The Role of Community Mobilization in People's Healthcare-seeking Behavior during the COVID-19 Vaccination Journey: Select Case Studies from Madhya Pradesh

"This approach allows for the development of a tailored framework that could guide future vaccination campaigns, ensuring they are more community-specific and culturally sensitive."

Various innovations and activities have been initiated in the area of community mobilisation to increase the uptake of vaccinations, as has been seen in the example of polio vaccination in India, among other places. The purpose of this study is to understand the impact of community mobilisation initiatives on citizens' health-seeking behaviour through the lens of COVID-19 vaccination in the state of Madhya Pradesh, India. This study follows a case study approach to understand community mobilisation initiatives that led to increased COVID-19 vaccination uptake.

India has been selected for this study due to its significant and diverse population. The country's vast and varied demographic landscape offers a valuable context for evaluating how community mobilisation impacts different communities across a wide range of socioeconomic, cultural, and geographical settings. This diversity allows for an in-depth exploration of the effects of community-driven health initiatives in adapting and responding to local needs and challenges. In addition, Madhya Pradesh's well-established public health infrastructure and network of community health volunteers are crucial for implementing and assessing health campaigns, making it a promising model for understanding community mobilisation's effects on health initiatives and informing broader national and global strategies.

Thirty-four semi-structured interviews were conducted online with purposefully sampled multiple stakeholders, with 6-9 interviews for each of the four districts that were selected. These stakeholders represented officials with roles and responsibilities related to community engagement in the COVID-19 vaccination campaign in Madhya Pradesh.

The four districts involved in the study, with rationale for selection and selected results, are as follows:

• Indore district: Rationale: It had the highest COVID-19 first-dose coverage (100%) and the highest urban composition. Summary of findings: The effective coordination and implementation of community efforts in the form of crisis management groups, community leaders, and the private sector enhanced vaccination coverage. The district administration brought all the departments together, which led to seamless planning and implementation. Information was disseminated through community mobilisers such as Accredited Social Health Activists (ASHAs) and Anganwadi workers, printed banners at vaccination sites, special jingles related to COVID-19 vaccination, and social media. To ensure equitable access, "Nari Tikakaran Kendra" (women's vaccination centres) for females was planned. A control room was established to receive calls from the public related to the COVID-19 vaccination process and for regular follow-up post-COVID-19 vaccination.
• Harda district: Rationale: It transformed over time and showed the highest improvement in COVID-19 vaccination coverage among other districts. It has a high forest cover. Summary of findings: Persuading the Harda district locals to vaccinate, especially in the tribal and rural areas, was a difficult task. Moreover, Harda did not show the expected coverage performance during the initial stages; however, it started to perform the following measures that were taken to resolve the challenges. Officials took steps to localise information, education, and communication (IEC) materials and communication strategies, and the local administration deployed mobilisers and local volunteers who were familiar with the local dialect to mobilise the community. Forest staff, Anganwadi workers, ASHAs, and government teachers were involved in the awareness campaigns, such as "Chaupal" (village public space) meetings that were conducted to raise people's awareness about the COVID-19 vaccination and encourage them to be vaccinated. "Jan Bhaagidari", which is a people's participation model in the form of collective efforts by the district leadership, administration, vaccination teams, community leadership, and volunteers, led to the success of COVID-19 vaccination in Harda.
• Dindori district: Rationale: It showed consistent COVID-19 coverage performance throughout the vaccination programme and has a high tribal population (signifying the presence of different sets of social and cultural norms). Summary of findings: The population was vaccine hesitant in the initial phase of vaccination. There was misinformation that only COVID-19-affected people should be vaccinated. In addition, people were skeptical about the side effects of vaccination. Dindori overcame the challenges with innovations and community involvement. Various initiatives were adopted to mobilise the people, including announcements at places with high footfall and crossroads, neighbourhood meetings, the use of banners and posters, city cable advertisements, "Nukkad nataks" (street shows), and the use of the local language for interpersonal communication with the people. Localised techniques using traditional customs and community-led campaigns made Dindori's vaccination coverage consistent with a focus on equity and measures to reach one and all.
• Datia district: Rationale: It showed consistent COVID-19 coverage performance throughout the vaccination programme and comprises both urban and rural populations. Summary of findings: At the beginning of the vaccination process, people were reluctant to be vaccinated. During the second wave of the COVID-19 pandemic, various myths prevailed among the people. However, as information gradually filtered through, and with the involvement of people from different sectors and communities, as well as the adoption of local initiatives, the hesitancy started to decrease. The community mobilisers and administrative staff adopted a transition approach in which people were not directly approached to vaccinate; instead, people were first made aware of the benefits of vaccination and inspired to vaccinate. Only thereafter were they directly approached to vaccinate. The challenges encountered in mobilising the urban and rural communities were different. In rural areas, local solutions were devised to plan sessions and mobilise beneficiaries. In urban areas, factors such as local leadership, support of businesspersons and community leaders, and use of social media facilitated the COVID-19 vaccination process. District administration focused on generating trust in the government health system.

A cross-case analysis was also performed to identify the common and distinguishing factors among the four districts. It is based on interviewees' ranking of the impact of key factors in the categories of "high", "medium", and "low". Based on this analysis, an overall framework was proposed (see Figure above) to understand the role of the key components that influenced community mobilisation in these four districts.

For example, although various media (print, TV, social media, etc.) of communication were utilised in the vaccination campaign, most of the interviewees pointed to the impact of in-person communication, which indicates that human relationships still play an important role in influencing people. They also observed that a message delivered by a known person (with credibility in the community) was more effective in convincing the community because of the trust local influencers could generate.

In short, the study highlights the key components of community mobilisation that were adopted: the involvement of local leadership (at district, block, and village level), support of vaccination/mobiliser teams, the role of in-person communication, involvement of influential community heads and social workers, localised strategies and IEC materials, and support from the state administration.

Among the implications of the study: Related to the domain of social and public health programmes and behavioural change in communities, the study highlights how different factors influence the behaviour of people and how community mobilisation can influence this behaviour.

The researchers conclude that community mobilisation, led by key influencers and thematic activities, is essential, especially in times when public fear of the virus diminishes and the perceived urgency for vaccination wanes. The fluctuation in community willingness to engage with health interventions underscores the necessity for ongoing, effective communication strategies that deliver accurate health information and maintain public engagement.

They hope that the findings of this study will help the policymakers and practitioners in the domains of health and medical humanities, health policy and services, and social sciences to clarify the roles of community mobilisation activities and initiatives in increasing vaccination coverage. Furthermore, the study provides evidence for the adaptation, integration, and enhancement of these activities based on the four case studies discussed.