Designing Appropriate, Acceptable and Feasible Community-Engagement Approaches to Improve Routine Immunisation Outcomes in Low- and Middle-Income Countries: A Synthesis of 3ie-Supported Formative Evaluations

"The community-engagement tools and approaches were successful in obtaining community buy-in, both among caregivers and community members at large."

Community engagement has been deemed pivotal in conveying the value of vaccines, in increasing demand for immunisation, and in combatting vaccine hesitancy. In line with this recognition, the International Initiative for Impact Evaluation (3ie) commissioned an evidence programme in 2015 to generate rigorous evidence on the role of community engagement approaches in low- and middle-income countries (LMICs) in addressing issues around last-mile delivery of vaccination services and behavioural, social, and practical constraints faced by caregivers. This paper qualitatively synthesises findings from the six 3ie-supported formative evaluations undertaken in Ethiopia, Myanmar, Nigeria, and Pakistan and reflects on learnings in designing context-appropriate, feasible, and acceptable interventions.

The synthesis paper conforms to reporting guidelines as set out in the Standards for Reporting Qualitative Research. It is based on secondary research, drawn from published reports that can be found on the 3ie website (and see Related Summaries, below).

The paper provides an overview of the interventions described in the six papers. The theoretical framework below captures the diversity of the approaches undergirding the interventions and broadly indicates the causal links and the assumptions made along the way to affect the behavioural, social, and practical drivers of immunisation and improve service delivery:

Almost all the interventions included a component on health worker sensitisation and training and assigned key roles to community leaders in awareness-raising and health system monitoring to improve immunisation coverage. More specifically, the interventions are varying combinations of the following three types:

1. Engagement in intervention design: The community has input in the design of the intervention, varying from simply being consulted to having some decision-making power to being the final decision-maker.
2. Engagement in intervention implementation: The community can affect implementation either by providing resources or making decisions such as those around targeting, monitoring, and governance.
3. Engagement as the intervention: This may include obtaining community buy-in or creation of new community-based structures and cadres of community health workers (CHWs) who are trained to provide culturally appropriate health services.

Formative evaluations help interrogate theory of change assumptions by unpacking how aspects such as appropriateness, acceptability, and feasibility impacted intervention logic. Some synthesised findings (examples from each of the six evaluations are provided in the paper) include:

• Appropriateness:
  • Despite the varied contexts, the studies found the barriers to immunisation uptake to be somewhat similar. Most studies found that caregivers were aware of the benefits of immunisation and that vaccine refusal was not a major barrier to immunisation. The baseline surveys revealed a fair understanding of the importance of vaccination in preventing diseases among communities across contexts. Overall, health providers remained an important source for immunisation-related information.
  • Almost all studies revisited intervention modalities to ensure they aligned well with contextual realities and participant preferences.
• Acceptability:
  • By frontline health workers, or FHWs (vaccinators) and CHWs: An important concern with introducing new tools and approaches was that they could add to health worker workload and lead to demotivation or poor performance.
  • By caregivers and other community members: A key distinguishing aspect of every approach was centring the role of community members by putting in place systems and structures that ensured their participation in monitoring activities, setting up feedback loops, and making immunisation an agenda item in community platforms. In doing so, most interventions either leveraged existing community institutions, like ward development committees and social mobilisation committees, or set up their own platforms to create opportunities for dialogue between service providers and the community to facilitate collective ownership and action.
• Feasibility:
  • While interventions were generally found to be feasible at the scale on which they were implemented, the studies identified key issues around health worker capacity and intervention costs. Extensive engagement with stakeholders at all levels of the health systems and trainings for CHWs and FHWs were key in ensuring that piloted interventions fit into the mandates of the health delivery systems. Designing and promoting tools and engagement approaches that eased health worker workload and were perceived as collaborative further helped secure buy in. Though financial incentives were offered to health workers in some contexts, they were limited, and their role in motivating health workers was unclear.
  • The formative evaluations helped highlight design aspects that were critical to consider for intervention feasibility, including CHW literacy and skill sets, financial constraints, and tool design. As an example of the latter, in Fifth Child Ethiopia, while the health providers and the community members found the tools useful, suggestions were made to include pictures of men to encourage male participation in maternal and child health.

As noted here, appropriateness, acceptability, and feasibility of interventions hinge on a few key aspects. At the outset, there needs to be political will and commitment to address immunisation issues. These elements were demonstrated in all country contexts covered by the six studies and helped the teams get buy-in for piloting community-based interventions. Preexisting relationships between researchers or their implementing agency counterparts and country governments and the ability to identify and create champions within the government also mattered. Embedding community engagement approaches into the existing health system and extensive health worker training further helped in intervention delivery. However, from a provider perspective, intervention feasibility is mediated by other factors, including health worker capacity, a lack of cost data, and the limits of the overall health system. Whether local capacity is sufficient to deliver these interventions in low-resource LMIC contexts remains a concern.

Based on this review, the paper examines some lessons in implementing formative evaluations. For instance, learnings at baseline and through the course of the study can be used to strengthen community engagement in design and implementation. Systematic monitoring that captures process indicators can point to gaps in the intervention theory of change. However, the six studies reviewed here did not use a core set of indicators systematically to explore factors such as caregiver knowledge and awareness. For example, while adverse events following immunisation were reported as an issue in Nigeria, it is unclear if this was absent in other contexts or simply was not explored.

In conclusion: "Interventions designed around community engagement strategies can be appropriate, acceptable, and feasible approaches to overcome barriers to vaccination in a variety of low- and middle-income country contexts. However, questions remain about the ability of health systems to implement interventions at scale, both from a cost perspective and a capacity perspective."