Diagnosing the Determinants of Vaccine Hesitancy in Specific Subgroups: The Guide to Tailoring Immunization Programmes (TIP)

"The Guide to Tailoring Immunization Programmes (TIP), an evidence and theory based behavioral insight framework, issued in 2013...could be a valuable tool for use in all WHO [World Health Organization] regions, to help address countries' vaccine hesitancy problems. The TIP principles are applicable to communicable, noncommunicable and emergency planning where behavioral decisions influence outcomes."

This paper explores TIP (see also the Related Summaries below), which provides tools to: identify and prioritise vaccine hesitant populations and subgroups, diagnose the demand and supply-side barriers and enablers for vaccination in these populations, and design evidence-informed responses to vaccine hesitancy appropriate to the setting, context, and hesitant population.

As the authors explain, given growing concerns about vaccine hesitancy in the region, in 2011, the European Technical Advisory Group of Experts on Immunization (ETAGE) requested that the WHO/EURO (Regional Office for Europe) Vaccine-preventable Diseases and Immunization (VPI) Programme develop tools to help countries address hesitancy more effectively. The 2013 TIP emerged as a guide to define and diagnose behaviourally related hesitancy determinants and propose appropriate interventions. While TIP is underpinned by social marketing, it is broader than this as it encompasses aspects of the whole immunisation process, including:

1. The situation analysis, which involves analysing the context in which the intervention operates in order to ensure selection of the most appropriate intended group and behaviour and to identify strategic priorities for the marketing plan.
2. Audience insight: getting to know the intended group on a level that goes beyond just as a set of demographics.
3. Brand positioning
4. Marketing objectives
5. The four marketing "P's" - Product, Price, Place and Promotion - which specify what strategies one will use to achieve the marketing objectives.
6. The research plan
7. An integrated budget and work plan.

In the WHO European Region, TIP has been applied in Bulgaria, Sweden, and the United Kingdom to diagnose causes of hesitancy and develop targeted interventions for subgroups with lower than expected vaccine uptake. For example: "Subgroup segmentation of those who are vaccine hesitant can be seen in the examples from Bulgaria (e.g. the late child, the mobile child, the invisible child, the wary caregiver, the poor child...) and Sweden (e.g. within the anthroposophic group: conformers, pragmatists, attentive delayers, and promoters of natural immunity)....Of note, these subgroups cut across many common profiles used to describe populations, such as socioeconomic status, ethnicity, and religion. In both countries, application of TIP led to customized solutions that specifically addressed the hesitancy problem with available resources. In some instances, a combination of policy, legal, and communications changes may be needed, once the specific hesitancy problems are identified."

The Strategic Advisory Group of Experts on Immunization (SAGE) Working Group on Vaccine Hesitancy (WG) followed the development, implementation, use, and evolution of TIP. "Presentations to the Working Group by experts from Africa, India and Pakistan highlighted the growing importance of and need for community-directed research to better understand the determinants of hesitancy....In late 2013, the Working Group proposed that four major areas be addressed in order to move TIP to the global level:

1. Rework and simplify the document by region or by level of income (high, middle, lower income countries) to better fit end users' needs. This is being addressed in part by the development of the more practical immunization manager field guide.
2. Develop resources/expertise/training to support implementation of TIP in WHO regions and countries. A cadre of TIP facilitators is needed. A training course held in June 2014 by WHO/EURO was an initial step in addressing this gap.
3. Ensure that each WHO region has regional expertise and tool kits adapted to its region to support TIP implementation and facilitator training, which may need to be tailored to fit high, middle and low income settings in different regions. Experience is needed to determine how training can best be adapted to local needs.
4. Develop a means of sharing the lessons learned from TIP interventions and outcomes, both successes and failures, across regions and globally."

According to the authors, wider roll-out of TIP requires "knowledgeable facilitators with sophisticated expertise." So, a TIP consultant training course was held in June 2014. In parallel, with support from the United States Centers for Disease Control and Prevention (CDC), a practical TIP field guide for national immunisation managers is being developed as a companion to the current 2013 TIP Guide. This document will support the use of TIP in settings where personnel and financial resources are scarce. The 2013 TIP Guide is also being updated, with new examples included, and a more accessible step-by-step approach to implementation incorporated.

The WG notes that "the success of TIP in Europe underlined how application of research evidence from behavioral sciences, economics, the medical humanities, psychology, and neuroscience can help decision-makers understand vaccine acceptance decisions. These insights can better equip decision-makers and programme managers in tackling vaccine hesitancy. TIP explores the determinants that influence vaccination behavior, and it emphasizes the importance of diagnosing both the demand- and supply-side factors, and emphasizes the value of audience research. SAGE agreed with this conclusion. The applied behavioral insight methods that underpin TIP make positive behaviors easier in the segmented population where the appropriate interventions are targeted. TIP makes changes that encourage healthy choices (the object of health promotion) for the hesitant individual and community. These TIP principles might also be applicable to other communicable and noncommunicable diseases where patient behavioral choices and context markedly influence outcomes; for example prevention of transmission of some sexually transmitted diseases....The Working Group concluded that given this breadth of potential for benefit, the integrated knowledge and skills of sociologists, behavioral psychologists, anthropologists, experts in social marketing and communication as well as specific disease experts need to be brought together to form integrated core behavior insight groups both at WHO headquarters and in the regional offices. Initially, these core groups would provide insights into vaccine hesitancy and driving demand for vaccine(s) and then potentially expand work in other areas, including both communicable and noncommunicable diseases."