Drivers of Early Childhood Vaccination Success in Nepal, Senegal, and Zambia: A Multiple Case Study Analysis Using the Consolidated Framework for Implementation Research

"The coordination, engagement, and contributions of different stakeholders (e.g., ministries, communities) at all levels is essential to vaccine program intervention."

The use of implementation science frameworks to examine childhood vaccination programmes in countries with high immunisation coverage rates provides an opportunity to identify and describe factors that may have supported effective programmes and childhood vaccination improvements in low- and middle-income countries (LMICs). The Consolidated Framework for Implementation Research (CFIR) is a widely applied framework that includes five domains: intervention characteristics, inner setting, outer setting, individual characteristics, and process. The purpose of this study was to identify critical facilitators and barriers to the implementation of common interventions across three countries that have dramatically increased coverage of early childhood vaccination over the past 20 years, and to qualify common or divergent themes in their success.

The Exemplars in Vaccine Delivery research project focused on how Nepal, Senegal, and Zambia succeeded in achieving catalytic growth in childhood routine immunisation coverage from 2000 to 2019. Details about the overall project and methodological approach can be found at Related Summaries, below. For the present study, qualitative data were collected between August 2019 and April 2021. The researchers conducted 278 key informant interviews and focus group discussions with public health leaders at the regional, district, and local levels and community members in Nepal, Senegal, and Zambia. They examined the CFIR inner setting (i.e., Ministry of Health, or MoH) and outer setting (i.e., external partners and stakeholders) constructs that were related to vaccine service delivery and demand generation. Table 3 in the paper outlines key interventions, programmes, and policies across all three countries, organised by level of implementation.

The researchers found that the common facilitators to programme implementation across the three countries were the CFIR inner setting constructs of:

• Networks and communications: Interventions to foster communication and coordination in all three countries included: (i) frequent meetings to discuss vaccine data, review and identify improvements, and improve data quality; (ii) communication channels between levels of government that support shared ownership of immunisation activities; (iii) micro-planning at district and community levels to align priorities and tailor strategies; and (iv) a clear chain of command that facilitated the flow of information.
• Relative priority: Public health professionals perceived that there was strong political will and commitment by the government to conduct childhood immunisation programming in all three countries.
• Goals and feedback: All three countries had mechanisms for communicating their immunisation goals to ensure feedback was shared across all levels.
• Readiness for implementation: For example, Senegal stakeholders discussed that knowledge is passed from the national level to lower levels through training sessions, modules, and manuals. Some district-level staff reported organising and conducting training for community-level workers.

Outer setting constructs that facilitated implementation included:

• Cosmopolitanism: The extent to which an organisation is connected to external partnerships or networks was instrumental in implementation. For example, at the local level, MoH workers collaborated with religious leaders, schools, non-governmental organisations (NGOs), the media, and community health workers (CHWs) to increase vaccination in all the countries.
• External policies and mandates: External agencies gave guidance to country leaders who needed their support and approval to implement policies or adopt new vaccine technologies.

In sum, critical to the success of these national immunisation programmes were: prioritisation and codification of health as a human right, clear chain of command and shared ownership of immunisation, communication of programme goals and feedback, offering of incentives at multiple levels, training of staff central to vaccination education, the provision of resources to support the programme, key partnerships, and guidance on implementation and adoption of vaccination policies.

The common barriers were:

• Incentives and rewards: A lack of tangible incentives (money and awards to staff), and inconsistent motivation of CHWs were highlighted as barriers in Nepal and Senegal.
• Available resources: Participants at the sub-national level reported a lack of available resources (e.g., human resources), which resulted in consistent barriers across the three countries.
• Access to knowledge and information: There was limited, or infrequent, vaccination training and educational community outreach to all staff, organisations, or partners. Education was sometimes provided to only selected staff, or training information was not disseminated to others in the organisation or partners.
• Patients' needs and resources: Community barriers included families facing economic hardship, a lack of knowledge about childhood vaccination, reliance on traditional healers or medicine, vaccine hesitancy, low literacy, and language barriers. These patient unmet needs were often in context to the country's topography, cultures, and infrastructure.

Table 4 summarises findings categorised by CFIR constructs and country.

The findings from this qualitative investigation have various practical implications for how to enhance the implementation of childhood immunisation programmes:

1. The prioritisation of health or vaccines by ministries or governments and the provision of resources for vaccination programmes, supplies, and workforce at all levels and facilities are essential to vaccine programme implementation.
2. Coordination and engagement of different levels of the country (e.g., MoH, districts/sub-national, and local community) and stakeholders was crucial to public education to increase community demand and rollout of the programmes. Related to this, communication and feedback loops and incentives provided motivation for reaching immunisation goals.
3. Partnership engagement at all public health levels and community stakeholder engagement is critical to the success of these programmes.
4. Incentives were helpful in motivating staff and provinces or regions to improve vaccination rates.

According to the researchers, the application of the CFIR model enabled a comprehensive assessment of implementation context; the use of this framework to assess vaccination programming could be expanded to support adaptation of successful implementation strategies and factors for other countries.

In conclusion: "The shared success factors on immunization across the three countries may have salience in other countries with similar contexts and can inform implementation of vaccine delivery interventions."

Full list of authors, with institutional affiliations: Cam Escoffery, Emory University; Emily Awino Ogutu, Emory University; Zoe Sakas, Emory University; Kyra A. Hester, Emory University; Anna Ellis, Emory University; Katie Rodriguez, Emory University; Chandni Jaishwal, Emory University; Chenmua Yang, Emory University; Sameer Dixit, Center for Molecular Dynamics Nepal; Anindya Bose, WHO Nepal Immunization Preventable Disease Division; Moussa Sarr, Institut de Recherche en Santé de Surveillance Epidemiologique Et de Formation, or IRESSEF; William Kilembe, Center for Family Health Research in Zambia, or CFHRZ; Robert A. Bednarczyk, Emory University; and Matthew C. Freeman, Emory University