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

The paper situates the COVID-19 vaccination campaign within India’s broader pandemic response and examines how community mobilization shaped health-seeking behavior. Following WHO’s declaration of COVID-19 as a pandemic (March 11, 2020) and India’s phased vaccine rollout starting January 16, 2021, the authors note both technological and non-technological innovations that supported vaccination. They identify a research gap: while many studies assess vaccine intentions and acceptance, few analyze how community mobilization strategies—engagement of civil society, local governments, grassroots groups, and in-person communication—directly influence vaccination uptake, particularly in localized, diverse settings. India, and specifically Madhya Pradesh, is chosen due to its demographic and geographic diversity, enabling assessment across urban, rural, and tribal contexts. The study aims to analyze implementation of COVID-19 vaccination with emphasis on community mobilization and public participation, documenting challenges, solutions, stakeholder experiences, and effects on attitudes and coverage across four selected districts (Indore, Dindori, Harda, Datia). Using a case study approach and thematic analysis, the authors seek to develop a framework for tailoring community-specific, culturally sensitive vaccination strategies and to inform future public health campaigns.

The paper reviews global and Indian literature on community mobilization in public health, noting its role in improving health knowledge and behaviors through involvement of civil society, local government, religious organizations, and community groups. Prior work documents mobilization for polio (Nigeria, India), cholera (Haiti), hepatitis B (Vietnam), malaria prevention (India, Ethiopia, Rwanda), and maternal and neonatal health (Bangladesh, Nepal), highlighting tools like in-person counseling, posters, leaflets, street plays, community meetings, and volunteer networks (e.g., ASHAs, Anganwadi workers). Studies on COVID-19 largely examine vaccine intentions and acceptance, but the authors identify insufficient exploration of how mobilization strategies directly affect vaccine uptake, especially localized initiatives integrating public participation and trust-building. The review underscores trust in mobilizers, culturally adapted messaging, and continuous communication as determinants of successful uptake and reduced morbidity/mortality in other health domains, motivating the current focus on COVID-19 vaccination in Madhya Pradesh.

Design: Narrative descriptive case study approach with thematic analysis focused on district-level community mobilization processes; unit of analysis is the district. The study analyzes challenges, initiatives, and stakeholder perspectives to derive generalizable insights across multiple variables. Setting and rationale: Madhya Pradesh selected for geographic and demographic diversity, variability in vaccination coverage, presence of tribal and rural populations with limited access, and established public health infrastructure and community health volunteer networks. District selection: Three-stage process using (1) first-dose coverage above state average, (2) consistency of vaccine consumption against stock (standard deviation of utilization from March–September 2021; low SD = high consistency; one district with highest SD but positive trend; two with low SD), and (3) demographic indicators (population composition, geography, forest cover). Final selection: Indore (highest first-dose coverage; urban), Dindori (consistent performance; high tribal population), Harda (largest improvement; high forest cover), Datia (consistent performance; primarily rural). Sample and data collection: 34 online semi-structured interviews (6–9 per district) with stakeholders involved in community engagement: District Information Education Officer/District Magistrate/Media Officer (n=6), District Immunization Officer (n=4), Chief Medical Officer/Chief Medical and Health Officer (n=4), Vaccination Team incl. ASHA and AWWs (n=7), Community Mobilizers (volunteers, social workers, NGOs, others) (n=13). Interviews lasted 30–60 minutes, eliciting open-ended responses on resources, challenges, innovations, coverage, and knowledge sharing. Analysis: Narrative case studies were compiled using interview and secondary data. Cross-case analysis categorized key factors’ impact (high/medium/low) based on respondent rankings to propose a framework of components influencing community mobilization.

