The Contribution of Community Influencers to Vaccination Acceptance in Uttar Pradesh, India: Best Practices & Lessons Learned

"Communication is really important. Things will happen only when we will talk to people about it. By talking not only we will tell them what we want but we will also get to know what they think about certain things. Then only we will be able to bring about the change we want." - community influencer (CI)

Leveraging community influencers (CIs) to build trust between the health system and communities was a key strategy for eradicating polio in India. This report examines the role of CIs in the CORE Group Partners Project (CGPP) in Uttar Pradesh, India, exploring how CIs were instrumental in mobilising communities for polio eradication, routine immunisation (RI), and COVID-19 vaccination. By amplifying CI voices, the study examines the factors that both initially inspired them to engage with the project and then kept them motivated over time. In the global context of increased vaccine hesitancy and the ongoing effort to eradicate polio, the lessons learned from this programme experience may be relevant to policymakers and programme planners in India and beyond.

The report begins with an overview of the programme and its people-centred approach through many iterations. In brief, starting 1999, CGPP has worked to eliminate polio across 7 countries (India, Ethiopia, Kenya, Somalia, Nigeria, South Sudan, and Uganda - and earlier Bangladesh, Nepal, and Angola) with funding from the United States Agency for International Development (USAID). In India, the CGPP consortium comprises 3 private voluntary organisations (PVOs): Catholic Relief Services, the Adventist Development and Relief Agency (ADRA), and Project Concern International (PCI) as well as their local non-governmental organisation (NGO) partners. These organisations work across 12 districts of Uttar Pradesh, 2 of Haryana, and 1 in Assam. Overall, CGPP India's direct intervention had reached approximately 3.8 million people as of 2021.

Once polio was eliminated from India, as part of the national "endgame" strategy, the key lessons learned and promising practices from polio were applied in government RI programmes to augment coverage. Some of these practices include microplanning (planning down to the household level), social mobilisation (engaging communities to augment programme goals), and surge support (targeted high-intensity programming). Under the banner of social mobilisation, one of the promising practices that was identified and applied under CGPP in the context of RI was engaging CIs to mobilise communities. Since the CIs are insiders from the community, they are able to build trust between health system actors and families. The CIs were educated both formally through scheduled trainings as well as informally through interactions with programme staff and government frontline workers on the various aspects of the diseases, vaccines, and relevant health services. The accuracy of the information provided through the programme ensured that the CIs were seen to be credible in the eyes of the community.

The process for leveraging CIs for vaccination campaigns involved mapping communities, identifying vaccine-resistant families, and based on the nature of their resistance, identifying suitable CIs who were then briefed to encourage people to accept vaccination. The primary role of CIs was interpersonal communication with vaccine-resistant individuals and families. Along with this they also supported programme staff in community outreach activities, leveraged mass communication tools such as social media, and helped people to access government immunisation booths, which were set up at regular intervals to provide information and polio vaccine drops. In addition, street plays and rallies were conducted to spread information about the immunisation programme.

CIs have been deployed globally across a number of areas. A review of the global literature provides a snapshot of both successes and challenges in the programmatic approach. One of the key programmatic barriers in the CGPP deployment of CIs was initiating and maintaining influencer motivation.

A team of researchers interviewed CIs, CGPP programme staff, and secretariat members across 6 districts in Uttar Pradesh in order to:
 

• Identify and document the strategic approach and inputs from CGPP in terms of working with CIs, with a focus on understanding which inputs were catalytic in supporting motivation and increasing immunisation rates; and
• Identify and document the challenges and enabling factors for CIs in their effort to address vaccine hesitancy among children and the general population.

