A Qualitative Analysis of Vaccine Decision Makers' Conceptualization and Fostering of 'Community Engagement' in India

"The pertinence of community engagement (CE) in achieving vaccination goals and promoting health equity though acknowledged intuitively is not well-defined and remains an underutilized approach. Realizing national-level vaccination policy and program goals and fostering equitable distribution of public health outcomes needs a revised approach to CE, including development of CE metrics."

Community skepticism about vaccines has a long history in India, where vaccination uptake prevalence among vaccine-eligible children (12-23 months) languishes at 62%, compared to the 90% target set under the Universal Immunization Program (UIP) to be achieved by the end of 2020. In this context, community engagement (CE) has been explored as a strategy for facilitating transparent vaccine communication between communities and decisionmakers and supporting efforts to address inequities in vaccination coverage, especially among under-reached and underserved populations. However, while decisionmakers have recognised CE for vaccination as a core component of working toward health equity, with a focus on its power to ensure that vaccines are translated into affordable, accessible, and acceptable public health solutions, several studies have suggested that CE has not been clearly defined, articulated, or its effectiveness measured in the context of vaccination programmes. To address that lapse, these researchers interviewed Indian vaccination decisionmakers to derive a shared understanding of the evolving conceptualisation of CE in the context of India's UIP.

Alfred Schütz's Social Phenomenology Theory was used as an underlying approach for this study, in part because it highlights the need to consider the dynamic contexts in which decisionmakers conceive of and operationalise CE. In preparing for the study, the lead author purposefully identified 30 individuals who had authoritative roles related to vaccine discovery, development, and delivery, such as policymakers, programme heads, and/or associates in the government, private sector, non-governmental organisations (NGOs), and country offices of international donor and United Nations (UN) agencies. A 2-step participatory approach for data collection was used: (i) semi-structured interviews conducted from December 2017 to February 2018 with 25 of the "elites" who agreed to participate, followed by (ii) a check-in meeting in January 2018 to ensure that the overall summation and meaning-making of the findings prepared by the research team made sense to both the vaccine decisionmakers and their teams in India. All interactions used a community-engaged approach, including emphasis on mutual respect and recognition of the knowledge and expertise of study participants.

Key themes included:

1. Conceptualisation of community, and how vaccine decisionmakers define community: Interviewees typically understood community to include one or more of the following: vaccine-eligible children and their parents and vaccine-eligible adults, frontline healthcare providers, local-level stakeholders, vaccine gatekeepers, and local-level implementing organisations. Most of the participants acknowledged their distance from the community, with one saying, "if I went to the community nobody will accept me," and noting that local organisations such as grassroots non-profit organisations (NPOs), community-based organisations (CBOs) like women's self-help groups, local-level representatives of occupational groups like brick-kiln workers and barbers, and the local chapters of technical and youth organizations can "help raise community demand for routine immunization."
2. Conceptualisation of CE, with particular attention to critiquing extant efforts: The participants variously defined CE as segments of processes comprised of:
   • Vaccine policy and programme formulation;
   • Capacity-building of frontline stakeholders;
   • Targeted community-level interventions to curtail recurring incidents of vaccine-related community backlash, ranging from vaccine imposition to respectful engagement with community stakeholders; and
   • Vaccine information dissemination among communities to promote vaccination uptake Participants described a wide variety of different communication methods, as well as perceived benefits and disadvantages to each. Most respondents mentioned "bilateral information transfer [interpersonal and behaviour change communication] sent down to communities" as CE. Some participants highlighted the need to be creative and explore web-based media, considering its ease of use, cost-effectiveness, and penetration to interior locations.

   Several participants critiqued that CE interventions came in waves, mostly during vaccine introductions, before and during vaccine trials, and in response to a disease outbreak. They also noted that there were no tools or metrics to measure its impact.

3. Different tangible ways in which CE might be fostered: Participants endorsed a wide variety of types of approaches to fostering CE, which fall on a spectrum ranging from empowered to disempowered. Table ​2 in the paper provides exemplar quotes illustrating efforts or actions that might be categorised into these different levels. Participants acknowledged "decision makers' good intention for CE", but said "they were not matched with recipes of successful CE models". Most of the CE interventions reported occurred during the National Polio Surveillance Program.
4. Evolution and transformation of CE: All participants acknowledged the need for a better understanding of CE and, in the check-in meeting, came to a consensus on a definition of CE, which can be summarised as:
   • "CE is an upstream policy imperative rather than downstream interventions to build trustworthy relationships between vaccine decisionmakers and communities. It involves demystifying vaccine science and transparent communication for empowered community agency. This would enable communities to critically analyze vaccine related myths and misinformation and enable knowledge co-production in building community sensitive vaccine policies and programs. [CE] is incumbent to sustained political-will and resources to ensure evidence-informed, tailored, vaccine policies and programs, providing equitable, quality, and tangible vaccination and capacity building benefits to community members."

   Meeting participants recognised the need to carry out interventions in ways such that trustworthy relationships between communities and decision makers are established. They also recommended creating more opportunities for relationship-building and group discussions between community healthcare workers and vaccine decisionmakers. Meeting participants were especially interested in addressing inequities in vaccination coverage by building on the existing range of interventions while innovating newer mechanisms such as: mobilising the community for vaccination; designing strategic interventions with vaccine gatekeepers; providing immunisation information using traditional, digital, and social media; and dispelling vaccine misinformation and disinformation while formulating rumour management strategies.

In reflecting on the findings, the researchers note that study participants described current iterations of CE as contributing to vaccine demand generation; however, they conceived of this demand on the part of communities as "passive". Per the researchers: "Ideally, communities would actively seek vaccines and there would be community demand reflecting social support for vaccination as a norm...Accordingly, doing empowered CE may require a paradigm-shift to perceive communities as integral parts of the policy and delivery systems, incorporate CE metrics into vaccine surveillance, and create new roles with a focused responsibility to coordinate CE."

In conclusion: "The results from this study can be used both to understand past CE challenges and successes and to prospectively plan community-led, tailored CE initiatives for better vaccination outcomes. Of note, there appears to be conceptual tension between multiple vaccination-related goals, such that each can be perceived as CE for health equity; namely, top-down vaccination programs may be successful in achieving some short-term immunization, but there may be backlash, and longer-term increases in immunization rates may suffer as a result. At this stage, it will be critical to devise CE process and outcome indicators for vaccination programs in India, and to advocate for their incorporation in vaccination surveillance datasets."