The Guide to Tailoring Immunization Programmes (TIP)

"Overcoming vaccine hesitancy barriers, including lack of confidence, inconvenience and lack of access, and complacency, can lead to improved equity and improved vaccine uptake, with more individuals and communities valuing vaccines and demanding immunization as both their right and their responsibility."

This guide aims to provide proven methods and tools to assist national immunisation programmes (NIPs) design targeted strategies that increase uptake of infant and childhood vaccinations. The guide provides tools to identify susceptible populations, determine barriers to vaccination, and implement evidence-based interventions. The strategies outlined here may be used at any time to maintain high coverage rates but may be particularly valuable when pockets of low vaccination coverage or increased susceptibility to vaccine-preventable diseases (VPDs) are identified.

In designing the TIP guide, the World Health Organization (WHO) Regional Office for Europe considered service delivery issues and also looked at socio-cultural, environmental, and household influences/factors on why children may be missing vaccinations. The context: WHO/Europe is taking steps to renew the focus on immunisation of infants and children, with an emphasis on measles and rubella elimination by 2015 and maintenance of polio-free status in the region. As detailed in the guide, in the European Region, reasons for not vaccinating an infant or child are complex and multiple; they include lack of access, marginalisation, low risk perception, fear, distrust and complacency, and alternative philosophical health beliefs. Research to inform the guide was conducted in Bulgaria in 2012.

The TIP approach draws on health programme planning models, including social marketing and social and behaviour change communications. It is noted (footnotes removed by the editor) that a "'one-size fits all' approach to immunization programming and communications cannot suffice to respond to existing vaccination barriers and concerns, or meet current immunization needs. Innovative and meaningful models are required to place infant and childhood immunization as a positive, protective and caring practice for primary caregivers, and to propose convenient ways for all caregivers to succeed in this practice....The TIP Guide takes into consideration the context in which immunization programmes evolve and the degree of health equity and potential social determinants of health, as well as health-care seeking behaviours and actions that exist in this context....Health equity depends vitally on the empowerment of individuals to challenge and change the unfair and steeply graded distribution of social resources, to which everyone has equal claims and rights."

With the driving premise that first listening to the individual caregiver's point of view is crucial, the TIP conceptual framework and maps offer diagnostic tools to do the following:

• Identify and prioritise susceptible populations: TIP conducts a step-by-step approach to segment groups of caregivers, taking into account their children's vaccination status: fully and timely vaccinated; partially vaccinated; not vaccinated. Its segmentation analysis is designed to help identify the susceptible populations that the NIP should focus on addressing.
• Diagnose the demand- and supply-side barriers to vaccination. TIP employs conceptual pathways and maps to: (i) guide a detailed level of understanding as to what drives caregivers' vaccination practices; and (ii) explore the role that vaccination providers play in influencing caregivers' vaccination choices and actions.
• Design evidence-informed responses: TIP provides: (i) guidance for designing, implementing, monitoring, and evaluating TIP interventions based on the results of the segmentation and profiling process; and (ii) an inventory of promising practices in immunisation programming, to which immunisation programme designers can refer.