Selected key findings:
 

• Understandings of vaccine hesitancy: Several participants described vaccine hesitancy in structural terms, pointing to the lack of education, mobility restrictions (among women and children), limited access to information, and poverty in the communities where they operate. CIs and programme staff also pointed to a deep-seated mistrust of government as a cause of vaccine hesitancy. This mistrust stemmed from limited contact between government and some communities, along with a perceived sense of government neglect. A number of participants described the confusion about the singular focus on polio when children were dying for other reasons, and access to services generally was poor. 
• Negotiation: Once community members could see the urgency of the government's efforts for vaccination, they quickly used vaccination as a bartering tool to get what they needed in terms of development support. Some community leaders would only allow vaccination camps to be held if they were able to get other development inputs first, such as roads, electrification, or health centres. Communities' active and creative negotiation around vaccination is a reminder that communities cannot be considered passive beneficiaries of health system interventions but instead must be strategically brought on board.
• Strengthening the health system: As members of the community themselves, CIs could help spread appropriate information, counter rumours, and alleviate fears through everyday interactions, a more effective approach than through the formal channels of communication available to programme staff. The CIs build trust between the health system and marginalised communities, improving long-term engagement and community resilience. They are an asset that can be deployed for other goals in support of universal health coverage.
• Complementary CHW modalities: The CIs have been an effective complement to the different NGO and government cadres of female community health workers (CHWs), helping extend their reach and build their local knowledge and confidence.
• Motivation: Personal factors that led people to volunteer as CIs, including a high value placed on community service and personal experience with polio or other diseases. The CIs derived their motivation from the social capital and respect they accumulated through their work and through the programmes success. They were recognised by senior government officials, which raised their status within the community and made them feel respected. They also derived some personal gain from their role as CIs, such as expanded political platforms and improved business prospects.
• Sustainability: The CGPP programme staff used multiple strategies to further support and ensure continuity of engagement through the CIs. These strategies included sharing up-to-date information with them and holding regular meetings and training sessions. When CIs were asked what programme inputs were required to maintain their work beyond the life of the project, they identified information about vaccines, coordination support, and the backing of the programme. Beyond that, CIs were able to be self-sufficient in their outreach work. Looking forward, they discussed a hope and an expectation that they could continue as a health system resource through ongoing liaison with other health workers through the Community Action Groups (CAG) - a community-level coordination platform that is described in more detail at Related Summaries, below.

Recommendations emerging from this research:
 

• CIs can help increase awareness of integrated primary health services, including vaccination, under the Ayushman Bharat model. This approach can make care seeking at the primary care level more attractive and accessible and dissuade people from travelling to secondary and tertiary care facilities for minor ailments and maternal, neonatal, and child health (MNCH) services.
• Many actors came together to work in partnership to end polio and promote vaccination. In particular, the experience of CIs working alongside Accredited Social Health Activist (ASHAs), Auxiliary Nurse Midwives (ANMs), and Anganwadi Workers (AWWs) suggests there is scope for CHWs who are institutionally linked (with job roles and some kind of payment) to work alongside those who are more socially anchored. The CIs can complement the ASHA workers and extend their reach.
• The work of the CIs requires some infrastructure and support for their work to endure. A network can be created between the ASHAs and these CIs so that they can leverage support from each other. The CAGs can provide this structure and support. Therefore, efforts should be made to accelerate the deployment of CAGs so that they are organised and well structured.
• Deploying and sustaining CIs as a volunteer cadre requires a strategic approach to maintaining motivation over time. The CGPP gave the CIs respect and visibility in meetings at the community, block, district, and state levels. They were able to take pride in the programme's success in eliminating polio. Applause from their peers and appreciation from district and state officials increased their status and motivation. CIs can gain similar benefits in other programmatic and socio-cultural contexts.

In conclusion: "CIs were high-status individuals within the community with strong self-efficacy and intrinsic motivation. These individuals helped create an enabling environment for the immunisation program by facilitating programmatic activities through interpersonal communication for persuasion of resistant individuals and families. Being members of the community themselves, they were able to offer feedback and advice to the implementers on practical aspects of the program. The findings from this assessment indicate that what motivated the CIs was a commitment to the community and their status within it. This was also key to their effectiveness."