Vaccines have been one of the most effective public health measures for preventing and controlling infectious diseases. However, despite the availability of vaccines, many people in low and middle-income countries are not fully protected due to several reasons, such as limited access to vaccines, limited access to vaccination centre/outreach clinic, lack of awareness of the importance and benefits of the vaccine and misconceptions about the safety and efficacy of vaccines. Integrating vaccine promotion and delivery into existing hygiene behaviour change programmes can be an effective approach to addressing this gap.

Hygiene behaviour change programmes are crucial for improving public health by addressing the underlying determinants of diseases, such as poor hygiene, unsafe water, and inadequate sanitation. By integrating vaccine promotion and delivery into existing hygiene behaviour change programmes, we can leverage existing resources, infrastructure, and community networks to promote and deliver vaccines to the target population.

This learning brief will explore lessons learned and recommendations towards effectively integrating vaccine promotion and delivery within existing hygiene behaviour change programmes. We reflect on the importance of integrating hygiene behaviour change and vaccine programmes and the use of behaviour change frameworks before providing an overview of key lessons and action points followed by a more in-depth look at each lesson.

The brief aims to provide practical guidance to water, sanitation, hygiene (WASH) practitioners, behaviour change specialists, policymakers, and donors on how to effectively integrate vaccine promotion and delivery into their programmes to improve vaccination coverage and, ultimately, public health.

The brief draws on experiences of COVID-19 responses from insights that have been gained through programming funded by the Hygiene and Behaviour Change Coalition, other sectoral initiatives on integrating vaccine into the existing hygiene programme from individuals working within the WASH sector and a desktop review of the pandemic response.

Other Hygiene Hub resources that may be of interest include:

Integration of vaccines with key public health interventions is a central component of WHO's Immunization Agenda 2030 framework. This approach capitalises on the relatively high immunisation coverage in many countries compared to other healthcare initiatives, making it an effective foundation for additional interventions. Childhood immunization schedules involve regular, well-defined contact points during a child's first year of life, followed by further visits during their second year, school age, and adolescence. Hygiene behaviours are intrinsically linked to immunisation, as they can help alleviate the burden of infectious diseases targeted by vaccines. Furthermore, incorporating hygiene behaviour change programme interventions into vaccination programmes can enhance the cost-effectiveness of health interventions and offer mutual benefits, maximising the impact of resources and efforts dedicated to public health.

Knowledge alone does not always change behaviour, as behaviour change is a complex phenomenon, influenced by an array of physical, social, and cognitive determinants. Therefore, behaviour change programmes should be embedded in a behaviour change framework, such as Behaviour Centred Design. For more information on types of frameworks, see our resource on what works to change behaviour.

The Behavioural and Social Drivers of Vaccination (BeSD) framework is a Behaviour Centred Design framework that supports the design of effective, context-specific interventions through systematic exploration of the behavioural and social drivers and barriers of vaccination. This BeSD framework is further supported by the following WHO position paper. Below we explore some specific ways in which the framework can support the integration of vaccine promotion and uptake into hygiene behaviour programmes.

1) Identify behavioural and social drivers of vaccination: The first step in using the BeSD framework is to identify the behavioural and social drivers of vaccination in the target population. This can be done through data collection (pre-existing and new), including surveys, interviews, observation, focus group discussions to assess the behavioural determinants. The BeSD framework helps identify key drivers, such as motives, knowledge,

attitudes, beliefs, social norms linked to behaviours, social support, access to healthcare, power relations, public hesitancy, access to services and or products etc., that can influence vaccine uptake

2) Tailor interventions to specific drivers: Once the key drivers of vaccine uptake have been identified, interventions can be tailored to address specific drivers. This can be done through a creative process with a multi-disciplinary team to design context specific behaviour change interventions that integrate both hygiene behaviour change and vaccine programmes. For example, if perceived vaccine safety is a barrier to uptake, interventions should focus on using assets highlighting the vaccine safety, motivational content showing benefits of the vaccine for all target groups. If the access to vaccination site is a limiting factor, a mobile clinic and or pop-up vaccination site in a specific location can be mobilised. If social norms and support are important drivers, interventions can be designed to engage community leaders and influencers to promote vaccination.

