A qualitative analysis of vaccine decision makers' conceptualization and fostering of 'community engagement' in India

Community readiness and acceptance for the implementation of a novel malaria vaccine among at-risk children in sub-saharan Africa: a systematic review protocol

BACKGROUND

The World Health Organization novel malaria vaccine for at-risk children has the potential to greatly reduce the current malaria burden in sub-Saharan Africa. However, most studies have reported contradictory findings regarding community willingness for the vaccine, which could easily undermine the expected benefits of the vaccine. This study aims to ascertain the current state of community readiness and acceptance for the implementation of a novel malaria vaccine (RTS,S/ASO1) among at-risk children in sub-Saharan Africa, based on available evidence.

METHODS

This study will follow the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol (PRISMA-P) guidelines. Relevant studies will be comprehensively searched from PubMed, ScienceDirect, Web of Science, Google Scholar, and African journals online, in accordance with the Cochrane search guidelines. Two independent reviewers will screen titles, abstracts and full texts of eligible studies based on some specified eligibility criteria. When it is feasible to conduct a meta-analysis, a random effects model will be employed to estimate the common effect due to anticipated high heterogeneity of the data. The effect measure for readiness or acceptance will be reported as a pooled proportion with corresponding 95% confidence interval. Additionally, odds ratios with 95% confidence interval will be estimated to assess factors associated with readiness. These will be presented on a forest plot.

DISSEMINATION PLANS

The findings of the study will be peer-reviewed and published in a scientific journal. Conference presentations will also be made to the different stakeholders in the malaria vaccination campaigns.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered with PROSPERO Registration Number: CRD42023480528.

College leadership decisions and experiences during the COVID-19 pandemic: an elite interview study

OBJECTIVE

This study at a US Native American-serving Nontribal Institution (NASNTI) deeply analyzed collegiate leadership's responses and experiences during the first year of the COVID-19 pandemic.

PARTICIPANTS

Elite interviews were conducted between April and June 2021 with the college president, provost, dean of student engagement, human resources director, and chief of police. Interviewees were purposively selected due to their positions of authority.

METHODS

Each one-hour interview used a semi-structured guide for standardization and was conducted either virtually or in-person while following COVID-19 protocols. The general inductive method was used to identify nodes and categories within the transcripts.

RESULTS

Six nodes (conceptual domains) and 18 categories were identified. Though there was variability in interviewee emphasis, the respondents described the motivations, drivers, and sentiment behind their decision-making in a transparent way.

CONCLUSIONS

NASNTI leadership reported being able to navigate the pandemic by emphasizing transparency and engaging students, while working alongside the community.

Public Engagement as the Fifth Dimension of Outbreak Communication: Public's Perceptions of Public Health Communication during COVID-19 in India

Public health/risk communication is the foremost responsibility of a government during a pandemic. Risk communication aims to educate people, enhance their risk perceptions to help them engage and understand the benefits of compliance with recommendations. The existing legal enforcement of recommendations in India is criticized for failing to influence the public's compliance. While existing research provides conceptual and empirical support in explaining compliance during COVID-19, we note a lack of studies that might bring out country-specific areas of improvement. We argue that value-aligned risk communication is more likely to influence the public's behavioral intentions to adopt the government's recommendations. We employed a triangulation mixed-method study to link risk communication attributes to the public's end goals and values. We triangulate these findings using the COVID score survey. We found that timeliness and transparency constitute risk communication's functional component, and empathy and trust constitute risk communication's emotional component. We found a difference in the preference of functional and emotional components among the public and health partners. Irrespective of this divide in perception, the study found that both groups unanimously noted engagement as the crucial aspect for empowerment and involvement to aid the public in teaming with the government to combat the pandemic effectively.

Caregiver perceptions of the broader societal benefits of vaccination: A path toward sustainable vaccine advocacy in India

Over the last decade growing public health evidence suggests that, in addition to health-related benefits, there are also social and economic benefits of vaccination. Research to understand how caregivers in low-and-middle-income countries perceive these social and economic benefits, or if these benefits factor into their vaccination decisions for their children, has been limited. Leveraging qualitative strategies to gain more nuanced insights into caregiver perceptions of vaccination benefits has also been significantly underexplored. We conducted in-depth interviews with 13 caregivers of children, at which point we reached saturation, in Mewat District, Haryana, an area in India with low vaccination coverage. Interview results suggest that caregivers of children associate positive health outcomes with vaccination programs, and some additional social and economic benefits beyond improved health outcomes. Caregivers also shared how local advocacy and gaps in vaccination programs can affect their perceptions of vaccination benefits. Qualitatively exploring the perceived benefits provides a unique understanding of the value that caregivers assign to vaccination and complements existing knowledge on factors that dissuade caregivers from vaccination. These insights will allow researchers to better identify and design context-specific advocacy strategies to strengthen vaccination programs in communities with low vaccine uptake and acceptance.

