Module C: Why

Welcome to Module C!

Purpose

This module looks at why immunization rates can be low. It focuses on challenges facing caregivers and the healthcare system, including healthcare workers.

What You’ll Achieve

By the end of Module C, you will:

Discuss the key reasons why the priority communities have low immunization rates.
Identify the main barriers your strategy will address.

What You Need

Room Set-up

Activity #1: Map Immunization Barriers

There are many reasons why children are underimmunized. These reasons come from two sides: the challenges faced by caregivers, family members, and communities, and those linked to the healthcare system, including challenges linked with the capacity and availability of healthcare providers.

Barriers from a caregiver perspective: Caregivers might not know about vaccines, find them too expensive, or face community pressure not to vaccinate.
Healthcare system barriers: Issues like under-resourced healthcare facilities leading to overworked healthcare workers, or clinics being too far away, can make it harder for caregivers to vaccinate their children. They may also have challenges with data.

In this activity, groups will discuss the main reasons children are not vaccinated, focusing on five main types of barriers.

How to Prepare

If you haven’t already, put up the header poster for Module C: Why ****on the main wall.
On each table, ensure every group has one copy of Table Worksheet: Barriers and one set of Double-sided Prompt Cards: Why.

ℹ️ If you identified existing immunization demand strategies or plans in Initial Insights, review any barriers to immunization identified in those existing strategies. Consider sharing these with participants as prompts.

Facilitation Steps

Introduce immunization barriers
Ask participants to stand near the Module C Header Poster: Why.
Explain the barriers clearly, focusing on caregivers and the healthcare system. You can say: “Many things affect whether people vaccinate their children or not. In this activity, we’ll look at why some families don’t vaccinate. We’ll think about problems faced by caregivers and issues in the healthcare system. These problems are grouped into five main types, and we’ll review them together.”
- Vaccine beliefs, knowledge, and feelings include what caregivers know about vaccination, and their thoughts on vaccine safety and benefits. For healthcare providers, this refers to their confidence in giving vaccines and the vaccination process.
- Trust refers to whether caregivers feel confident that the healthcare system and providers will act in their child’s best interest. For healthcare providers, it includes feeling well-trained, supported, and capable of delivering vaccines effectively.
- Community, religious, and gender beliefs are shared ideas and values across people within a community, culture or religion that influence how people think or behave towards vaccination.
- Intention and motivation describe the willingness and plans of caregivers to vaccinate their children when needed. For healthcare providers, this includes feeling valued and supported to stay motivated in their roles.
- Practical barriers and experience of care include logistical challenges such as knowing when and where to get vaccinated, and having a positive experience at the clinic. From the healthcare system perspective, this refers to challenges around accessibility of healthcare services, healthcare data systems, and resources available for healthcare, which can all impact the service experience.
Guide participants to think about the immunization barriers for their priority community
- Back in their groups, ask participants to discuss the barriers their community faces, both from caregivers and the healthcare system.
- Tell groups to read the Double-sided Prompt Cards: Why to understand the five types of immunization barriers and see examples. They should think about which of these barriers exist in their priority community.
- Ask the groups to fill out the Table Worksheet: Barriers.
  - They should write down the barriers found in their community in the relevant boxes on the worksheet, spending 15 minutes on each category of barriers. If they run out of space, get a blank piece of A3 flip chart paper to add more thoughts!
  - If they think of barriers but don’t have data, they should write these in the “Gaps in the Data” box at the bottom of the worksheet.
  - You can show participants the (EXAMPLE) Table Worksheet: Barriers for inspiration.

📝 Ensure each group keeps their Table Worksheet: Barriers and Persona. If possible, keep the workshop room the same overnight or otherwise keep all the materials safe. Ensure you take a photo of each group’s work.

▲ End of Day 1 (suggested)

▼ Start of Day 2 (suggested)

Activity #2: Prioritise and Discuss Barriers

Now that groups have mapped barriers for both caregivers and healthcare providers, it’s time to decide which ones to focus on.

How to Prepare

Ensure every group has their Table Worksheet: Barriers from the previous day with all the barriers they wrote down.
Ensure every group has a Table Worksheet: Barrier Prioritisation.
Have one copy of the Strategy Summary Poster: Health System Barriers on the facilitator’s table, ready for the last step of this activity.

Facilitation Steps

Prioritise barriers
Tell participants they will prioritise barriers using two criteria on the Table Worksheet: Prioritise Barriers.
- Impact: Which barriers, if solved, will help the most people and have the biggest effect on immunization?
- Complexity: Which barriers are easy to solve? Which ones are harder or more complicated?
- Ask each group to write their identified barriers in the appropriate box on the matrix. For example, if “80% of mothers forget to return for the second dose” affects many people and has simple solutions, it would go in the High Impact, Low Complexity box.
Select top priority barriers
- Ask participants to review the barriers in the High Impact quadrants (top left and right) and choose their top three to five barriers that the strategy will focus on for their priority community.
- They should make a note of the top three to five barriers prioritised.
- You can show participants the (EXAMPLE)Table Worksheet: Barrier Prioritisation for inspiration.
Present to group
Ask each group to present their prioritised barriers to the other groups, and get feedback. Use these prompts to guide the discussion:
- Can you think of any other barriers that may be important to this target group or community?
- What common barriers do we see across communities?
- Which barriers must be addressed in our demand strategy?
- Are any of these barriers at the healthcare system level, so they affect all communities and groups? For example, infrastructure challenges, healthcare system lacking resources, or issues with data management or technology in the healthcare system.
Identify if there are any healthcare system barriers that affect all communities
After all groups have presented, have all participants discuss any barriers that were commonly found across different groups. Ask participants: “Are any of these barriers due to a problem with the entire healthcare or government system?”
Explain what is a Health System Barrier: “Health System barriers are structural issues within the wider government or healthcare system, so they will often affect all communities. For example:
- Supply and Cold Chain: Limited supply of services or vaccines, or problems with keeping vaccines safe during transport (cold chain issues).
- Data Management: Poor data systems within healthcare systems to track vaccinations or other limitations in the available health surveillance data.
- Healthworker Availability: Insufficient numbers of skilled healthcare workers or vaccinators.
- Governance or policy issues: A lack of or poor management of government or wider healthcare policy, impacting governance and the standard of healthcare across sites.
Encourage groups to use the Double-sided Prompt Cards: Why, titled “Health System Barriers” to better understand which of their barriers may be related to the health system.
Document your top one to three healthcare system barriers on the Strategy Summary Poster: Health System Barriers.
Explain that you will return to these barriers in Workshop 2.
Put this poster on the wall next to the Module C Header Poster: Why.
If you don’t have any healthcare system barriers, confirm with the group that these either don’t exist or that they aren’t critical to solve for this strategy.

📝 In Workshop 2, a new group will be formed to focus on these healthcare system barriers, instead of focusing on community-level barriers. Ensure you bring this completed poster to Workshop 2.

If there are no health system barriers, or your group does not want to prioritise any health system barriers for the strategy, you can leave this poster blank.