The Second Annual Vaccination Acceptance Research Network Conference (VARN2023): Shifting the Immunization Narrative to Center Equity and Community Expertise

"Promoting vaccine acceptance and demand is an essential, yet often underrecognized component of ensuring that everyone has access to the full benefits of immunization."

Convened by the Sabin Vaccine Institute, the Vaccination Acceptance Research Network (VARN) is a global network of multidisciplinary stakeholders working to advance and apply social and behavioural science insights, research, and expertise to the challenges and opportunities facing vaccination decision-makers. The second annual VARN conference, When Communities Lead, Global Immunization Succeeds, was held June 13-15 2023, in Bangkok, Thailand. This article synthesises evidence-based insights from the VARN2023 conference.

As outlined here, VARN2023 provided a space for the exploration and dissemination of a growing body of evidence, knowledge, and practice for driving action across the vaccination acceptance, demand, and delivery ecosystem. Co-convened by Sabin and the United Nations Children's Fund (UNICEF) and co-sponsored by Gavi, the Vaccine Alliance, VARN2023 brought together 231 global, regional, national, sub-national, and community-level representatives from 47 countries to share knowledge from research and practice, as well as agenda setting, around 3 core impact areas:

• Vaccine equity: Setting a new course for reaching marginalised and zero-dose communities, dealing with challenges in conflict settings, and reducing gender barriers;
• Reimagining essential childhood immunisation: Accelerating the reversal of current backsliding trends and improved integration into comprehensive health service delivery programmes (from policy to community-level responses); and
• Life-course immunisation: Extending the opportunities of COVID-19 vaccination investments to integrate, expand, and strengthen vaccination across the life course.

Recorded sessions are available on the conference website, here.

Four key themes, with recommendations, emerged:

1. Make vaccine equity and inclusion central to programming to improve vaccine confidence, demand, and delivery: The keynote remarks from Anuradha Gupta, President of Global Immunization at the Sabin Vaccine Institute, highlighted how structural inequities remain a major barrier to vaccination access and uptake. Marginalised communities often have a history of negative experiences within the health system and with public health authorities more generally, and they face systemic inequities in healthcare that lead to gaps in immunisation. Across diverse settings, presenters at VARN2023 described various gender-specific barriers to vaccination across multiple contexts, including women often having less decision-making power within families compared with men and less access to information and communication sources. VARN2023 participants shared different frameworks, tools, and approaches to make immunisation services more equitable, particularly among marginalised groups. One lesson: Vaccine equity cannot be achieved without engaging and involving those affected by inequities in the design and implementation of solutions.

2. Prioritise communities in immunisation service delivery through people-centred approaches and tools that amplify community needs to policymakers, build trust, and combat misinformation: At VARN2023, presenters discussed the different ways that behavioral science approaches can be used to robustly investigate the underlying psychological, sociological, and structural barriers to vaccine uptake and co-design responsive solutions that meet their needs in a way that is culturally relevant, respectful, and impactful. For example, Patricka Chulamokha (International Organization for Migration) shared how human-centred design (HCD) was applied to increase COVID-19 vaccine confidence, demand, and uptake among displaced persons of the Karen community on the Thai-Myanmar border. Other presenters shared how motivational interviewing has been used in diverse settings to address vaccine hesitancy.

For instance, several presentations explored how different social listening approaches have been used to glean insights into common concerns or barriers in real-time and share timely reports with the health system and policymakers for a response. In addition, information, education, and communication (IEC) materials need to account for the different communication needs of culturally and linguistically diverse populations to ensure they resonate with the community. Also suggested was the engagement of vaccine champions (trusted community members who can be powerful motivators around immunisation) and/or journalists, who can disseminate relevant information for policy and decision-makers and mobilise communities to change the narrative around immunisation. Furthermore, as several examples included in the presentations highlight, innovative approaches that sit at the intersection of art and science (e.g., methods of storytelling that are evolving to incorporate different contemporary mediums, like short-form videos, podcasts, and advertisements/commercials) have the power to inspire people and allow them to share their realities in a human-centred way.

3. Encourage innovative community-centric solutions for improved routine immunisation coverage: Recognising that there are no one-size-fits all solutions to this complex issue, community-centric programmes are needed to reach children who are under-vaccinated, particularly as they often belong to marginalised communities facing multiple barriers to vaccination. At VARN2023, one presentation shared how social influencers were deployed to increase demand for routine childhood immunisations among working mothers in Ibadan, Nigeria. Another highlighted a community-based strategy to improve childhood vaccination in a remote fishing community in Cameroon, where almost all children were previously zero-dose.

4. Strengthen vaccination across the life course by building vaccine demand, integrating services, and improving the immunisation service experience: The introduction of newer vaccination programmes at different stages of life - in particular, the human papillomavirus (HPV) vaccination programme in adolescence - requires specific strategies to foster confidence and demand. Presenters shared insights around the need to integrate routine and life-course immunisations, as well as approaches that have been investigated to integrate service delivery for COVID-19. Making sure that immunisation services are person-centred is an important component of ensuring good vaccine uptake and demand. A side event facilitated by JSI Research & Training Institute, Inc. (JSI) and Vaccination Demand Hub partners looked at the role of behavioural science approaches in improving service experience. JSI and partners showcased two main models: (i) the World Health Organization's behavioural and social drivers of vaccination (BeSD), which provides a framework to understand what drives vaccine uptake, and (ii) the journey to immunisation model, developed by UNICEF and partners, which provides a human-centred overview of the different barriers and enablers that may affect health workers and caregivers across six key pillars of the immunisation experience.

VARN2023 also highlighted priorities for future research to improve acceptance, demand, and delivery. Key among these are: strategies to reach zero-dose children; approaches to intensify recovery from backsliding in immunisation rates; proactive, ongoing efforts to combat misinformation around vaccination; and approaches that address both vaccine demand and service-side barriers to vaccination uptake.

In conclusion, "Insights from VARN can be applied to positively impact vaccination acceptance, demand, and uptake around the world." Looking forward, VARN intends to continue to provide a forum to stimulate discussions and drive collaboration.