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

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.