embedding. Use NPT to check whether screening becomes routine work.
4. Assess. Fidelity of screening using Carroll's fidelity framework. Service outcome: share of eligible visits with all due vaccines given.

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Routine immunization and campaigns · Domains 7, 6

Nigerian anchor. WHO's 2022-2023 results report states Nigeria has the largest number of zero-dose children affected by conflict. WHO has supported mobile health teams for nomadic settings in Borno.

1. Understand equity determinants. Use HEIF or EquIR to name them explicitly. Levesque for access. CFIR critical incidents and local conditions.
2. Improve. Tailor strategies, change service sites, build a coalition with traditional leaders and community structures.
3. Assess adaptation. FRAME and FRAME-IS.
4. Assess. Reach by population group. Appropriateness of the delivery model as judged by communities.

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Transition to government ownership · Domains 1, 4, 5

1. Understand sustainment risks. EPIS sustainment phase and bridging factors, such as contracts, partnerships and data-sharing arrangements.
2. Understand what sustains. Consolidated Framework for Sustainability Constructs and PRISM implementation and sustainability infrastructure.
3. Improve. Access new funding, alter incentive or allowance structures, develop a formal implementation blueprint owned by the state or LGA.
4. Assess. Proctor sustainability and cost. RE-AIM maintenance. Expect adaptation, as the Dynamic Sustainability Framework argues.

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