Designing a Pro-Equity HPV Vaccine Delivery Program for Girls Who Have Dropped Out of School: Community Perspectives From Uttar Pradesh, India

India experiences a substantial burden of cervical cancer and accounts for nearly one third of cervical cancer deaths worldwide. While human papillomavirus (HPV) vaccines have been introduced subnationally in some states, HPV has not yet been rolled out nationally. Given the target age group, schools are the most common delivery channel for HPV vaccines, but this fails to account for local girls who never attended or no longer attend school. We conducted a qualitative, design-informed, community-based study conducted in Uttar Pradesh, India. We assessed facilitators and barriers among out-of-school girls and proposed program characteristics to inform the design of pro-equity HPV vaccine delivery programs for out-of-school girls. Programs should improve parental knowledge of the risk of cervical cancer, engage vaccinated girls as vaccine champions, utilize varied media options for low-literacy populations, and ensure that HPV vaccine services are accessible and flexible to accommodate out-of-school girls. In areas with poor or irregular school attendance among adolescent girls, HPV vaccine coverage will remain suboptimal until programs can effectively address their needs and reach this priority population. Our findings present a meaningful opportunity for program planners to purposefully design HPV vaccination programs according to these parameters, rather than modifying existing programs to include HPV vaccine. Adolescent girls, their parents, and other community members should be involved in program design to ensure that the program can effectively meet the needs of adolescent girls who are not in school.

Communication lessons learned from the 2017 measles–rubella campaign in India: perspectives from vaccine decision-makers

In 2017, to reduce the burden of measles and rubella, a nation-wide measles–rubella campaign was launched in India. Despite detailed planning efforts that involved many stakeholders, vaccine refusal arose in several communities during the campaign. As strategic health communication and promotion is critical in any vaccine campaign, we sought to document lessons learned from the 2017 MR campaign from a strategic health communication and promotion perspective to capture lessons learned. To inform future campaigns, we conducted in-depth interviews through a perspective that is not usually captured, that of government and civil society stakeholders that had experience in vaccine campaign implementation (n = 21). We interviewed stakeholders at the national level and within three states that had diverse experiences with the campaign. Three key themes related to strategic health communication and promotion emerged: the importance of sensitizing communities at all levels through relevant and timely information about the vaccine and the vaccine campaign, leveraging key influencers to deliver tailored messaging about the importance of vaccines and mitigating vaccine misinformation rapidly. Our study findings have important implications for health communication and promotion research related to vaccine campaigns. The field must continue to enhance vaccine campaign efforts by identifying important health communication and promotion factors, including the importance of sensitization, trusted messengers that use tailored messaging and mitigating misinformation, as vaccine campaigns are crucial in improving vaccine acceptance.

A policy analysis of policies and strategic plans on Maternal, Newborn and Child Health in Ethiopia

Significant progress has been made to advance Maternal, Newborn and Child Health (MNCH) in Ethiopia. Further, the country has enshrined equity as a core value in their strategic and development frameworks and policies. Although national statistics show improved health outcomes, there exists persistent inequities in avoidable health risks and premature deaths. Additionally, the improving health statistics mask the disparities in health outcomes based on education, employment status, income level, gender and ethnicity dimensions.

The EquiFrame framework was used to assess the extent to which equity was entrenched in MNCH health policies and plans. The framework, which describes core concepts against which health policies and plans can be assessed, also provides a scoring criterion for policy assessment. The framework was modified to include the concept of intersectionality, which is increasingly gaining significance in the health policy ecosystems. The policies and plans reviewed in this analysis exercise were selected based on (1) their relevance – only policies and plans in force as of the year 2020 were considered; (2) availability in the public domain as this study was limited to desk research; and (3) relevance to MNCH. A total of five policies and plans were analyzed and evaluated against the 15 core concepts presented in the modified EquiFrame framework. Following the outcomes of the assessment, documents were ranked as either being low, moderate, or high, in exhaustively addressing the core concepts.

The Ethiopia Health Sector Transformation Plan (2016–2020) is the only policy or plan that earned a high ranking. The other four policies and plans were ranked as moderate. This shows that while majority of the Ethiopian health sector policies and plans exist and address the core health equity concepts, they fail to: (i) spell out plans to implement and monitor the proposed interventions; and (ii) demonstrate evidence that the interventions were implemented or monitored. With the global goal of leaving no one behind, future policy development in Ethiopia needs to prioritize equity considerations in order to enhance the ongoing health improvement.

