A User-Centered Approach to Developing a New Tool Measuring the Behavioural and Social Drivers of Vaccination

"To develop effective vaccine delivery programmes and monitor intervention impact, vaccine programme implementers need to understand reasons for under-vaccination within their local context."

Globally, children remain unvaccinated for many reasons, including hesitancy, cultural norms, and logistics and supply issues. The World Health Organization (WHO) Working Group on the Behavioural and Social Drivers of Vaccination (BeSD) is developing standardised tools for assessing childhood vaccine acceptance and uptake that can be used across regions and countries. The tools will include: (i) a validated survey available in long and short form that provides measures of demand and acceptance; (ii) qualitative interview guides; and (iii) user guidance to support the deployment of these tools in various settings worldwide. In keeping with the user-centred approach to product or process development, this paper reports the detailed needs assessments of the envisaged end users of the BeSD multi-component tool.

This prospective, descriptive, multi-country study involved 20 qualitative interviews (April - August 2019) with purposively sampled vaccine programme managers, partners, and stakeholders from the United Nations Children's Fund (UNICEF) and World Health Organization (WHO) country and regional offices. The interviews focused on:

• The systems and practices currently in use for collecting vaccine-related data, and the challenges faced - Participants described a variety of settings, data systems, and frequencies of vaccination attitude measurement. They reported that the majority of data used is quantitative, and there is appetite for increased use of qualitative data. Participants discussed a range of difficulties in collecting and using data. Cultural and political sensitivities were reported to hinder how the data are reported and used, which impeded advocacy for change. Also, capacity for conducting BeSD studies was lacking in some jurisdictions. To address this, some interviewees reported training local researchers to deploy surveys in a culturally acceptable way (e.g., utilising interviewers of a certain religion or gender), some trained local researchers to translate surveys written in a national language into the local dialects as needed, and others reported bringing in external researchers and pairing them with local social mobilisers.
• Reflections on the proposed BeSD tools - Participants expressed a need for the tools to focus on healthcare worker perspectives, the practical and social or cultural factors affecting vaccine uptake, the specific reasons for vaccine refusal, and data that is standardised enough to enable comparison between jurisdictions. When asked about what they felt the tools should include, among other things, participants highlighted the importance of awareness of the different ways that vaccine decisions are made in various cultures, as well as the fact that individual-centred questions might not be useful in all settings. Almost all participants discussed the need to modify or adjust the tools for local settings.

The researchers incorporated the interviewees' input into their development and refinement of the BeSD tools, such as by translating the survey and interview guides into all six UN languages and by incorporating qualitative interview guides in the package for healthcare workers, as well as community advocates and other immunisation stakeholders. As of this writing, the BeSD tools were in the early stages of field testing across several countries and languages. Learnings from these experiences are systematically reviewed and evaluated to inform iterative modifications to the tools and the suggested processes for their implementation.

In conclusion, this study has illuminated the challenges faced by immunisation programme managers, partners, and stakeholders in obtaining and utilising good-quality BeSD data. It also serves as an illustration of how a user-centred approach can help develop tools to address global health issues.