3) Use behaviour-centred design principles: The BeSD framework is rooted in behaviour-centred design principles, which focus on designing interventions that are user-centred, making it emotional, empathetic, and contextually appropriate. This means that interventions should be designed with the needs, preferences, and beliefs of the target population in mind which can be implemented at scale in future. From the outset interventions should also consider the cultural and social context in which the target population lives and interventions should engage with social norms linked to the specific behaviours.

4) Consider the role of hygiene behaviour change programmes in vaccine uptake: Hygiene behaviour change programmes can play an important role in promoting vaccine uptake by improving access to healthcare, creating a supportive environment for vaccination, and addressing health inequalities. Interventions can be designed to leverage hygiene behaviour infrastructure and services to promote vaccination by incorporating vaccine content (motivational information) into hygiene behaviour programmes. The interventions need to be delivered in such a way that it can reach a diverse population, multiple times, with a repeated frequency. Interventions should mitigate fatigue as much as possible.

5) Evaluate intervention effectiveness: As with any intervention, it is important to evaluate the effectiveness of vaccine promotion and uptake interventions that are designed using the BeSD framework. This can be done through monitoring vaccine uptake rates, tracking changes in behaviour, knowledge, social norms, attitudes, and beliefs, and gathering feedback from the target population. It can be done cross sectionally, longitudinally and or setting-up a specific research design.

In the following sections, we will explore key lessons for integrating vaccine promotion and hygiene behaviour change programmes.

Community engagement is crucial when integrating vaccine promotion and delivery with hygiene behaviour change programmes. The engagement of communities is essential to ensure that vaccines are accessible to all, to build trust and that individuals and families are informed about the benefits of vaccination, as well as the risks of not being vaccinated. Below we explore why engagement is crucial and how it can be strengthened.

1) Builds trust and increases participation: Community engagement builds trust between healthcare providers and community members. It increases the likelihood that community members will participate in vaccination campaigns and encourages them to follow public health guidelines. Trust can be built using famous, non-controversial characters into behaviour change assets such as print, mass and digital media that include celebrities, sports personalities and comedians etc.

2) Provides valuable feedback: Engaging communities allows healthcare providers and or hygiene promoters to receive feedback on vaccination and hygiene promotion campaigns. This feedback can help healthcare workers and or hygiene promoters to identify areas for improvement and refine vaccination and hygiene campaigns to make them more effective.

3) Increases awareness and level of motivation: Community engagement increases awareness about the benefits of vaccination and the risks of not being vaccinated. It can help address misinformation and rumours that can discourage individuals from getting vaccinated. A well facilitated community engagement session will also increase the level of motivation to make use of services.

4) Addresses barriers to vaccination: Community engagement allows healthcare providers to identify and address barriers to vaccination. For example, if transportation is an issue for some community members, healthcare providers can work with community leaders and other response actors (e.g., NGOs) to identify transportation options to vaccination sites and or conducting mobile vaccination clinics in remote areas to ensure easy access to the vaccine.

What are some of the ways in which we can strengthen community engagement?

1) Involve community leaders in vaccine promotion and delivery efforts: They can help disseminate information about vaccines to community members and encourage participation in vaccination campaigns. Community leaders can also co-lead hygiene behaviour demonstrations during vaccination e.g., demo of handwashing with soap and water and can encourage their community to get the vaccine through role modelling by being publicly observed in receiving the vaccine.

2) Use local media: Use local media outlets such as radio stations, newspapers, and social media to promote vaccination and hygiene campaigns. Ensure that information is presented in a local language that is easily understood by the community.

3) Partner with community-based organizations: such as religious institutions (mosques, churches, temples), and community centres to promote vaccination campaigns. These organizations can help disseminate information about key behaviours and vaccines to community members.

4) Conduct community outreach: to engage a two-way conversation with community members about the benefits of vaccination and preventative hygiene behaviours and address concerns they may have.

