THSTI-CGPP Sabin Vaccine Hesitancy Project 2019-2021: Final Report

"Social and behavior change communication interventions play a vital role in increasing the uptake of vaccination, and these have been demonstrated in immunization programs. However, there are limited or no strong evidence-based interventions to address vaccine hesitancy..."

With the goal of promoting vaccine acceptance, the CORE Group Polio Project (CGPP) India, in collaboration with the Translational Health Science and Technology Institute (THSTI), conceptualised and conducted intervention research to assess the effectiveness of a social mobilisation intervention to increase communication skills and vaccine confidence among Accredited Social Health Activists (ASHAs).

This intervention research was conducted in Nuh (also known as Mewat) district of Haryana, a state in northern India where the full immunisation coverage was far below (13%) the national average (63%) in the 2015-16 Demographic and Health Survey. Low coverage in the district might be a joint result of demand- and supply-side issues.

The Nuh and Punhana blocks together have three Primary Health Centre (PHC) areas, of which Jamalgarh PHC area was selected as the "intervention area" and the Marora PHC area of Firozpur Jhirka block, the "control area". Although both areas consist of the rural populations, the profile of ASHAs differs between the two areas: Most of the ASHAs from the control areas were educated (i.e., went to formal schools); in contrast, about one-tenth of the intervention areas' ASHAs did not go to formal schools. Also, the intervention areas had more ASHAs from Muslim communities than control areas.

In addition to the ongoing routine immunisation (RI) activities of the government health department (e.g., organisation of vaccination sessions), the following activities were performed from December 2019 to December 2020 in the intervention area:

1. Skill-building of ASHAs on vaccination: ASHAs' skill training was built around adult learning principles, peer-to-peer appreciation, and use of interactive methodology such as games and role-plays to understand the science of immunisation and the immunisation schedule and to accelerate vaccine confidence. The emphasis was on strengthening the quality of ASHAs' activities (e.g., house visits and group meetings) by introducing no-cost indigenous communication tools and developing their capacity to prepare appropriate due lists for vaccination. They were given a kit with communication materials on RI to support mobilisation activities (available at the link below). Pictorial messages on the use of communication tools on RI were also shared through WhatsApp.
2. Supervisory support to ASHA facilitators: A simple supervisory checklist was introduced for ASHA supervisors with a focus on improving the quality of their visits in a non-authoritarian way. To enhance supportive supervision performance, data use for decision making and regular follow-up with ASHAs was promoted to ensure the assigned tasks are implemented and completed correctly.
3. Immunisation appreciation event: To motivate and honour the contribution of village-level immunisation teams, appreciation events were conducted, with the presentation of certificates signed by their supervisors to the ASHAs and their facilitators.
4. Community mobilisation: As a part of ASHAs' routine activity (e.g., visits to households with pregnant women and newborns), the project strengthened the following to address vaccine hesitancy:
   • Effective home visits: During home visits, ASHAs addressed myths and dispelled beliefs related to immunisation by using indigenous and pictorial communication material. They distributed pictorial invitation cards with details of due antigens for each child, which were redeemed at the session site by the vaccinators/ASHAs. They also promoted the distribution of "Timely Immunization Certificates" to parents whose children were vaccinated as per schedule, thereby motivating others.
   • Village-level meetings: Since the ASHA is a member of the Village Health, Sanitation and Nutrition Committee (VHSNC), she used the meetings to promote immunisation by listing its benefits and invited influential people to support in mobilising drop-out, left out, and resistant families.
   • Awareness generation: Khushi Express (Happy Express) is conducted using a comprehensive approach whereby a decorated mobile van with space for street plays/magic shows is parked at a busy site in a high-risk area. A question-and-answer session for the audience is conducted to reinforce key messages.
   • Improvement of immunisation session sites: ASHAs were trained to make immunisation session sites more welcoming and comfortable within the confines of available resources.