Monitoring and Evaluation of National Vaccination Implementation: A Scoping Review of How Frameworks and Indicators Are Used in the Public Health Literature

An effective Monitoring and Evaluation (M&E) framework helps vaccination programme managers determine progress and effectiveness for agreed indicators against clear benchmarks and targets. We aimed to identify the literature on M&E frameworks and indicators used in national vaccination programmes and synthesise approaches and lessons to inform development of future frameworks. We conducted a scoping review using Arksey and O’Malley’s six-stage framework to identify and synthesise sources on monitoring or evaluation of national vaccination implementation that described a framework or indicators. The findings were summarised thematically. We included 43 eligible sources of 4291 screened. Most (95%) were in English and discussed high-income (51%) or middle-income (30%) settings, with 13 in Europe (30%), 10 in Asia-Pacific (23%), nine in Africa (21%), and eight in the Americas (19%), respectively, while three crossed regions. Only five (12%) specified the use of an M&E framework. Most (32/43; 74%) explicitly or implicitly included vaccine coverage indicators, followed by 12 including operational (28%), five including clinical (12%), and two including cost indicators (5%). The use of M&E frameworks was seldom explicit or clearly defined in our sources, with indicators rarely fully defined or benchmarked against targets. Sources focused on ways to improve vaccination programmes without explicitly considering ways to improve assessment. Literature on M&E framework and indicator use in national vaccination programmes is limited and focused on routine childhood vaccination. Therefore, documentation of more experiences and lessons is needed to better inform vaccination M&E beyond childhood.

Integrating Telepsychiatry Into Rural Primary Care for Upstream Prevention: Feasibility Case Study of the Faith Net Program

Introduction

For decades, there has been a deficit of mental health services in rural areas of the United States. Beyond that longstanding need, the COVID-19 pandemic has reportedly increased the prevalence of unmet mental health needs among adults. Presently, many non-critical but urgent mental health concerns are first identified in rural emergency departments. This report describes the results of a 6-month feasibility case study of a program to integrate telepsychiatric triage “upstream” from emergency departments in rural primary care.

Methods

At routine primary care encounters in a single midwestern rural county, patients at risk for moderate-severe or severe depression, expressing thoughts of self-harm, or otherwise presenting in a way that raised clinical concern for mental or behavioral health, were referred to on-site telepsychiatric triage. Patients whose triage indicated further concern were provided six psychiatric and/or social work encounters for stabilization and treatment.

Results

68 patients were referred to telepsychiatric triage during the pilot study (.85% of the estimated adult population in the county). Of those, only two had a documented mental/behavioral health diagnosis prior to triage, but 46 were diagnosed with at least one psychiatric disorder during the program.

Conclusions

This model of telepsychiatric triage was feasible in rural primary care and may support identification and mitigation of unmet mental health needs.

Attitude towards COVID 19 vaccines and vaccine hesitancy in urban and rural communities in Tamil Nadu, India - a community based survey

BACKGROUND

Effective and safe COVID 19 vaccines have been approved for emergency use since the end of 2020 and countries are actively vaccinating their people. Nevertheless, hesitancy towards the vaccines exist globally.

OBJECTIVES

We conducted this study to understand the attitudes towards COVID 19 vaccines and hesitancy to accept it among urban and rural communities in Tamil Nadu, India.

METHODS

We conducted a community based cross sectional study in urban and rural communities among 564 persons who had not been vaccinated yet, selected through multistage random sampling. The vaccine attitude scale (VAX) was used to measure attitudes towards the vaccines and their acceptance of the vaccine was captured by responses to a direct question.

RESULTS

More than 50% of the respondents had positive attitudes towards the COVID 19 vaccines. Based on their attitudes, they were segmented into four clusters, first with preference for natural immunity compared to vaccines and low concern regarding adverse effects. Second with high level of trust in vaccines and low mistrust. The third cluster members had high level of concern regarding the adverse effects and low levels of mistrust in vaccines and the fourth had high trust in vaccines and low preference for natural immunity. Older individuals with higher education and occupation were more likely to belong to cluster four with high trust in the vaccines. Younger individuals, women, rural residents, belonging to low income labourer class were highly mistrusting of the vaccines. The prevalence of vaccine hesitancy was 40.7% (95% CI - 36.67 - 44.73%), while 19.5% (95% CI = 16.23 - 22.77%) of the respondents were vaccine deniers. While vaccine acceptance was greatest in cluster 1, it was least in cluster 3.