5) Address language barriers: by providing information about vaccines in multiple languages. This ensures that all members of the community can access information about vaccines. For people with different needs, it is also important to produce the information in accessible formats.

6) Strengthening capacity: to healthcare providers, hygiene promoters, and community members about vaccine safety and efficacy. This helps to build trust, increased participation in vaccination campaigns and empowered to represent, ask, and answer questions in community and health settings.

Partnership with local government is crucial in the integration of vaccine promotion and delivery into existing hygiene behaviour change programmes, as governments are responsible for the implementation of national health policies, regulations, standards, and promotional health programmes. Therefore, engaging with governments can help ensure that vaccine promotion and delivery is conducted effectively and efficiently together with hygiene behaviour change interventions, whilst simultaneously strengthening the sustainability and resilience of programmes.

Why are partnerships with local government crucial upon integration of vaccine promotion and delivery with hygiene behaviour change programmes?

1) Policy, standards, and guideline development: Governments play a critical role in developing policies and guidelines that govern vaccine delivery and hygiene promotion. By collaborating with governments, organizations can ensure that their programmes align with national policies, standards, and guidelines. In order for health workers and or hygiene promotors to promote hygiene and vaccine uptake, they must be equipped with the endorsed policy, standard and or guideline which can then be consistently applied across the intervention areas.

2) Supply chain management: Governments are responsible for managing the vaccine supply chain, which includes procurement, storage maintaining cold chain, transportation, and distribution of vaccines. Collaboration with governments can help ensure that vaccines are available and delivered on time to the target populations.

3) Health worker personnel and capacity: Governments are responsible for resourcing and training health workers who promote hygiene as well as uptake and administer vaccines. Collaborating with governments can help organizations ensure that health workers are resourced effectively and efficiently (equipped with personal protective equipment and salaries), and are trained in how to conduct hygiene sessions, vaccine administration, safety, and monitoring.

4) Monitoring and evaluation: Governments are responsible for monitoring and evaluating the effectiveness of hygiene and vaccine programmes. Collaboration with governments can help organizations ensure that the program is being monitored effectively and evaluated accurately. These national systems also strengthen sustainability and resilience, as it provides data and insights that can be used to improve and adapt future routine immunization programmes.

5) Funding: Governments often play a central role in funding for hygiene and vaccine programmes. Collaborating with governments can help organisations secure funding for their programmes and ensure that the funds are used effectively.

Integration coupled with a creative mindset is necessary for the design and delivery of vaccine promotion and uptake with hygiene behaviour change programmes to overcome challenges such as lack of infrastructure and products, poor access to healthcare, and vaccine hesitancy.

What are some of the ways we can integrate creative approaches?

1) Microplanning: involves conducting a detailed assessment of the target population, their needs, and existing infrastructure. It can help identify gaps and develop targeted strategies to improve vaccine delivery.

2) Community health worker training: Community health workers can be trained to provide vaccines, promote hygiene, engage communities and convey information and or answer questions about vaccine safety and efficacy, preventative hygiene behaviours and thereafter promote vaccine uptake. See the following case study from Kenya that presents an overview of the Leap mHealth learning platform; a phone-based learning platform to facilitate remote training of CHVs on COVID-19. The platform uses simple text messages and Interactive Voice Recordings (IVR) to provide community health volunteers with information and two-way dialogue about COVID-19.

3) Mobile clinics and or pop-up vaccination sites: can be used to bring vaccines to hard-to-reach areas in order to reach remote communities and or can be set up in high-traffic areas such as urban transport hubs, markets and community centres to increase vaccine accessibility.

4) Technology-based approaches: such as SMS reminders, mobile apps, and telemedicine can be used to improve vaccine delivery and tracking.

5) Innovative communication strategies: such as social media campaigns, radio programmes, and community engagement events can be used to address vaccine hesitancy and misinformation.

6) Partnerships with the private sector: can be used to leverage their expertise and resources to support vaccine promotion and delivery, together with hygiene promotion. For example, pharmaceutical companies can help with vaccine distribution, and telecommunication companies can provide technology-based solutions. Product promotion such as soap promotion platforms can be used for the vaccine offer too.

