Addressing Missed Opportunities for Vaccination among Children in Hospitals: Leveraging the P-Process for Health Communication Strategies

"By harnessing the power of the P-Process, researchers can forge a context-specific path towards impactful vaccination communication interventions, one step at a time."

A missed opportunity for vaccination (MOV) refers to any contact with the health system by an individual who is eligible for vaccination but does not receive the doses for which they are eligible. There is a dearth of data on strategies to address MOVs; the few available studies are from high-income countries, which may not be generalisable to other settings. The P-Process is a 5-step plan to design effective public health messaging whose utility has been demonstrated in several public health domains (e.g., HIV, family planning), but its specific application in vaccination communication programmes remains relatively underexplored and under-documented. This paper describes how the P-Process facilitated the design of a multi-pronged communication intervention aimed at enhancing vaccine uptake among hospitalised children in two tertiary hospitals in India and Nigeria.

The P-Process allows teams to design, implement, monitor, and evaluate strategies to address public health issues. It provides a framework to develop a clearly defined strategy that addresses social and behavioural drivers, integrates into existing health delivery systems, and facilitates collaboration with local experts.
 

1. In the Inquire stage (Step 1), the public health problem is assessed through formative and baseline research by analysing local knowledge, attitudes, and practices and reviewing existing data and policies. Insights from this step inform a situational analysis that outlines the problem, causes, and potential solutions.
2. During the Design Strategy stage (Step 2), stakeholders collaboratively develop a strategic plan, deciding on intended audiences, interventions, objectives, communication channels, and implementation plans.
3. In the Create and Test stage (Step 3), stakeholders co-develop and pilot communication materials.
4. The Mobilize and Monitor stage (Step 4) involves deploying communication materials and assessing their effectiveness in real time.
5. In the Evaluate and Evolve stage (Step 5), the impact of the communication efforts is assessed, and results are shared to guide future initiatives and facilitate capacity building.

The process integrates three cross-cutting concepts into each step: social and behaviour change communication (SBCC) theory, stakeholder engagement, and continuous capacity strengthening.

For this study, the steps of the P-Process were carried out in both participating tertiary-care hospitals in Chandigarh, India, and Kano State, Nigeria. 
 

• For the Inquire stage, between August and September 2020, the researchers conducted in-depth interviews (IDIs) with caregivers of hospitalised children to assess barriers to vaccination in a hospital setting.
• In the Design Strategy stage, the researchers developed a blueprint for activities, identifying intended audiences and communication channels and developing implementation plans. While the data collected in Step 1 informed the strategy, they identified the need for two virtual human-centred design (HCD) workshops to further refine the strategic plan. They chose to use virtual platforms to conduct HCD for two reasons. First, this research was conducted during the COVID-19 pandemic, so online gatherings were safer. Second, using web-based platforms to conduct research has been found to be an effective strategy to combat systemic barriers associated with in-person activities - particularly in hierarchical (e.g., hospital) settings - such as power, economic, social, and gender dynamics.
• During the Create and Test stage, the researchers brought together a range of stakeholders to co-develop a communication intervention through HCD workshops, which resulted in two distinct prototypes to motivate routine vaccine uptake among hospitalised children. The team then piloted the materials in both hospitals, where they were used to engage healthcare workers (HCWs) and caregivers (parents) of children, empowering them to make more informed vaccination decisions for children in hospitals. The communication activities addressed misconceptions and barriers that were identified in the Inquire stage by leveraging the identified communication channels. Specifically, communication activities focused on (i) disseminating information to increase awareness for caregivers and educating HCWs on how to communicate new knowledge to caregivers; (ii) improving communication of vaccination status from HCWs to caregivers; (iii) enhancing communication between immunisation workers, physicians, and caregivers to improve vaccination delivery to under-immunised children; and (iv) providing advice to caregivers upon discharge through educational and informational pamphlets.
• In the Mobilize and Monitor stage, the researchers launched the communication and intervention aspects (between December 2020 and January 2021). The research teams held individual and collaborative monthly meetings from initiation through May 2021 to discuss progress, refine materials based on monitoring activities, and prepare for future evaluations.
• In the Evaluate and Evolve stage, the researchers conducted IDIs with HCWs and caregivers to measure outcomes and assess the impact on caregivers' decisions to vaccinate their hospitalised children. Analysis of these interviews revealed that caregivers were discussing their child's vaccination status more frequently while hospitalised and that their vaccination concerns were more regularly addressed. HCWs were more diligent in checking a child's immunisation card and were more willing to vaccinate a child while they were hospitalised. They noted that external aids and specific communication strategies (e.g., stickers or posters) served as consistent reminders to ensure that admitted children were up to date on all vaccines. These results served to qualitatively indicate a post-intervention increase in vaccine uptake among the caregivers and HCWs. The analysis also uncovered gaps: Despite improved communication between HCWs and caregivers, some vaccine hesitancy persisted among caregivers, and some children discharged from the hospital remained under-vaccinated.

By following the P-Process for the design, caregivers reported that many of their concerns about vaccines were alleviated, and HCWs reported that they were able to communicate with caregivers more effectively about vaccination. The P-Process approach may have worked because it faciliated the following:
 

• Designing and implementing contextually relevant strategies using a single methodology: The P-Process methodology allows for strategic, evidence-based, socio-behavioural change initiatives, assisting with driving positive outcomes for communities in different contexts.
• Using research insights as a foundation for programme development: By leading rapid yet rigorous formative research to develop baseline knowledge before designing and initiating communication campaigns, researchers can turn research insights into effective programme ideas before advancing further in the design of a communication campaign or intervention.
• Translating research findings into actionable programme ideas: After completing formative research, researchers can collaborate with local experts to develop specific communication materials and strategies that are more effectively aligned with the needs of the intended audience.
• Maximising impact through evidence-based communication: Implementing activities that are evidence based and made in conjunction with the community have the potential to broadly improve health behaviour. As vaccination decisions are complex - influenced by family beliefs, access issues, community norms, and political influences - engaging deeply with the intended populations to identify barriers and facilitators, actively monitoring progress, and making iterative changes can maximise the impact of communication efforts.

In conclusion: "Leveraging this approach for MOVs in tertiary-care settings was particularly beneficial, as it facilitated an iterative approach to allow for adjustments in response to rapidly shifting beliefs, changing norms, and emerging sources of dis/misinformation - all of which are common in vaccination. Using the P-Process to design iterative communication and intervention activities can enhance the success of future public health initiatives, transforming the landscape of health communication..."