Harnessing Community Engagement and Multisectoral SBC Approaches to Address Vaccine Hesitancy

The community engagement initiative was strategically designed using evidence-based approaches and tailored to resonate with local cultural values. Experts involved in its development and implementation emphasised that fostering trust - both among the general population and within the healthcare workforce - is essential to increasing acceptance and uptake of routine vaccines. The campaign brought together health, education, local public authorities (LPAs), and local business stakeholders with the aim of combining resources to increase demand for routine immunisation and strengthen the quality of service delivery through an intersectoral approach.

The implementation strategy aimed to address demand-side factors and was based on the following three pillars:

1. Pursuing an appropriate intervention design and engagement strategy for each community;
2. Addressing the contextual barriers to vaccination uptake; and
3. Considering existing resource constraints and practical application to each setting.

Communities involved were encouraged to take a lead in identifying, owning, and resolving issues that contribute to low immunisation uptake. Mobile health teams conducted outreach in underserved regions to ensure broader vaccine access and education.

The key interventions included:

• Adaptation of existing communication materials for different audiences, followed by review and approval by the National Agency for Public Health (NAPH)
• Gender-responsive interventions, including:
  • Inviting male and female parents/caregivers to community meetings in kindergartens and schools;
  • Reaching out to male and female parents/caregivers in follow-up activities for under-vaccinated children; and
  • Ensuring inclusion of adolescent boys in human papillomavirus (HPV) education sessions at schools, which had previously only included girls
• Community-level partnerships, including with private businesses, to promote increased rates of vaccination in priority communities
• Capacity building for specific audiences:
  • Trainings for HCWs to strengthen their capacity for community engagement and communication to promote immunisation and address the barriers to uptake;
  • Capacity building for local public administration representatives to strengthen their commitment to promotion of immunisation through partnerships, action plans to build community trust, and community engagement; and
  • Information sessions and communication skill-building for preschool and primary school teachers to build a collective sense of responsibility for children's health and strengthen their ability to promote vaccination
• Outreach information sessions for specific audiences to promote routine immunisation:
  • Information sessions for parents and caregivers of children aged 0-5 years and pregnant women, through parent-teacher association meetings, promotion by volunteer teachers, health facility education, vaccination leaflets, and door-to-door visits;
  • Education for school children aged 10-15 years to strengthen their own knowledge about immunisation;
  • Information sessions for community influencers, such as bloggers and journalists, to strengthen their promotion of immunisation campaign messages;
  • Information sessions for Ukrainian refugees and Roma communities conducted by mobile health teams involved in food distribution centres and other community activities;
  • Engagement with religious leaders through workshops and trainings to address concerns about immunisation and build trust, leading to greater involvement in awareness raising; and
  • Training and information sharing by mobile teams to employees of private companies with over 50 employees to encourage participation in the campaign.
• Monitoring and assessment of the interventions through feedback mechanisms and immunisation data collection

UNICEF Moldova notes that:

• The sustainability of the immunisation programme was supported by strong governance, collaboration, evidence-based decision-making, community ownership, and an overall commitment to health and prioritisation of vaccine programming from all stakeholders at the community level.
• The project promoted a two-way communication strategy between the priority population and partners working to promote routine vaccination through face-to-face discussions and door-to-door visits with community members.
• Initiation and leadership of the community engagement by LPAs also contributed to the sustainability of the approach. For example, some political issues arose from challenges in reaching refugee communities due to their high mobility and difficulty involving parents/caregivers and children in the campaign. These challenges were addressed through bringing key stakeholders together to discuss, collaborate, and identify solutions.

Context:

In 2021, the Vaccine Confidence Project reported a high level of vaccine hesitancy in Moldova compared to other countries in Eastern Europe, in particular highlighting the lack of confidence in vaccine safety and effectiveness. World Health Organization (WHO) and UNICEF estimates of national immunisation coverage (WUENIC) show that Moldova's national DTP-1 coverage decreased from 91% in 2019 to 86% during the first year of the COVID-19 pandemic (2020). Contributing factors included the increased scarcity of resources, data quality issues, and negative impacts of lockdown restrictions on routine immunisation. The country recovered coverage levels to 89% in the following two years but saw a further decrease to 87% in 2023.

UNICEF carried out a Social Media Practice and Monitoring in Public Health social listening project from September 2022 to January 2023 to better understand vaccine hesitancy and to inform the campaign described above. One insight to emerge: Social media platforms play a prominent role in shaping the discourse of the general population related to immunisation. In addition, surveys carried out by the CHSP in 2022 in 24 of Moldova's 35 rayons were analysed to understand current attitudes and beliefs of community members toward COVID-19 and routine immunisation. HCWs were also surveyed to identify their perceptions of the barriers to uptake in the communities where they work. The survey of 1,870 community members revealed:
 

• Low importance of local HCW promotion of immunisation: 53% of people surveyed considered the recommendations of HCWs to be of little importance in their decision-making about vaccination, and 18% were uncertain or had no opinion about the role of HCWs in their decision-making about vaccination.
• Reasons for not getting vaccinated: not enough information (35%), lack of confidence (28%), perception of vaccines as unnecessary (27%), perception of vaccination as potentially harmful (11%).
• Information sources regarding immunisation: social media (33%), HCW (31%), close friends and family (21%), opinion leaders (community/religious) (20%), radio and television (19%).

The barriers to immunisation uptake among communities, as identified by 845 participating HCWs, are categorised into the following themes: mis/dis-information and myths, low trust in the health system and HCWs, and inadequate information. Related to the practices of HCWs, participating health professionals also identified concerns about the sharing of non-evidence-based vaccine contraindications by some doctors, which may contribute to vaccine hesitancy.

Impact:

An evaluation of the programme was carried out by the CHSP through year-on-year comparison of regional vaccination reports from the National Register of Public Health. The analysis found that community engagement interventions had positive effects on the rates at which children received vaccinations, as well as the timeliness of those vaccinations. The initiative also empowered local authorities to sustain vaccination efforts through action plans and institutionalised community partnerships. School-based educational interventions were well-received by school-age children, who discussed the potential benefits of making vaccines more student-centred, being more involved in the decision-making process about vaccination, and improving the management of vaccine-related anxiety.

Recommendations for programme teams planning cross-sectoral strengthening of community engagement to improve immunisation outcomes:
 

• Engagement with diverse stakeholders: Strengthen community engagement and mobilisation by working with local authorities, HCWs, teachers, religious leaders, community influencers, and local journalists to promote routine immunisation.
• Capacity building of health workers: Provide refresher training sessions to reinforce knowledge and skills related to immunisation. Cultural competence of HCWs and communication strategies to address the needs of diverse populations, including religious minorities and Roma communities, should be taken in account.
• Tailored strategies for communities: To increase vaccine coverage, strategies should address geographical, social, and cultural barriers specific to each community.
• Building trust: Trust is essential for improving vaccine acceptance, among both the general population and health professionals, particularly in rural areas. Efforts to strengthen relationships within communities are vital to increase the demand and acceptance of vaccination.
• Effective communication: Vaccine-related communication must be well-documented, empathetic, proactive, transparent, and tailored to the specific needs of different population groups to ensure clarity and trust.

Recommendations from the social listening project discussed above include:
 

• National strategies for health communication should take a long-term approach and diversify messaging to effectively reach men and women, religious groups, and minority populations.
• Partnerships between health authorities and media institutes should be developed, and skills and strategies of health authorities and communication teams strengthened, to respond to misinformation, including from online sources.
• Intersectoral communication partnerships should be strengthened to increase trust in the health sector.