key: cord-0306760-itho3kvj authors: Hester, K. A.; Sakas, Z.; Ogutu, E. A.; Dixit, S.; Ellis, A. S.; Yang, C.; Chanda, C.; Freeman, M. C.; Orenstein, W. A.; Sarr, M.; Bednarczyk, R. A. title: Critical interventions for demand generation in Zambia, Nepal, and Senegal with regards to the 5C psychological antecedents of vaccination date: 2022-04-28 journal: nan DOI: 10.1101/2022.04.25.22274035 sha: 6e8484f168a3219404cab70e8fb7c65a82a66401 doc_id: 306760 cord_uid: itho3kvj Introduction: Childhood vaccination is an effective intervention for lowering the burden of infectious disease. Progress was made to increase coverage globally, but vaccine hesitancy and refusal has threatened to erode said increases. The 5C psychological antecedents of vaccination (5C) model provides a validated measure of vaccine hesitancy or confidence to assess individual thoughts and behaviors behind vaccination. Our purpose was to investigate population-level factors that contributed to high and sustained vaccination coverage via interventions in Zambia, Nepal, and Senegal, and alignment with the 5Cs. Methods: FDGs and KIIs were collected at the national, regional, district, health facility, and community levels. We assessed the demand environment, as relayed by participants, and identified interventions that key informants reported as successful for demand generation, then retroactively aligned the interventions with the 5C constructs. Results: Demand was positively correlated with high confidence and collective responsibility. Psychological constraints sometimes impacted demand. Physical constraints created barriers in some communities, particularly difficult to access (i.e., mountainous). Occasionally, physical constraints did not affect vaccination behavior - parents believed the benefits of vaccination worth pursuing. Factors negatively correlated with demand and intent, complacency and calculation, had limited impact. The most critical interventions were: targeted and tailored health education activities (i.e., media partnerships, school outreach); community engagement; community ownership; and involvement of community (i.e., community health workers, leaders, religious figures). Conclusion: We found similar interventions were used to generate demand, and those strategies aligned with the 5C constructs. Categorizing interventions by drivers of demand may help strategic planning and the division of resources; decision makers may choose to implement our suggested interventions. Assessing the 5Cs allows for decision-makers to operationalize demand generation into concrete interventions and policies, and determine the individual impact of these constructs on the population and focus efforts on interventions tailored to a specific need. Group on Vaccine Hesitancy's original 3C model [5] .The scale was validated through two 27 studies; one to correlate psychological constructs with the scale, the other to correlate the scale 28 with vaccination behavior. The resulting scale statistically correlates to vaccination behavior, 29 and was predictive of future intent to vaccinate [5] . This model is considered ideal for assessing 30 vaccination behavior [7-10]. The 5C model was developed with the intent to measure individual level behavior; it is currently 33 unknown how this scale translates to community-level perceptions and activities, including how 34 the government, programmatic, and community behaviors affect vaccination decision-making. Understanding the role of vaccine hesitancy at large may provide insight on the performance of 36 demand generation activities. The purpose of this study was to review interventions that key 37 informant interviewers (KIIs) attributed to increased vaccine uptake in Zambia, Nepal, and 38 Senegal, and assess how these interventions affected the community vaccination behaviors as 39 seen on the 5C model. We observed innovative approaches to generating demand as part of our 40 research in Zambia, Nepal, . Interventions were often implemented from 41 existing global guidelines and further refined to country context [14] . These interventions 42 ultimately utilized constructs seen in the 5C model, and may be useful to other low-and middle-43 income countries (LICs and LMICs, respectively) within similar contexts to address challenges 44 in vaccine uptake. This multiple case study analysis was conducted using data from the Exemplars in Vaccine guides were translated into local languages by research assistants. All interview guides were 75 piloted before use and adjusted iteratively throughout data collection. An initial list of KIIs was 76 developed with local research partners and MoH officials; snowball sampling was used to identify 77 additional key informants. Our sampling approach included a diverse sample of participants in This study was considered exempt by the Institutional Review Board committee of Emory (Federal Assurance No. FWA00000338, REF. No. 166-2019) ; and the National Health Research We found that the 5C's were an effective way to analyze intent and demand generation within our used to generate demand, and these interventions ultimately aligned with all constructs of the 5c 106 model (Table 4) . Key informants from all three countries reported high levels of intent to vaccinate 107 and demand for vaccines among their communities. Demand was positively correlated with high 108 confidence and collective responsibility. Psychological constraints sometimes impacted demand 109 for vaccine, hindering uptake. Physical constraints were barriers in some communities, 110 particularly in those that were difficult to access (i.e., rural or mountainous communities). Occasionally, physical constraints did not affect vaccination behavior -parents believed the In all three countries, the MoH utilized existing channels -including media and schools -to 119 disseminate factual information regarding vaccines. These targeted health education 120 interventions aligned with each construct in the 5C model. Confidence in vaccines was fostered 121 through dissemination of accurate and timely information from trusted sources, and raised the 122 awareness of vaccine benefits. Collective responsibility was maintained by filtering vaccination 123 messaging through societal norms and cultural ties. Complacency was addressed by education of 124 parents and children on immunization and danger of infectious disease. The MoH addressed 125 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 dissemination of vaccination information via strategic partnerships with media organizations and According to key informants, the AJSP developed a "strategic partnership" with the MoH at the 149 national level, and was composed of members from radio, TV, written press, and online media. