Immunisation Intervention Led by Root Cause Analysis Assessment

This initiative used RCA as a tool to identify root causes of a problem, craft evidence-driven interventions, and engage local leaders in immunisation efforts. By conducting a structured, facilitated team process (a comprehensive RCA), key obstacles to vaccination were identified across different domains, including:
 

• Communication and demand generation - e.g., low vaccine demand and uptake among religious communities and among Roma communities are among the most serious factors that affect the National Immunization Program's performance in achieving target coverage rates at both national and subnational levels.
• Service delivery - e.g., insufficient capacities of PHC service providers to effectively communicate about the importance and safety of vaccines among caregivers and beneficiaries contribute to increased concern of vaccination among parents.
• Information systems - e.g., unavailability of real-time data from information immunisation systems creates problems with tracking children who have missed routine immunisation due to population mobility.
• Programme management - e.g., staff responsible for supportive supervision visits either do not use or do not follow the standard operating procedures, guides, and data collection and analysis tools.

Tailored interventions were developed to strengthen immunisation coverage in Balti District based on RCA. With the support of UNICEF and WHO, several strategies were applied:
 

• Community engagement: To build trust and confidence in immunisation, local influencers, including healthcare professionals, religious and community leaders, and public figures, were enlisted to disseminate accurate information about immunisation. This approach was designed to enhance vaccine acceptance within the community and address concerns raised by caregivers. A detailed plan of activities for increasing vaccination and a comprehensive media campaign was conducted across local TV and radio stations, featuring video and audio spots, interviews, and TV shows. To ensure maximum reach and impact in the hesitant vaccination groups, including religious minorities and Roma communities, informative materials including culturally relevant posters and flyers were created in local languages. Reportedly, local leaders were instrumental in strengthening community engagement, building trust, and ensuring the success of vaccination campaigns among hesitant groups. Their involvement fostered a sense of ownership, leading to increased acceptance, participation, and ultimately better public health outcomes.
• Healthcare worker (HCW) training: HCWs are at the forefront of immunisation efforts, and their expertise and communication skills are crucial in addressing vaccine hesitancy and providing accurate information. A comprehensive training programme developed by Drexel University and the UNICEF Europe and Central Asia Regional Office equipped HCWs in Balti district with up-to-date knowledge on vaccine safety, addressed common concerns associated with vaccination, and shared effective communication techniques. In total, more than 270 physicians and nurses underwent interpersonal communication (IPC) training and false contraindication training, enabling them to positively engage with caregivers and dispel myths surrounding vaccines.
• Logistical support: UNICEF and WHO supported the delivery of vaccines and necessary supplies to healthcare facilities and supportive supervision visits in Balti District. PHC providers played a key role in coordinating these efforts, ensuring that children who had missed vaccines were identified and reached.

Going forward, the results of the RCA will be used to guide continued efforts to strengthen immunisation programmes in Moldova by:
 

• Strengthening community engagement and mobilisation - working with local authorities, HCWs, teachers, religious leaders, community influencers, and local journalists to form a community engagement task force;
• Building capacity of HCWs to effectively communicate with caregivers - implementing comprehensive training programmes and providing refresher training sessions to reinforce knowledge and skills, with a focus on cultural competence and communication strategies to address the needs of diverse populations, including religious minorities and Roma communities;
• Fostering stakeholder engagement and evaluation - advocating for increased resources and support for immunisation programs from government authorities and development partners and strengthening partnerships with international organisations, such as UNICEF and WHO, to leverage their technical expertise and resources for immunisation activities;
• Ensuring data-driven decision making - enhancing data collection and reporting systems to ensure real-time availability of immunisation data and using resulting insights to develop targeted strategies for increasing vaccine uptake in specific communities and population groups; and
• Regularly conducting supportive and collaborative supervision visits.

Context:
In 2019, prior to the COVID-19 pandemic, more than 90% of Moldovan children had received the third dose of the diphtheria, tetanus, and pertussis vaccine (DTP3) - a key marker in vaccine coverage; around 88% had received the first dose of the measles, mumps, and rubella (MMR1) vaccine. But DTP3 vaccination rates dropped below 87% in 2021, and MMR1 vaccination rates dropped to 83%. In the Balti District, the decline was even more dramatic, with around 66% of children vaccinated with DTP3 vaccines and 60% vaccinated with MMR1 in 2021.

Impact:
After the implementation of tailored actions based on RCA in Balti District during March-June 2023, there was an increase of 35% in the number of vaccinated children with DTP3, with 387 children registered in 2023 compared with an average of 253 children vaccinated in the pandemic period of 2020-2022 between March and June. For the third dose of oral polio vaccine (OPV3), the increase was 36%, with 462 children registered in 2023 compared with an average of 296 children vaccinated in the pandemic period of 2020-2022 between March and June.

Sample takeaways:
 

• Tailored interventions, guided by comprehensive analysis, are crucial in addressing specific barriers to vaccine uptake. The RCA can empower PHC and engage local leaders to overcome challenges and achieve significant advancements in vaccine uptake. The timely support provided by UNICEF and WHO was instrumental in enabling the  implementation of tailored interventions.
• Community engagement plays a vital role in fostering trust and acceptance of vaccines. By incorporating feedback from local communities and assessing programme outcomes, immunisation efforts can remain agile and responsive, ensuring sustained vaccine acceptance and uptake. The success of the RCA-driven approach in Balti District showcases its potential for scalability, making it applicable to other regions in the country facing similar immunisation challenges.
• Efficient vaccine distribution is crucial in ensuring accessibility, and timely delivery ensures that vaccines reach all health care facilities, including those in remote and other hard-to-reach areas. PHC workers need regular capacity building on technical aspects and IPC to increase demand and timely administration of vaccines through effective communication with caregivers and the beneficiaries that reduces misconceptions around contraindications.
• Collaboration with international organisations, such as UNICEF and WHO, strengthens the impact of immunisation programmes and supports national health initiatives. The RCA-driven interventions have laid the groundwork for sustainable impact in Balti district. Evidence-based strategies can be continuously monitored, evaluated, and adapted to meet evolving needs and challenges.