Vaccination Demand Hub Meeting Report [2024]

"Intervention measures that are informed by social, cultural and community insights impact behavioural change. Such interventions can increase vaccine confidence, knowledge and ultimately improve vaccine uptake."

Data indicate that vaccine confidence significantly declined during the COVID-19 pandemic. Demand generation is a key component of overall strategies to engage communities and increase uptake of services, particularly among under-immunised groups. The Vaccination Demand Hub - a global interagency collaboration between immunisation partners working on vaccine acceptance and demand - convened its third face-to-face global meeting (April 16-18 2024, Kathmandu, Nepal). This report shares highlights from the gathering, which brought together 83 participants from 9 countries in the South Asia and East Asia and Pacific regions to discuss demand-related enabling actions and to identify opportunities for increasing demand and strengthening linkages between global, regional, and country-level work.

In opening the meeting, Dr. Ephrem Tekle Lemango, Associate Director of Immunization, United Nations Children's Fund (UNICEF), and Rita Rhayem, Head Equitable Immunization Programmes, Gavi, provided global context, followed by regional immunisation updates from UNICEF Regional Office for South Asia (ROSA) and the World Health Organization (WHO) South-East Asia Regional Office (SEARO). Country panel discussions followed, with government counterparts from India, Indonesia, and Pakistan. Deepa Risal Pokharel presented an overview of the Demand Hub, with workstream leads providing details and resources of each workstream in world café style. Countries then shared experiences in technical plenary sessions and formed working groups to identify priorities and potential actions for their respective countries to improve vaccine uptake and catch up to restore routine immunisation (RI) and reach zero-dose communities. (See the report for details from each of the 9 countries.)

Across the 3-day meeting, the participants shared their challenges and opportunities in implementing demand promotion and social and behaviour change (SBC) for immunisation strategies in their countries. They organised their insights in 7 thematic areas:
 