CONCLUSIONS

Vaccine hesitancy was high in urban and rural Tamil Nadu. The population could be effectively segmented into groups based on their attitudes and this understanding can be used to develop targeted behaviour change communication campaigns.

Perceived enablers and barriers of community engagement for vaccination in India: Using socioecological analysis

BACKGROUND

There is high level policy consensus in India that community engagement (CE) improves vaccination uptake and reduces burden of vaccine preventable diseases. However, to date, vaccination studies in the country have not explicitly focused on CE as an outcome in and of itself. Therefore, this study sought to examine the barriers and enablers of community engagement for vaccination in India.

METHODS

Employing qualitative methods, twenty-five semi-structured elite interviews among vaccine decisionmakers' were triangulated with twenty-four national-level vaccine policy documents and researcher field notes (December 2017 to February 2018). Data collected for this study included perceptions and examples of enablers of and barriers to CE for vaccination uptake. Concepts, such as the absence of formal procedures or data collection approaches related to CE, were confirmed during document review, and a final convening to review study results was conducted with study respondents in December 2018 and January 2019 to affirm the general set of findings from this study. The Social Ecological Model (SEM) was used to organize and interpret the study findings.

RESULTS

Although decisionmakers and policy documents generally supported CE, there were more CE barriers than facilitators in the context of vaccination, which were identified at all social-ecological levels. Interviews with vaccine decisionmakers in India revealed complex systemic and structural factors which affect CE for vaccination and are present across each of the SEM levels, from individual to policy. Policy-level enablers included decisionmakers' political will for CE and policy documents and interviews highlighted social mobilization, whereas barriers were lack of a CE strategy document and a broad understanding of CE by decisionmakers. At the community level, dissemination of Social-behavioral Change Communication (SBCC) materials from the national-level to the states was considered a CE facilitator, while class, and caste-based power relations in the community, lack of family-centric CE strategies, and paternalistic attitude of decisionmakers toward communities (the latter reported by some NGO heads) were considered CE barriers. At the organizational level, partnerships with local organizations were considered CE enablers, while lack of institutionalized support to formalize and incentivize these partnerships highlighted by several decisionmakers, were barriers. At the interpersonal level, SBCC training for healthcare workers, sensitive messaging to communities with low vaccine confidence, and social media messaging were considered CE facilitators. The lack of strategies to manage vaccine related rumors or replicate successful CE interventions during the during the introduction and rollout of new vaccines were perceived as CE barriers by several decisionmakers.

CONCLUSION

Data obtained for this study highlighted national-level perceptions of the complexities and challenges of CE across the entire SEM, from individual to systemic levels. Future studies should attempt to associate these enablers and barriers with actual CE outcomes, such as participation or community support in vaccine policy-making, CE implementation for specific vaccines and situations (such as disease outbreaks), or frequency of sub-population-based incidents of community resistance and community facilitation to vaccination uptake. There would likely be value in developing a population-based operational definition of CE, with a step-by-step manual on 'how to do CE.' The data from this study also indicate the importance of including CE indicators in national datasets and developing a compendium documenting CE best-practices. Doing so would allow more rigorous analysis of the evidence-base for CE for vaccination in India and other countries with similar immunization programs.

Healthcare Provider Attitudes toward the Newly Developed COVID-19 Vaccine: Cross-Sectional Study

Background: During the long wait and the global anxiety for a vaccine against COVID-19, impressively high-safety and effective vaccines were invented by multiple pharmaceutical companies. Aim: We aimed to assess the attitudes of healthcare providers and evaluate their intention to advocate for the vaccine. Methods: This was a cross-sectional study conducted in a tertiary private hospital where an electronic survey was distributed among healthcare providers (HCPs). The survey contained two sections: socio-demographic characteristics and Likert-scale perception, with 72% internal consistency. Results: The response rate to the email survey was 37% (n = 236). In addition, 169 (71.6%) of respondents were women, with more than half (134, 56.8%) aged ≤35 years. A total of 110 (46.6%) had over 10 years of experience, and most of them were nurses (146, 62%). Univariate analysis revealed that older participants significantly accepted and advocated for the new vaccine more than the younger ones. In the multivariate analysis, men were significantly more likely than women to accept and advocate for the new vaccine, as were those with chronic illnesses. Participants with allergy were significantly less likely to accept the vaccine than others. odds ratio (OR) and p-values were 2.5, 0.003; 2.3, 0.04; and 0.4, 0.01, respectively. Conclusion: The acceptance rate for the newly-developed COVID-19 vaccines was average among HCPs. Sex, age, presence of chronic illnesses, and allergy were significant predictors of accepting the vaccine.