Community Health Worker-Led Intervention for Vaccine Information and Confidence (CIVIC)

The interventions for the project were co-designed by the research team and community iteratively. This strategy was used to strengthen the decision-making power of community members, learn from their problem-solving skills, and ensure that the interventions would be tailored to the specific needs of the population. As faith leaders represent a key resource in building vaccine confidence in the community, organisers explored their perspectives regarding vaccines and engaged them to partner with local health workers in promoting messages of best practices with regard to both routine immunisation and COVID-19 vaccines.

CIVIC used a combination of broadcast, print, and social media sources to disseminate vaccine messaging from faith leaders in an effort to improve community-level vaccine awareness and acceptance. The intervention consisted of a three-E approach:

1. Exploration of community perspectives regarding vaccines and identification of specific barriers to vaccine acceptance: The project began with a series of formative interviews with 10 community members and 10 CHWs. Next, two virtual human-centred design (HCD) workshops were conducted with both these groups. Preliminary data indicated that faith leaders are one of the most trusted sources of information in the community. To facilitate faith leaders' involvement in the intervention, the research team approached 10 (male) faith leaders in the area. Initial conversations revealed that the faith leaders themselves had several doubts and questions about vaccines; thus, they were hesitant to promote vaccines among their communities.
2. Establishment of vaccine trust and awareness among faith leaders: To address faith leader concerns regarding vaccines and boost their confidence with advocating for their uptake in the community, the research team facilitated a series of discussions and feedback with the faith leaders spanning a 6-month period (January-July 2021). The two approaches used to connect with the faith leaders and build their trust were: (i) informal knowledge-sharing sessions, where faith leaders to comfortably share their concerns, and (ii) enabling interactions with healthcare providers. While the informal sessions reassured the faith leaders of the positive impact of vaccines on child health outcomes and long-term community health, they were unsure of how their involvement could benefit vaccine acceptance. Therefore, the research team facilitated interactions between faith leaders, CHWs, and other health professionals, including representatives from polio campaigns. Evidence shows that faith leaders played a major role in polio eradication in India by countering faith-based hesitancy through community engagement, especially in the neighbouring state of Uttar Pradesh. These interactions enabled the faith leaders to learn more about these success stories, motivating them to actively participate in the CIVIC project.
3. Engagement in vaccine promotion activities: Collaboratively, the research team, CHWs and other health workers, and the faith leaders designed activities that would provide platforms for the faith leaders to provide information about vaccines to the community in a manner that would ensure reach to the community despite COVID-19-related social distancing norms and in the absence of community gatherings. The two key activities were:
   • Messaging in popular media: Faith leaders, along with other trusted community members (teachers, social workers), spoke in short video messages in which they advocated for vaccines. These context-specific videos were tailored to the needs of the community and used local vernacular to ensure their message was heard and understood. These short videos were leveraged by CHWs in door-to-door communications with caregivers, and they were shared across social media platforms in Mewat. Of these platforms, WhatsApp was a particularly popular mode of circulating this video. The messages from these videos were also discussed over broadcasting media channels such as the local station Radio Mewat. Further, print articles highlighting these messages and the CIVIC project were published in five local news outlets spanning English, Hindi, and Urdu language papers.
   • Participation in the Community Accountability Board (CAB): The CAB consisted of 10 members, with one Hindu faith leader and two Muslim faith leaders (Maulanas). They met virtually via video conferencing platforms every month to discuss progress of the CIVIC Project, make changes to the project's intervention aspects as needed by the community, and discuss other health issues in Mewat. Through engagement in monthly meetings, the CAB offered a platform for the faith leaders to continue to share concerns, perspectives, or misconceptions observed from their congregations, as well as to identify effective means to address these with other CAB members.

According to organisers, the involvement of faith leaders in the CAB, as well as other aspects of the intervention, facilitated trust in vaccination in Mewat.

Immunisation and Vaccines

While vaccine coverage has been increasing in India, inequities abound, especially in populations with historically low vaccine confidence. The COVID-19 pandemic has led to major disruptions in delivery of routine immunisation services for children. In Mewat, low rates of vaccine coverage have been a longstanding obstacle to health improvement. According to data from the National Family Health Survey (NFHS-5, 2019), 53.8% of children between the ages of 12-23 months were reported to be fully vaccinated with Bacille Calmette-Guerin (BCG), measles, and three doses each of polio and diphtheria, pertussis, and tetanus (DPT) vaccines. This value lags far behind the national average of 76.4% and falls short of the World Health Organization (WHO) goal of reaching 80% coverage for all vaccines in national programs for every district, as per the Global Vaccine Action Plan (GVAP).

Previous research exploring community perceptions of vaccination in Mewat has highlighted several factors that limit vaccine acceptance, such as fear of side effects, low education levels, poor communication with CHWs, and religious factors. However, according to the research team, through CIVIC, community members who expressed distrust in vaccines and were skeptical about the potential side effects felt reassured by seeing a faith leader they recognised and respected support vaccines via the video. Disseminated via social media, the video was also helpful in motivating mothers, their husbands, and their families to understand the benefits vaccines offer. Leveraging WhatsApp to share the videos reportedly aided CHWs' communications with caregivers, inspiring willingness to receive vaccines for themselves and their children.

Lessons learned include:

• It is essential to involve faith leaders in a sensitive, consistent, and long-term manner. Their comprehensive role in not only the advocacy efforts but also in the formative research, design and dissemination of interventions, and follow-up activities to improve vaccination proved to be a fruitful investment for CIVIC and may be impactful in future work.
• The creation and involvement of faith leaders in the CAB meetings provides a long-term platform for community members and faith leaders to continue to engage on vaccine and other health-related issues beyond the duration of the project. These CAB meetings can develop community accountability and ensure long-term sustainability of CIVIC interventions.
• To ensure long-term sustainability, it is important for the interventions to be context specific and feasible with resources accessible to the community.
• Going forward, exploring and enabling the involvement of women religious leaders in community decisions pertaining to health would be beneficial.