1. Zero-dose and catch-up - selected discussion highlights:
   • COVID-19 containment and lockdown led to non-conduct of outreach sessions, resulting in a fall in immunisation coverage.
   • Increased workload on health workers was compounded by stigma.
   • In India, the use of behavioural insights for design of human-centric solutions and periodic behavioural and social drivers (BeSD) of change surveys are outlined as the evidence for way ahead in strengthening demand for RI. Other key actions include increasing community engagement through civil society organisations (CSOs) by strengthening microplanning through community participation, designing and implementing of effective SBC and gender-responsive interventions, and increasing advocacy for community monitoring and social accountability for immunisation.
2. Social behavioural data - selected discussion highlights:
   • Vaccine-related knowledge gaps and misconceptions persist in communities.
   • A mother's autonomy and attitude about family vaccination play dominant roles in RI. Family norms, education and income status, and as the ease of accessing vaccines are other drivers impacting RI.
   • People fear side effects and financial implications of treating potential adverse impacts from vaccination.
   • Identifying community behaviour is crucial to addressing the vaccination gap.
   • Appropriate intervention measures should be developed based on data generated through continuous monitoring and collection of behavioural data.
   • Activities such as listening to health workers, strengthening linkages between health workers and communities, and developing the capacity of health workers and peer-to-peer learning can lower the barriers to immunisation.
3. New vaccine introduction (human papillomavirus, or HPV) - selected discussion highlights:
   • A detailed plan with specific guidelines and strong government commitment are crucial for the success of a new vaccine programme. Including the HPV programme within the fold of existing national vaccination systems will facilitate the vaccine roll out.
   • Governments can be persuaded to support an HPV programme by presenting a strong evidence-based case drawn from the country data on the prevalence of cervical cancer.
   • Reaching out to schoolgirls is a credible path to ensure the success of an HPV programme. Yet, equal emphasis should be placed on reaching out-of-school girls, who can be immunised at private clinics.
   • High public trust is key to demand formation. Health workers, teachers, parents and faith leaders can be engaged to create demand for vaccination.
   • Communities can doubt the HPV vaccine, citing possible adverse impacts on fertility and misconception that the HPV vaccine may be seen as encouraging girls' sexual activity. Health workers, teachers, and community leaders should be trained to dispel any rumours or negativity surrounding the vaccine.
   • A robust communication strategy is required to dispel doubts and misunderstanding on HPV. Multiple channels, including print and online mediums, can be engaged to create vaccine demand. A hotline to answer any queries on HPV vaccination can benefit demand promotion efforts.
4. Service experience - selected discussion highlights:
   • High-quality facilities and outreach services, with a positive service experience, result in positive outcomes. Vaccination services should be affordable and accessible, and health workers should be well informed about vaccination schedules, timing, and clients' potential questions, worries, and information needs.
   • Strong motivation of health workers/volunteers yields positive results. They need supportive facility/work environments, willpower and the means to travel to remote areas, and sufficient time to provide services and maintain records of their clients.
   • A functional mechanism should be established to ensure RI and full vaccination (e.g., a vaccination card or a home-based record). Use of text messages, mobile phone calendars, and/or community mobilisers can help inform and remind caregivers. Information, education, and communication (IEC) materials should be designed and developed in local languages to overcome communication barriers.
   • Women and girls in some communities are hesitant to receive vaccines in an open place, so vaccination sessions and health workers should respect individuals' privacy and information needs. Infrastructure of a healthcare facility also affects the service experience, so gender-related concerns also need to be addressed.
   • Imparting SBC communication (SBCC) and interpersonal communication (IPC) training to health workers helps to improve service experience. India shared the example of 'BRIDGE' IPC training, which is complementing other health worker training strategies in immunisation skills and service quality, such as the e-learning 'RISE' phone app.
   • Feedback from the beneficiaries is key to improving the service experience. Key informant interviews with service providers, service appraisal systems, and client exit interviews can be instrumental for improving the overall service experience.
5. Social listening and digital engagement - selected discussion highlights:
   • Social listening with knowledge on how to use online and offline data is important to design effective interventions. End users should get the messages at low or no cost.
   • Increasing digital literacy of communities helps them to identify misinformation. Insight reports generated by the social listening mechanisms should be used to inform and correct the course of interventions and strategies.
   • Media often spread rumours highlighting side effects of vaccines. There should be preparedness to dispel such rumours. Countries need to develop a fact-checking mechanism to counter misinformation, which can be facilitated by maintaining a close relationship with social influencers and by mobilising them when necessary. Contents of digital information should be appealing and easy to digest.
   • Misinformation should be traced and tackled outright. Presenters shared an example of how Pakistan conducted a field visit and persuaded a person airing misinformation to withdraw the misleading video. Indonesia erased vaccination hoaxes through capacity development of its health workers and by mobilising young people.
6. Community engagement - selected discussion highlights:
   • Field plans should be revised to align with the community engagement strategy, which is requires a commitment to continually identifying the needs and problems of people. A multi-sectoral approach of data collection such as inquiry from service providers, caretakers, social influencers, and household surveys can be helpful.
   • Providing incentives to health workers and volunteers, and increasing their capacity building in raising awareness of community on vaccination, eases access to zero-doze children.
   • The main objective of the human-centred design approach is to deepen the understanding of barriers and opportunities to vaccine uptake and to co-create local solutions with communities. Developing this approach requires a concerted effort of people representing public health, social behavioural scientists, designers, and communicators.
   • A human-centric community engagement strategy should prioritise marginalised populations, such as migrant communities and zero-dose communities. It should also address the difficulties (caste/gender-based barriers) of marginalised communities.
7. SBC in fragile settings - selected discussion highlights:
   • Advocacy and orientation to various groups in a community and social influencers yield positive results. Likewise, mobilising religious leaders and health workers in SBC campaigns has positive impacts. Specifically, IPC by social mobilisers, religious leaders, and community influencers in religious/social gathering places, schools, and health facilities has been found to be effective.
   • Mass media such as radio and TV are helpful in launching SBC campaigns. Engaging digital platforms can also produce positive results.
   • Tailored SBC campaigns can be designed by incorporating the experiences of frontline health workers, who are active in areas of vaccine hesitancy or areas that have witnessed disruptions in essential immunisations.
   • Understanding the educational status of parents, as well as the underlying cultural norms, myths, beliefs, and rumours that discourage positive behaviour related to vaccination, is important. Reaching out to hesitant parents is crucial.

Following the 3-day meeting, participants recommended that more opportunities be offered for countries to learn through collective sharing of best practices and other resources through the Vaccination Demand Hub workstreams. They also requested technical clinics in the areas of human-centred design, service experience, zero-dose and catch-up, HPV and social listening, and digital engagement. To improve coordination, the Demand Hub will respond collectively to the countries to ensure the identified challenges, priorities, and needs are addressed.