Vaccine equity must be a priority in the integration of vaccine promotion and delivery into existing hygiene behaviour change programmes to ensure that everyone, regardless of their background, beliefs, or perceptions, has access to life-saving vaccines.

How can we increase vaccine equity?

1) Identify and prioritize underserved communities: One way to promote vaccine equity is to identify and prioritize populations and contexts that may be vulnerable to exclusion and discrimination. Specific groups will differ contextually, but might include people from minority groups, indigenous populations, older people, carers and people with disabilities, people with pre-existing conditions and women and girls. People in hard-to-reach areas, camps and camp-like settings and rural areas might also be disproportionately affected. Once identified, outreach efforts can be tailored to these communities, such as by partnering with community-based organizations to promote hygiene and include vaccine information. See our resource on defining vulnerability and our learning brief on identifying who may be vulnerable for further guidance.

2) Provide accessible and convenient vaccination and hygiene promotion locations: In addition to targeting underserved communities, it is important to provide accessible and convenient locations for both vaccination and hygiene promotion. This can be achieved by setting up clinics (vaccination and hygiene promotion) alongside community centres, schools, or places of worship. Outreach and mobile clinics can also be used to reach people who have limited access to healthcare facilities. People coming to receive the vaccine can attend a hygiene session, and vice-versa. A case study from Kenya, Nigeria, and Uganda describes the development of a COVID-19 vaccine facility locator to help people easily find vaccination centres. This tool was developed in response to the need for accurate and up-to-date information on vaccination availability and accessibility. Oxfam in Lebanon through their community perception tracker tool learned that Syrian refugees viewed the cost of transportation to and from the vaccine centre as a barrier to access the vaccine and some refugees were unable to read or fill in the online vaccine platform to register for the vaccine. Consequently Oxfam, a local partner and health authorities supported the refugees either with paying transportation costs, helped entering their details via the vaccine online platform and or activated mobile clinics.

3) Address vaccine hesitancy: Vaccine hesitancy is a major barrier to achieving vaccine equity. To address this, it is important to provide accurate and accessible information about vaccines, addressing concerns and misconceptions. Trusted community influencers, such as religious leaders, teachers, youth and women’s groups, can be engaged to help build trust in the vaccine and the vaccination process. In Cape Town, vaccine delivery teams identified that young men were particularly resistant to COVID-19 vaccination. In response, pro-vaccination murals targeted at young men, were painted by local artists on community walls in high-traffic areas. These murals were supported by pop-up clinics at each site.

4) Provide support for vaccine delivery: Integrating vaccine delivery with existing hygiene behaviour change programmes can help to ensure that vaccines are administered efficiently and effectively. This can include providing training for healthcare providers on vaccine administration, as well as support for vaccine supply chain management.

5) Monitor and evaluate vaccine equity: Monitoring and evaluation of vaccine equity is critical to ensure that vaccines are distributed fairly and efficiently. This can be done by tracking vaccine coverage by demographic factors such as age, gender, and geographic location. Additionally, feedback from communities on their lived experiences with vaccine promotion and delivery can help to inform program improvements and to counter vaccine hesitancy in communities.

6) Address language and cultural barriers: Addressing language and cultural barriers can help to ensure that all members of the community have access to accurate and relevant information about vaccines. This can be done by providing information in multiple languages, as well as by engaging trusted community members (women’s groups, youth groups, schoolteachers, religious leaders, community leaders etc) to help translate and disseminate information.

7) Address infrastructure and technology barriers: In some communities, infrastructure and technology barriers may prevent people from accessing vaccines. Addressing these barriers may involve setting up telehealth or virtual vaccine appointments or providing transportation to vaccination locations.

Effective communication is an essential element in the successful integration of vaccine promotion and delivery into existing hygiene behaviour programmes. Communication is crucial to ensure that people understand the importance of vaccines and the role they play in maintaining good health. This can be achieved by using various communication strategies, such as identifying trusted touch points and/or delivery channels including persons and or institutions, risk communication and community engagement (RCCE), social marketing and behaviour change communication. For an exploration of digital and mass media approaches, see our learning brief here.

