The role of community mobilization in people's healthcare-seeking behavior during the COVID-19 vaccination journey: select case studies from Madhya Pradesh

The COVID-19 pandemic, declared in March 2020 by the WHO, necessitated innovative approaches to overcome challenges in healthcare delivery. The subsequent COVID-19 vaccination campaign in India, launched in January 2021, highlighted the critical role of community mobilization in achieving high vaccination coverage. While technological advancements played a part, in-person interaction remained essential for behavioral change. Previous studies have examined community mobilization's role in various vaccination campaigns (polio in Nigeria, cholera in Haiti, etc.), but less attention has been given to its specific impact on COVID-19 vaccination coverage in diverse settings. This study addresses this research gap by focusing on four districts in Madhya Pradesh, India, selected for their varying vaccination coverage, geographical features, demographics, and socioeconomic factors. The study aims to analyze the implementation of the COVID-19 vaccination campaign in these districts, highlighting challenges, solutions, stakeholder experiences, and the impact of community mobilization on vaccination attitudes.

The literature extensively supports the use of case study methodology in healthcare research. Data collection methods employed in such studies often include semi-structured interviews, observations, surveys, and focus group discussions. Existing research acknowledges the importance of community mobilization in boosting vaccination rates, demonstrating its effectiveness in various contexts globally. However, studies focusing specifically on the impact of localized community mobilization strategies on COVID-19 vaccination uptake, particularly in diverse settings like Madhya Pradesh, are limited. This study aims to fill this gap by providing insights into how varied community engagement strategies influence outcomes in a high-stakes public health crisis.

This study adopts a narrative descriptive approach for case studies and community mobilization thematic analysis. The unit of analysis is the district. Four districts in Madhya Pradesh were selected based on vaccination coverage, standard deviation of vaccine stock utilization, and demographic factors. Indore was chosen for its high vaccination coverage and urban population; Dindori for its consistent coverage and high tribal population; Harda for its improved coverage and high forest cover; and Datia for its consistent performance and primarily rural population. A total of 34 semi-structured interviews were conducted with various stakeholders (District Information Education Officer, District Immunization Officer, Chief Medical Officer, Vaccination Team members, and Community Mobilizers) in each district. The interviews explored resources, challenges, innovations, vaccination coverage, and knowledge sharing.

The study presents four distinct case studies, highlighting the successful community mobilization strategies employed in each district. **Indore:** Achieved 100% first-dose coverage among the adult population. Success was attributed to strong inter-departmental coordination, private sector involvement, strategic microplanning of vaccination sites (including drive-in facilities), effective community engagement through various channels (ASHAs, Anganwadi workers, printed banners, social media), crisis management committees, and targeted outreach to specific community groups. The use of social media, particularly WhatsApp and Facebook, was a critical success factor. Special sessions were designed to cater to the specific needs of women, daily wage earners, and the elderly. AEFI management protocols, including a control room and detailed vaccination cards, were crucial. **Harda:** A primarily rural district with a significant tribal population, Harda initially faced challenges. Its success stemmed from the 'Jan Bhaagidari' (people's participation) model. Strategies included using electoral lists to identify eligible individuals, mobile vaccination teams for remote areas, evening vaccination camps for agricultural workers, translation of IEC materials into local dialects, door-to-door visits by community mobilizers, addressing misinformation and vaccine hesitancy, and the use of traditional customs such as 'peele chawal' (offering yellow rice) to attract people to vaccination camps. **Dindori:** Another largely rural district with a high tribal population and initial vaccine hesitancy. Strategies included door-to-door vaccination, the election campaign approach using voter lists, mass mobilization through various channels, active involvement of diverse community mobilizers (ASHAs, Anganwadi workers, local administrators, NGOs, community and political leaders, and volunteers), and use of traditional customs ('peele chawal') and 'nukkad nataks' (street plays). Reaching remote areas by boat and vaccinating farm workers in fields during harvesting season demonstrated adaptability. **Datia:** A mixed urban-rural district with challenges in mobilizing populations in both settings. Strategies involved localized planning with ward-level in-charges, afternoon vaccination sessions in areas with low morning turnout, door-to-door vaccination, 'Maha Abhiyan' (mega vaccine drives), use of private nursing college students, establishment of a call center to contact eligible individuals, focus on capacity building for vaccination teams, and using video calling and WhatsApp for communication with hospitalized COVID-19 patients and their families.

The study highlights the critical role of community mobilization in influencing healthcare-seeking behavior, particularly in the context of COVID-19 vaccination. The success of the campaigns in the four districts underscores the importance of a multi-pronged approach involving diverse stakeholders, localized strategies, and culturally sensitive communication. The findings align with existing literature emphasizing the importance of trust in community mobilizers and the effectiveness of in-person communication. Addressing misinformation and vaccine hesitancy through tailored communication and community engagement were crucial. The use of traditional customs and practices in rural and tribal areas demonstrated the effectiveness of integrating culturally appropriate strategies into public health initiatives. The study's findings have implications for designing future vaccination campaigns and other health interventions by emphasizing participatory approaches, localized strategies, and the critical role of community leaders and influencers.

This study demonstrates the crucial role of community mobilization in boosting COVID-19 vaccination uptake in diverse contexts within Madhya Pradesh. The success across four districts with varying characteristics highlights the importance of adaptable strategies involving local leadership, culturally sensitive communication, and the active participation of various community groups. The findings underscore the need for participatory approaches in public health initiatives. Future research should investigate the long-term sustainability of these strategies and explore the impact of factors such as mobilizer working conditions and incentives.

This study's findings are based on a limited number of districts in Madhya Pradesh and may not be generalizable to all of Madhya Pradesh or other Indian states. The qualitative nature of the study limits the generalizability of findings. The sustainability of the implemented initiatives was not assessed. The study did not analyze the mobilizers' working conditions or training and capacity-building aspects. The qualitative nature of the study restricts the empirical testing of social, geographic, and demographic factors impacting community mobilization.