Thinking outside of the [cold] box: implementing a human-centered design approach to understand barriers and craft solutions to cold chain equipment maintenance in Niger

Background: Vaccines require cold chain equipment (CCE) to ensure quality and potency, yet the risk of CCE failing is well-documented, often due to lack of equipment maintenance. While general barriers to a reliable CCE maintenance system are known, little has been done to understand the barriers from the cold chain technician's perspective. This human-centered design (HCD) study in Niger sought to better understand the gap in the current maintenance approaches from the technicians' perspectives and to collaboratively identify forward-thinking solutions.

Methods: The research team collected data through semi-structured and open-ended in-depth consultations. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions.

Results: The research team conducted 20 in-depth consultations in two regions with participants directly involved in the management of the cold chain. Fourteen people participated in the online co-creation workshop, and 20 people participated in the in-person workshop. Insights were organized in three main areas: (1) the lack of system agility and ability to optimize resources constrain performance of the maintenance system; (2) cold chain is often an afterthought within the overall context of immunization services and should instead be prioritized; and (3) knowledge sharing across the system and key stakeholders is ad hoc with limited understanding of roles and responsibilities. During the co-creation workshop, participants identified four main concepts as potential solutions: (1) create an on-line platform to connect people and to share knowledge across regions; (2) develop practical CCE technical resources; (3) use gamification and friendly competition to motivate staff to value maintenance; and (4) create a real-time maintenance tracking system.

Discussion: This study took a unique HCD approach to engage people directly involved in CCE maintenance to more deeply understand challenges with the current system and create space to identify innovative solutions that are tailored to the context. The results demonstrate that stakeholders can identify potential solutions that have not been part of the typical approaches to a maintenance system. This HCD approach has implications for all global health challenges and demonstrates a methodology that can encourage key stakeholders to think about problems and solutions differently.