How can we strengthen communication?

1) Embed and use behavioural change frameworks: To understand behavioural determinants in a specific target population and, based on the results, one can co-design interventions to positively change behaviours.

2) Use clear and concise local language: Communication materials should use simple and clear in local language to ensure that everyone can understand the information being presented. The use of technical jargon should be avoided, and information should be communicated in a way that is culturally appropriate.

3) Engage the community: The involvement of the community in the vaccine promotion and delivery process is critical. Risk communication and community engagement (RCCE) can be achieved by working with community and religious leaders and organizations, holding community meetings and workshops, and involving local health workers. This approach helps to build trust and confidence in vaccines and the health system. From the outset, map out who is most likely to be vulnerable (e.g., elderly) in the immediate to long-term and how their vulnerabilities might change over time.

4) Collaborate with stakeholders: Collaboration with stakeholders such as government agencies (vaccine lead), non-governmental organizations, and private sector partners is essential in the successful integration of vaccine promotion and delivery into existing hygiene behaviour programmes. This collaboration helps to ensure that resources are maximized and that efforts are coordinated to achieve common goals.

5) Monitor and evaluate: Monitoring and evaluating the impact of communication efforts is crucial in determining the effectiveness of communication strategies. This process involves collecting data on the reach and impact of communication efforts and using this data to improve communication strategies.

6) Behaviour change through motivation and reactive nudges: Encourage behaviour change using people’s emotions. We know fear is a temporary stimulation hence use affiliation, safety, comfort, nurture emotions. Remind and reinforce behaviours through visual and or verbal cues and nudges – which should be diverse, catchy, and up to date, plus high frequency.

7) Use diverse assets using multiple voices: Successful use of diverse assets using multiple voices can trigger an emotive and motivational narrative to alter behaviours and practices. Save the Children in Pakistan developed bulk voice messaging (BVM) that involved pushing a pre-recorded voice message to people’s phones. The first BVM variation addressed common concerns about the side effects, a second one addressed belief that vaccines are not suitable for pregnant or lactating women and the last addressed religious concerns about the vaccine (i.e., ingredients not being Halal). Diverse assets with multiple voices can increase vaccination uptake in a diverse range of contexts and locations (e.g., remote rural areas) and reach a large number of people.

One of the key lessons learned from integrating hygiene behaviour change interventions into vaccination programmes (and vice versa) is the importance of tailoring strategies to the specific local context. There is no one-size-fits-all approach; having a comprehensive understanding of the context in which the integration will occur is crucial for effective implementation. This involves assessing local barriers to access, social and cultural beliefs, and existing health infrastructure, understanding the right touch points as well as engaging with communities, local leaders, and stakeholders. By adapting interventions to the unique circumstances of each location, it is possible to optimize the efficiency and impact of integrated hygiene behaviour change and vaccination initiatives, ultimately promoting better public health outcomes.

A prime example of this approach is a successful project in Nepal, where formative research was conducted to understand the current routine immunisation system and examined the determinants of hygiene behaviours. The novel approach to hygiene promotion was led by the Ministry of Health and Population with technical and financial support from WaterAid. The pilot ran from February 2016 to June 2017 across four districts and aimed to integrate hygiene promotion into Nepal's routine immunisation programme, coinciding with the planned introduction of the rotavirus vaccine, and identify best practices for scaling up this approach nationwide. The pilot successfully incorporated hygiene promotion through a regular service delivery mechanism and effectively improved hygiene behaviours from 2% during the baseline to 54% after one year of implementation.