The baseline survey findings indicated the need to inform/convince mothers/caregivers about the importance of keeping the Mother and Child Protection (MCP)/vaccination cards safe, as more than half of the vaccination records (i.e., cards) of index children's (i.e., children aged 4-11 months) were not available. Findings indicated that communities are hesitant to vaccinate their children at the recommended age for the first dose of oral polio vaccine (OPV)/Penta. Delayed vaccination of the first dose and drop-out (from first to the third dose) contributes to low OPV 3/Penta 3 substantially. There was an immediate need to change some of the vaccination-related perceptions of ASHAs who would ultimately encourage/convince communities for on-time vaccination.

The endline survey revealed these selected findings:

• According to both data sources (i.e., vaccination cards and mothers' recall), the control area had 15 percentage points more OPV 3/Penta 3 coverage at baseline, significantly higher (63%) than the intervention areas (49%). After the intervention, the OPV3/Penta 3 coverage increased substantially by 23.7 percentage points in the intervention area, and the project's intervention increased the timely vaccination of the first dose of OPV/Penta and reduced the drop-out rate to 17.9%.
• The interventions were able to impact the extent of hesitancy against childhood vaccination and increased the timely vaccination of OPV2/Penta 3. From a baseline of 51.2% of children with no or delayed vaccination, the level reduced to 27.5% among community members (mothers) from the intervention areas. The findings indicate a 15-percentage-point increase in timely vaccination of OPV3/Penta 3 in the intervention area, and this is attributable to the communication and capacity-building interventions of the project.
• At baseline, more than half the mothers/caregivers from both areas had ever heard about vaccine-preventable diseases (VPDs). After the CGPP-THSTI intervention, the percentage of mothers who had ever heard of VPDs increased to 85% in the intervention area. Similarly, the percentage of mothers/caregivers aware of diseases against which vaccines are freely available under the government immunisation programme significantly increased from 42% to 82% in the intervention area.
• At baseline, about one-fourth of the respondent mothers from intervention areas were concerned about the side effects of vaccination, the safety of childhood vaccines, and the efficacy of vaccination. Data show that the CGPP-THSTI intervention was able to address the mothers' concerns and reduce vaccine hesitancy in the intervention areas.
• At baseline, one-fifth of the ASHAs from both the intervention and control areas were concerned about the side effects of vaccination, the safety of childhood vaccines, and efficacy of vaccination. After the intervention, most ASHAs became confident to address these vaccination-related issues.
• Most surveyed ASHAs were self-confident about their job. After the CGPP-THSTI intervention, almost all ASHAs considered their work important/very important. Similarly, ASHAs perceived they perform their duties very well and are satisfied with their work. Their families also feel proud of their work. The majority of ASHAs perceived they have adequate information, are skilled enough, and are efficient in convincing caregivers/community members about childhood immunisation. Most of them believed that community members trust them, respect them, and give credence to their advice.

Among the lessons learned going forward is related to reminders about due childhood vaccination, which about three-fourths of the mothers had received after the intervention. These reminders, which in the study were mostly conducted through verbal communication, were found to be significant in influencing vaccine uptake: Most OPV 3/Penta 3 vaccinated children had reminder visits, and the personal reminder visits were strongly associated with vaccination coverage. Among the children who had reminder home visits, most were vaccinated with the third dose of OPV/Penta, and a greater proportion of children without reminder visits were unvaccinated. At the endline, only about 8% of mothers from the intervention area said they received invitation cards/slips during the healthcare providers' personal visits, which indicates that there is scope to improve distribution of invitation slips to further improve timely immunisation.

In conclusion, the CGPP-THSTI intervention designed to address the communication and capacity-building needs of ASHAs helped reduce vaccine hesitancy and increase timely vaccination among children aged below 12 months. Although the intervention significantly contributed to increased first-dose OPV/Penta coverage, there was a six-week delay in first-dose administration. This gap can be addressed by continuing activities to address vaccine hesitancy. Such efforts would appear to be needed, as the endline survey found that a considerable proportion of mothers/caregivers are still hesitant about vaccination: About 26% of mothers/caregivers have concerns about vaccine safety, 21.8% are concerned about side effects, and 27% still perceive that vaccines may not prevent disease. Further investigation can assess the reasons behind delayed initiation and continue addressing caregivers'/ASHAs' doubts/worries about child vaccination.

Click here for the 29-page report in PDF format.
Click here for a 7-page PDF document featuring the communication materials used by the ASHAs during the intervention.