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 shared a variety of ways -radio being the most prevalent. Each country had unique modalities for 156 media dissemination, such as an online news portal (Nepal), peer-to-peer learning from recorded 157 visits (Zambia), and press caravans -defined as small scale campaigns (Senegal). The education systems in these countries were used to promote vaccination among children -166 either directly or indirectly. In Zambia, completed under-five cards -vaccination cards given at 167 birth for recording vaccination status -were necessary in many communities for enrolling 168 children in schools or registering for final exams. Although these requirements were not 169 consistent, informants did report that under five cards fostered intent to vaccinate among parents. Schools hosted immunization weeks for children to catch-up on vaccinations, and teachers would 171 provide immunization information to both parents and children. Senegal and Nepal directly educated children on disease and vaccines. In both countries, the The MoH in Senegal has collaborated with the MoE since the 1980s, and they produced courses 176 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101/2022.04.25.22274035 doi: medRxiv preprint of the National Education Program. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10. 1101 /2022 Across all sites, respondents spoke to the importance of community actors for the implementation 204 of demand generation activities -including their input on messaging and support for outreach. The MoH leveraged partnerships with community leaders, religious leaders, traditional leaders, CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10. 1101 /2022 In Zambia and Senegal, CHWs provided tailored messaging to communities to encourage and 232 reinforce vaccination. In Senegal, CHW cadres called relais and bajenu gox ("godmothers") were 233 critical to the success of the vaccination program. They sensitized communities several days 234 before vaccine days and checked vaccination cards to assess whether children needed to attend 235 upcoming events. In some cases, they called or texted parents to remind them of vaccination days. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101/2022.04.25.22274035 doi: medRxiv preprint recruited on an ad-hoc basis by community-based organizations and trained on-the-job as 362 temporary solutions to address health disparities [35, 36] . Similar to Senegal, elderly CHWs in 363 Japan are specifically recruited for their homogeneity, trustworthiness, and years of experience 364 in a community to increase overall involvement and effect of health promotion activities [39, 40] . CHWs can be utilized to reach populations facing vaccination barriers and increase rates [41, 42] . One recent study identified potential benefits of CHW-led interventions to increase influenza Not all constructs were directly transferrable at a population level as currently described in the 5C 375 model. For example, population level demand had improved alignment with constraints once we 376 separated it into two subcategories -physical constraints and psychological constraints. When 377 looking at physical constraints separately, we determined that for some communities, access did 378 not affect demand; in fact, parents' demand for vaccines was high enough to make physical 379 barriers, such as traveling long distances or waiting long periods, worth pressing through to 380 protect their children from diseases. We theorize this difference may be explained by the LMIC 381 status of Nepal, Senegal, and Zambia, and recommend that further use of the 5C model in 382 LIC/LMIC settings have the constraint construct separated into these distinct sub-categories. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 Our findings highlight that a population level assessment of the constructs in the 5C model can case study of Zambia 2000 to 2018 . medRxiv, 2021 : p. 2021 Nepal Demographic Health Survey 2001 , 2006 , 2011 , 2016 , 2017 496 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 /2022 CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 /2022 doi: medRxiv preprint Confidence "Trust in (i) the effectiveness and safety of vaccines, (ii) the system that delivers them, including the reliability and competence of the health services and health professionals, and (iii) the motivations of policy-makers who decide on the need of vaccines [5] ." "The willingness to protect others by one's own vaccination by means of herd immunity. The flip side is the willingness to free ride when enough others are vaccinated. Collective responsibility should correlate positively with collectivism, communal orientation, and empathy. It should correlate negatively with individualism [7] ." Complacency "Perceived risks of vaccine-preventable diseases are low and vaccination is not deemed a necessary preventive action [5] ." Physical constraints include the "physical availability, affordability and willingness-to-pay, geo-graphical accessibility, ability to understand (language and health literacy) and appeal of immunization service affect uptake [5] ." Psychological constraints deal with access and "a lack of perceived control [7]". Calculation "Individuals' engagement in extensive information searching. We assume that individuals high in calculation evaluate risks of infections and vaccination to derive a good decision [7]." Commented [HKA1]: @Yang, Chenmua can you add citation #7 here? . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 28, 2022. Easy access to vaccines; religious and cultural leaders promote vaccination. Constraints may vary by geography, particularly those in hard-to-reach mountainous areas or during the rainy season Barriers include long distances to health facilities and competing priorities; constraints may vary by geography and region but do not always affect uptake as parents will sometimes persist through barriers to ensure child is vaccinated Supply chain improvements; health post expansion; context specific adaptability to community availability in rural areas Constraints differ by province and geographyincludes long distances to health facilities, poor transportation, and poor infrastructure. Does not always negatively affect uptake; parents sometimes persist through barriers to ensure childhood vaccination Context specific adaptability to community availability in rural areas supply chain improvements; health post expansion Uncertainty, information searching, and cost-benefit calculations. High trust in government and vaccine information; FCHVs are highly regarded community members FCHVs for community level health information; Media partnership with MoH; Education via FCHVs/CHWs, schools, media; online news portal Believe and trust in information provided by government and community-based organizations CHWs for community level health information; Media partnership with MoH; Education via CHWs, schools, media Trust in media and government; may differ by province and social media use CHWs for community level health information; Association of Journalists Media Partnership; press caravans * Definitions adapted from Betsch et. al. 5C psychological antecedents of vaccination constructs Table 4 . Application of the 5C model to Nepali, Zambian, and Senegalese context with the associated interventions utilized to raise demand . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 28, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 Role of Vaccine Hesitancy, eHealth Literacy, and Vaccine Literacy in 11 Critical success factors for routine immunization performance: A 21 Open Sciences Framework (OSF) page: Exemplars in Vaccine Delivery Tipping Points for Norm Change in Human Cultures