Smart Investments that Improve Immunisation Equity: Evidence-based Activities for Practitioners, Managers and Influencers of Demand Promotion

"We cannot achieve broad, sustained coverage of vaccines, nor the full return on supply and vaccine investments, until all communities are empowered and enabled to access immunisation services."

Gavi, the Vaccine Alliance, joins the international community in recognising the need to increase demand for immunisation if countries are to achieve their coverage and equity goals. Demand promotion entails activities that reduce hesitancy and help convince people to accept and ask for vaccines. Gavi joined with the United Nations Children's Fund (UNICEF), the World Health Organization (WHO), and the Emory Vaccine Centre at Emory University to compile evidence on a range of demand promotion activities. A brochure and companion PowerPoint tool are available.

Making the case in a brochure intended to be used as an advocacy resource, these organisations contend that:

• A range of different strategies, approaches, and tools have been shown to be effective at increasing demand for immunisation amongst unimmunised and under-immunised groups. This "evidence base" organises findings within a simple framework of behavioural change that considers how values, attitudes, and intentions can play a role in public demand for vaccines.
• The value of these demand interventions is tangible, and the impact can be measured and demonstrated, using appropriate tools. Further resources for demand promotion planning, monitoring, and evaluation, as well as a checklist of key action steps, are presented in the concluding pages of this brochure.

The examples presented in the brochure come from a review of published studies on immunisation demand promotion in the academic literature. They are intended to point to novel, varied, and inspiring practices that are relevant to different contexts and that help to overcome different types of demand barriers - whether related to values, attitudes. or intentions to vaccinate. This brochure can serve as a starting point to encourage decision-makers to begin investing in more proven, effective demand promotion interventions.

For instance, the reader interested in moving people from attitudes to intentions through personalised appeals can learn that "Using media channels and formats that are familiar to specific target populations, and with which they culturally identify, can be effective in changing negative attitudes to immunisation. Examples might include storytelling via radio and television programmes, or live cultural or dramatic performances....After listening to 'radionovelas' with plot-lines that addressed uptake of the human papillomavirus (HPV) vaccine, US [United States]-living, rural Hispanic parents of Mexican descent demonstrated higher knowledge and positive-vaccine beliefs." In this case, as in all examples, the original source reference is provided in the form of a DOI (digital object identifier) or the PMID (unique identifier number used in PubMed). This provides a link to the source on the internet for further reading/research.

Also available to help boost national demand programmes is a companion PowerPoint tool that is intended to stimulate and facilitate country-level action planning and decision-making. It features a working session on smart investments to improve immunisation equity that centres around a tool for multi-stakeholder discussion on demand promotion. Specifically, it includes:

1. The case for demand promotion and the evidence base findings: proven activities or tools to stimulate demand in specific contexts.
2. Input slides: an opportunity for the presenter to share information about national activities; designed to inform discussions and build tailored, relevant action plans.
3. Questions for discussion meant to spark reflection on specific questions for each national context; a blank table is provided at the start of each section so that the presenter can take notes.

It is organised as follows:

• Section 1: A framework for stimulating demand
• Section 2: Evidence base
• Section 3: Case studies: (i) Mass media delivering cost effective improvements in child survival outcomes in Burkina Faso; and (ii) Social mobilisation networks contributing to the eradication of polio in India
• Section 4: Checklist
• Annex: Further resources

Part 1 - The case for investing in demand promotion - lasts approximately 2 hours (including discussions); Part 2 - Novel, proven approaches to demand promotion - lasts approximately 2 hours (including discussions). The two parts could be completed in a (short) one-day working session; they could also be split up across different days. Facilitators and moderators may consider convening stakeholders for the presentation during:

• Gavi Joint Appraisal sessions (JAs)
• Demand promotion related meetings of Inter-Agency Coordinating Committees (ICCs)
• Meetings of communications or national demand promotion Working Groups
• Efforts to develop new, national or sub-national immunisation communication strategies or plans, or to revise existing such strategies or plans
• Design of the demand components of any new proposals to Gavi or other donors
• Expanded Programme on Immunization (EPI) Reviews or similar exercises that seek to review the performance or improve the delivery of immunisation interventions, including demand-side interventions.

Presenters are instructed: "In addition to providing your own inputs where prompted, and facilitating discussion points: We encourage you to tailor this presentation to your needs. Feel free to delete any slides that may not be relevant to your context, or add slides that can help further inform your stakeholders. Lastly, please note that there is a place to include your logo (EPI,...other) indicated by a light grey box at the bottom left of each slide."