Furthermore, integration increased immunisation coverage, lowered drop-out and vaccine wastage rates, and assisted in reaching hard-to-access populations. The success of the pilot led to retention of the programme for another 3 years in the same districts with co-financing from the government. Consistent demonstration of the benefits for both the programme (for behaviour change and vaccine uptake) led the decision to scale up the programme nationwide in 2019, with scale-up formally beginning in July 2020. Since it was launched following the outbreak of the COVID-19 pandemic, the package included the promotion of handwashing, water treatment, food hygiene, clean use of toilet, exclusive breastfeeding. Because of COVID-19 pandemic, the existing hygiene integration into nationwide routine immunization programme also included the COVID-19 sensitive additional behaviours including mask wearing, maintaining physical distancing to address emerging public health challenges.

Key lessons learnt from this project include government engagement and leadership since inception. Formative research findings provided a clear understanding of the setting, the population, hygiene behaviour determinants and mapping of enablers and barriers. This presented the case for the use of emotional, engaging, and surprising hygiene behaviour change interventions.

In contrast, a project in Kenya demonstrated the challenges faced when formative research is not conducted. The project integrated hygiene promotion into routine child immunizations targeting mothers with children under 12 months of age accessing vaccination services. Mothers were provided with a hygiene kit – (soap, WaterGuard sodium hypochlorite to treat household water) and an educational brochure. An evaluation of the project suggests the intervention may have had a positive impact on reported household water treatment, hygiene knowledge, and hygiene behaviour in one of the districts, but not the other. The effect of the intervention on vaccination coverage was less clear. Although implementation and up-to-date vaccine coverage in increased at follow-up in urban areas in one of the districts, there was no change in rural vaccine coverage.

One of the main learnings from the project was the importance of understanding the unique challenges and barriers faced by communities in rural and urban areas through conducting formative research, including a needs assessment.

The Integrated Outbreak Analytics (IOA) approach is highly effective in providing a comprehensive understanding of outbreak dynamics. This method aims to foster a holistic perspective by integrating multidisciplinary data, such as health information systems, environmental data, socioeconomic conditions of the area, community-level context, engagement with healthcare professionals, and existing programmes. The IOA enables Ministries of Health and their partners to compare trends against provincial and national averages, identify potential changes. Additionally, the inclusion of qualitative data can provide deeper insights into the factors influencing changes in health outcomes.

In 2022, the Integrated Analytics cell conducted research through the IOA approach to explore the factors influencing vaccination uptake in the Democratic Republic of Congo. The investigation was carried out after a polio vaccination campaign managed by the Ministry of Health failed to achieve the target coverage of 90%. The analysis provided a deep understanding of the gender, socio-behavioural, and environmental context, that intended to help tailor prevention strategies and improve vaccination coverage during future campaigns. For example, qualitative data showed that decisions related to child health are essentially the responsibility of the mother and only when there is money involved does the father usually intervene. Time and distance were cited as barriers to bringing children to routine immunisation in all health zones. Mothers communicated their preference for either Saturday or Sunday for routine immunization. The study also highlighted that there is limited knowledge about vaccination and the difference between polio and COVID-19 vaccines. Recommendations to inform a plan of action included (but not limited to) capacity strengthening of health workers, engagement of communities to reinforce the polio and COVID-19 vaccine as a means of prevention via radio broadcasts, community group discussions (Q&A sessions), door to door visits, and regular announcements of the polio and COVID-19 immunization plans.

This learning brief was written by Abrar Alasmari (LSHTM – Vaccine Confidence Project). Valuable inputs were also provided by Ana Bolio (LSHTM – Vaccine Confidence Project) Jenny Lamb (LSHTM – Hygiene Hub), India Hotopf (LSHTM – Hygiene Hub) and Fatima Ahmed (LSHTM – Hygiene Hub). External reviews were also provided by Om Prasad Gautam (WaterAid) and Georgia Plank (Vaccine Data CoLab).

The COVID-19 Hygiene Hub is housed at the London School of Hygiene and Tropical Medicine (LSHTM) and developed in partnership with Center for Affordable Water and Sanitation Technology (CAWST) and Wash’Em.

The Hygiene Hub is funded by the Foreign Commonwealth and Development Office (FCDO).

This project was made possible by UK aid from the UK government, however the views expressed do not necessarily reflect the UK government’s official policies.