Embedded research: An innovative approach to improving immunization rates

8 June 2018

When it comes to creating change – whether it’s at an individual, institutional or even systems level – it can be a complex process and a challenging task. Usually, there are many competing factors that work both for and against the desired change. And while it might be possible to change something in the short-term, it can be difficult for those changes to be sustained in the long term.

There have been many attempts to figure out an approach that works – especially an approach that can bring research and evidence to the table when making decisions about key policies or activities.

The benefits of embedded research

To that end, there have been increasing calls for embedding research in complex health systems and decision-making processes, whereby decision-makers and implementers work with researchers to understand better the specific challenges they are facing and identify innovative changes that can be made to bring about a desired result. According to a soon-to-be-published review of embedded health policy and systems research, the rationale for such an approach includes:

  • By working together, researchers, decision-makers, and implementers have a better chance of identifying the most relevant and pressing challenges within the health system.
  • The collaboration between these groups closes the ‘gap’ between them by creating understanding and buy-in to the need for research and the complexity of decision-making processes for creating and sustaining change.
  • A process of learning and iteration can help to continuously improve the health system to reach established goals and targets.

In that spirit, the Alliance for Health Policy and Systems Research and UNICEF, supported by Gavi, the Vaccine Alliance, recently hosted a number of decision-makers and researchers from around the world to share their experiences in embedding research within health systems. The focus of the projects was on strengthening routine immunization programmes and services and improving immunization coverage in the locations where the projects were undertaken. And while they may have shared a similar objective, the embedded research approach led to a huge diversity of context-specific problems and innovative solutions to addressing them.

Immunizing nomadic communities in Chad

In Chad, for example, the project focused on expanding immunization services to nomadic communities in one district. And here, the problem was stark: in some communities, immunization rates were higher among cows than children. The research focused on identifying effective strategies to reach nomadic communities. It revealed that there were several reasons why nomadic communities were not accessing the vaccination services, chief among them was an incorrect assumption that the vaccines would be costly. Using this information, the implementers and researchers developed a tailored communication strategy to address these incorrect assumptions that was found to be effective. It was then incorporated into the immunization programme. The implementers and researchers also explored the use of joint human and animal vaccination services, an approach that had been employed by the polio campaign to achieve high levels of polio coverage, and discovered that if the strategy were fully taken up, it would cost approximately 60% of the district’s entire health budget. Thus, this strategy was not feasible without navigating these financial challenges.

Creating dialogue and action cycles in Nigeria

In Nigeria, the focus was on establishing dialogues between communities, health providers, and local government to create action plans for improving immunization services in an area with a high number of unimmunized children. Because of these dialogue and action cycles, immunization coverage in the area increased from 61% to 91%. Not only did these dialogues improve immunization rates, but they also strengthened overall service delivery at the local health center by reintroducing key services and creating greater accountability. The research is now being disseminated to national decision-makers and may be used to inform the integration of the dialogue and action cycles in areas experiencing low immunization coverage as a part of the routine immunization strategy.

Combatting online misinformation in India

In Kerala state in India, they faced an entirely different challenge: how to deal with dropping immunization rates in certain communities because of the proliferation of misinformation through social media? Their research found that many of the health workers in the state were not equipped to respond to the critiques and concerns about vaccines raised in these social media posts. The educational material produced by the state only focused on the positive side – the benefits of immunization. Because the research was led by the government, they were able to begin drafting new educational materials and campaigns to discredit the claims made in the social media posts.

What's next for embedded research?

That the challenges discovered in these different contexts and the recommended changes are so varied points to one of the strengths of embedded research. Instead of presenting a one-size-fits-all model, embedded research offers the flexibility to remain responsive to the needs and realities of different contexts and health systems. While it is still early days for these studies, we are excited by the innovative solutions proposed and the level of change in the health systems that they have brought about. The questions now are can these changes be sustained and is this an approach that can work for a greater range of topics and across more diverse contexts.