INTRODUCTION: Vaccination averts an estimated 2-3 million deaths annually. Although vaccine coverage improvements across Africa and South Asia have remained relatively stagnant and below global targets, several countries have outperformed their peers with significant increases in routine immunization coverage. Examining these countries vaccination programs provides an opportunity to identify and describe critical success factors that may have supported these improvements. METHODS: We selected three high-performing countries in regard to childhood vaccination: Nepal, Senegal, and Zambia. This multiple case study analysis was conducted using data from the Exemplars in Vaccine Delivery project within the Exemplars in Global Health program. We used qualitative analysis to investigate factors that contributed to high vaccination coverage through key informant interviews (KIIs) and focus group discussions (FGDs) at the national, regional, district, health facility, and community levels. We triangulated these findings with quantitative analyses using publicly available data, which are published elsewhere. RESULTS: Our data revealed that the critical success factors for vaccine programming relied on the cultural, historical, and statutory context in which the interventions were delivered. In Nepal, Senegal, and Zambia, high immunization coverage was driven by 1) strong governance structures and healthy policy environments; 2) adjacent successes in health systems strengthening; 3) government-led community engagement initiatives; and 4) adaptation considering contextual factors at all levels of the health system. CONCLUSION: Throughout the study, our analysis returned to the importance of defining and understanding the context, governance, financing, and health systems within a country, rather than focusing on any one intervention. This paper augments findings from existing literature by highlighting how contextual factors impact implementation decisions that have led to improvements in childhood vaccine delivery. Findings from this research may identify transferable lessons and support actionable recommendations to improve national immunization coverage in other settings.

Critical success factors for high routine immunization performance: A multiple case study analysis of Nepal, Senegal, and Zambia

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.

Critical interventions for demand generation in Zambia, Nepal, and Senegal with regards to the 5C psychological antecedents of vaccination

Objective Senegal has demonstrated catalytic improvements in national coverage rates for early childhood vaccination, despite lower development assistance for childhood vaccines in Senegal compared with other low-income and lower-middle income countries. Understanding factors associated with historical changes in childhood vaccine coverage in Senegal, as well as heterogeneities across its 14 regions, can highlight effective practices that might be adapted to improve vaccine coverage elsewhere. Design Childhood vaccination coverage rates, demographic information and health system characteristics were identified from Senegal’s Demographic and Health Surveys (DHS) and Senegal national reports for years 2005–2019. Multivariate logistic and linear regression analyses were performed to determine statistical associations of demographic and health system characteristics with respect to childhood vaccination coverage rates. Setting The 14 administrative regions of Senegal were chosen for analysis. Participants DHS women’s survey respondents with living children aged 12–23 months for survey years 2005–2019. Outcome measures Immunisation with the third dose of the diphtheria-tetanus-pertussis vaccine (DTP3), widely used as a proxy for estimating immunisation coverage levels and the retention of children in the vaccine programme. Results Factors associated with childhood vaccination coverage include urban residence (β=0.61, p=0.0157), female literacy (β=1.11, p=0.0007), skilled prenatal care (β=1.80, p&lt;0.0001) and self-reported ease of access to care when sick, considering travel distance to a healthcare facility (β=−0.70, p=0.0009) and concerns over travelling alone (β=−1.08, p&lt;0.0001). Higher coverage with less variability over time was reported in urban areas near the capital and the coast (p=0.076), with increased coverage in recent years in more rural and landlocked areas. Conclusions Childhood vaccination was more likely among children whose mothers had higher literacy, received skilled prenatal care and had perceived ease of access to care when sick. Overall, vaccination coverage is high in Senegal and disparities in coverage between regions have decreased significantly in recent years. 

pdf/factors-associated-with-vaccine-coverage-improvements-in-3ioscsvdyj.pdf

Factors associated with vaccine coverage improvements in Senegal between 2005 and 2019: a quantitative retrospective analysis

Background: Understanding past successes in reaching unvaccinated or “zero-dose” children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. Methods: Focusing on 2000–2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential ‘exemplars’, demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called “neighborhood analyses” were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. Results: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions—national prevalence and subnational gaps—while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. Conclusions: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children—especially across variable contexts and different drivers of inequality—could support faster, sustainable advances toward greater vaccination equity worldwide.

/pdf/assessing-potential-exemplars-in-reducing-zero-dose-children-eraqtmbf.pdf

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children

pdf/critical-success-factors-for-high-routine-immunization-1yrhb5rn.pdf

Critical success factors for high routine immunization performance: A case study of Senegal

Rural communities are vital to the foundation of American agriculture and are currently disproportionately affected by health and environmental challenges that will require broad scientific solutions. Cooperative Extension professionals and agricultural communicators are increasingly tasked with communicating about the science surrounding these topics and need effective tools for determining strategic communication tactics to influence personal behaviors. The purpose of this study was to understand the role of community-based social marketing (CBSM) concepts and trust in science on rural Americans’ intentions and attitudes toward the COVID-19 vaccine. A hypothesized model was developed that included concepts of CBSM, trust in science, intentions, and attitudes all related to the COVID-19 vaccine. Results showed that CBSM principles had significant explanatory power for predicting intentions to receive the COVID-19 vaccine. CBSM and trust in science were also significant predictors of rural Americans attitudes toward the COVID-19 vaccine. Implications for this study reveal a need for future research and practice related to communicating about science and vaccines to rural Americans while building community-based principles for increasing trust and advancing perceptions of science. Future research should determine the impact of CBSM and trust in science on the end-state behavior of receiving the vaccine. Additionally, Extension professionals and agricultural communicators should prioritize CBSM concepts when developing programming and messages related to health behaviors. 

pdf/rural-redemption-a-model-to-help-understand-the-perspectives-337de483.pdf

Rural Redemption: A Model to Help Understand the Perspectives of Rural Americans Related to Vaccine Science

The UF/IFAS Center for Public Issues Education in Agriculture and Natural Resources (PIE Center) conducted a series of national public opinion surveys to examine the perceptions of Americans related to COVID-19. The PIE Center conducted four surveys with ~1,500 Americans per survey from mid-March 2020 to January 2021. The surveys sought to understand Americans’ perceptions of a range of topics including health and communication concerns, vaccination perceptions and acceptance, mask understanding and willingness, and compound disasters and stress. Presentations in this panel highlight key areas of research from this survey series and share how communicators can use this research to craft campaigns to effectively reach Americans during COVID-19 and future public health crises.

Public Opinion in a Pandemic: Four Surveys Conducted with Americans throughout the COVID-19 Pandemic

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Critical success factors for high routine immunization performance: A case study of Senegal

Rural Redemption: A Model to Help Understand the Perspectives of Rural Americans Related to Vaccine Science

Public Opinion in a Pandemic: Four Surveys Conducted with Americans throughout the COVID-19 Pandemic