Engaging Communities for Increasing Immunisation Coverage

"Our systematically collected evidence (we include a gap map of evidence on this subject) shows that co-management and co-delivery that actively involve communities in project design, implementation, monitoring and evaluation can be a significant factor in achieving success in increasing vaccine coverage." - Jyotsna Puri and Shagun Sabarwal

There is an increasing realisation that communities need to be more than just passive recipients of immunisation services; their involvement in planning and delivery of services can improve demand and potentially affect the quality of services. Funded by the Bill & Melinda Gates Foundation, this International Initiative for Impact Evaluation (3ie) scoping paper focuses on interventions and programmes that lie at the intersection of immunisation and community engagement approaches. It reviews the different types of community engagement approaches that have been used in the immunisation sector and the types of outcome indicators those studies measure and report on. It also highlights that lessons can be transferred to the immunisation sector from community-based approaches that have been used successfully outside of this sector.

Community engagement approaches are defined here as those in which the health system engages or partners directly with beneficiary communities to address both supply- and demand-side factors that would otherwise contribute to under- or non-immunisation. Specific aspects of this definition are: (i) the community is actively engaged, as opposed to being simply a community-based intervention; (ii) both supply and demand are mentioned; and (iii) there is explicit mention of the hardest-to-reach populations.

The paper discusses the role communities can play in not just encouraging demand within communities to take up vaccines and dispel mistrust but also in co-managing and co-delivering immunisation programmes in general. This discussion is relevant considering that distrust of vaccines remains widespread in the world today. In August 2003, a polio vaccination boycott was declared in the five northern states of Nigeria after political and religious leaders argued that the vaccines could be contaminated with anti-fertility agents, HIV, and cancer-causing agents. During the one-year period it took to resolve the boycott, there were polio outbreaks on three continents. This distrust continues in Afghanistan and Pakistan today.

In support of the 3ie evidence programme, Breaking through stagnation: testing innovative approaches to engaging communities in increasing immunisation coverage, the following instruments were used to cover the scope of the study: (i) a rapid evidence gap map that identifies and displays existing studies according to what intervention is evaluated and what outcomes are measured; (ii) a survey of key stakeholders, including implementers and researchers in the field of immunisation; and (iii) semi-structured interviews with key experts in immunisation, to get their views on opportunities in and challenges to increasing immunisation coverage through community engagement approaches.

In developing the gap map, 3ie devised a typology of community engagement approaches to increase immunisation. These interventions are divided into five categories (see Table 1 in the paper for definitions and examples): (i) communication and dialogue, e.g., work with community groups and sensitisation campaigns; (ii) planning and participation, e.g., with community members; (iii) monitoring and accountability, through community tracking; (iv) recognition and incentives, which may be either monetary or non-monetary; and (v) improving service delivery. As shown in Figure 2 in the paper, these different types of interventions tackle different possible weak links in the causal chain. For example, through communication and dialogue, community engagement in planning and participation involves making community members better aware of services and how to access them. Along those lines, most examples of innovative community engagement approaches centred on the involvement of religious and other key leaders. This causal chain highlights the role that communities can play at different stages to improve immunisation coverage. However, 3ie notes that in many cases, uptake of vaccination by beneficiaries may require existing norms be changed. This is especially true in contexts where there are cultural and religious barriers to vaccination. In such cases, sustaining vaccination uptake requires a continued effort to engage communities to inform and alter their norms.

Key findings:

• There is insufficient high-quality evidence that can causally relate changes in immunisation coverage to specific programmes and interventions that use community engagement approaches.
• Community engagement approaches within the field of immunisation are underused; results from the stakeholder survey suggest that communication is currently the most common form of community engagement in immunisation projects.
• Interventions that are co-managed with communities, where communities are actively involved in project design, implementation, monitoring, and evaluation, are likely to be more successful. In community co-managed programmes, a few lessons emerge from experiences in other sectors; these are some suggestions offered in the paper:
  • It is important that community leaders are involved from the beginning. However, the opinion of leaders must not completely govern project design and implementation. In communities that are particularly unequal, elite-capture by authority figures or the majority population is a risk.
  • Although communities can be engaged in monitoring and evaluation, the engagement process needs to be customised. In the context of immunisation coverage, the participatory model may be transferable with clear central guidelines and control functions that are determined and overseen by implementing agencies.
  • There is a need to follow a balanced approach so that local expertise and resources are coupled with external logistical and financial support.
• Contextual factors should inform the design of community engagement approaches; programmes and interventions need to be designed at the community level.
• Implementation and delivery capacity is likely to be a bottleneck: Many responses from expert interviews underscored the need to ensure continuous and consistent engagement for (micro-) planning, awareness creation, and monitoring and surveillance. An overwhelming majority of experts talked about the problems facing beneficiaries at the point where services are delivered. Two main areas where this is likely are: problems with interpersonal communication between the service provider and beneficiaries, and problems related to scheduling, cancellation, and lack of supplies.
• Some technology-based interventions - e.g., mobile technology to help remind parents about the vaccination schedule, especially for vaccines that have a relatively long interval between doses - that are designed to improve service delivery and tailor services that engage communities might work well, but more evidence is needed.

In conclusion: "Professional opinion is that programmes co-managed with the community are more likely to be successful than those that are not. However, what comes out forcefully is that there is currently insufficient evidence. Programmes that use these approaches should at the same time also generate evidence to help pilot, plan, deliver and learn more from their experience."