District profiles and vaccination statistics (as of April 1, 2022): - Indore: Total population 3,276,697; dose 1: 3.23M; dose 2: 3.11M; precaution: 0.10M; total: 6.45M. Reported 100% first-dose coverage among eligible adults. Strong inter-departmental coordination (district/block task forces), private sector involvement (hospitals, associations, mobile vans, drive-in sites), extensive community engagement (ASHAs/AWWs, religious sites incl. Gurudwaras, public announcements), social media and municipal app information, behavioral training to address hesitancy, women-only vaccination centers (Nari Tikakaran Kendra), special sessions for daily wage earners, expanded sites at religious/government premises, structured AEFI management (training, additional card with contacts, control room). - Harda: ~79% rural. Initial low coverage improved markedly through localized IEC and the Jan Bhaagidari (people’s participation) model. Strategies included using electoral rolls to identify 18+ eligible persons, mobile teams for remote areas, evening camps for agricultural workers, translation of IEC into local dialects, deployment of familiar local mobilizers (forest staff, teachers, ASHAs, AWWs), door-to-door outreach, myth-busting via examples of vaccinated leaders, AFI kits prepared (no adverse effects reported), culturally embedded invitations (peele chawal), village chaupals, and formal invitation cards (Nimantran Patras). - Dindori: ~95.4% rural; ~64.7% scheduled tribes; early hesitancy and misconceptions (e.g., only previously infected need vaccination). Consistent coverage achieved via door-to-door and field vaccination (second half of day), mapping eligible persons using voter lists with pick-and-drop to centers, added health checks (BP, sugar), mass mobilization (public announcements, local language IEC, cable TV), broad coalition of mobilizers (ASHA, AWWs, administrators, NGOs, leaders, youth, Jan Abhiyan Parishad, WCD department), public vaccinations by respected figures, localized tactics (peele chawal, nukkad nataks), equity actions (boat access to distant areas, vaccinating during harvesting in fields, MGNREGA paid half-day leave), data-driven targeting of low-coverage pockets and pending doses. - Datia: ~70.4% rural, mixed urban-rural. Localized microplanning by village and subdividing urban areas (wards/streets/colonies) with unit in-charges. Afternoon sessions in low-performing areas, then door-to-door vaccination. Regular Maha Abhiyan (mega drives) and mini drives; workforce augmented with trained private nursing students. Call center established to contact 18+ residents (active list), approach them and families. Ongoing capacity building (updated IEC for ASHA/AWW/ANMs). Transition communication approach (inform and inspire before direct solicitation). Technology for trust-building (video calls for hospitalized patients, WhatsApp bulletins), and feedback via video calls. Cross-district factors (from interviewee rankings): High involvement of district administration; high localization of planning and communication; high role of traditional mobilizers (ASHAs, AWWs, ANMs); high influence of community leaders; equity ensured across districts. Social/digital media impact high in Indore and Datia, low in Harda and Dindori. Baseline hesitancy medium to high; awareness lower in rural/tribal districts. Overarching mobilization components: eligible lists from electoral rolls; persistent follow-ups by ASHAs/AWWs; primacy of in-person communication; crisis management groups at multiple administrative levels; inter-departmental support (education, revenue, Panchayati Raj, police); engagement of community influencers (youth, religious groups, SHGs, livelihood groups, NGOs, CSOs) using culturally resonant activities (street plays, peele chawal, invitation cards, mobile vans). Key communication themes: countering myths/misinformation; explaining need, logistics (where/when/how), and second-dose reminders; locally tailored messages with jingles/songs/punchlines; credibility via known messengers; frequent internal updates to vaccination teams on sessions and stock. Quantitative highlights: District vaccination totals (in millions) — Indore 6.45; Harda 0.89; Dindori 1.09; Datia 1.26; precaution doses — Indore 0.10; Harda 0.005; Dindori 0.007; Datia 0.01.

Findings demonstrate that structured community mobilization—anchored in trusted local actors, inter-departmental governance, and culturally localized communication—substantially shaped health-seeking behavior and increased COVID-19 vaccination uptake across diverse settings in Madhya Pradesh. As public fear and perceived urgency fluctuated, sustained engagement and tailored messaging maintained momentum. Trust in mobilizers and visible leadership (community, religious, political, administrative) were pivotal in overcoming hesitancy and logistical barriers, consistent with evidence from other health domains (malaria, dengue, maternal/neonatal health). The cross-case analysis highlights common success factors (localization, equity, traditional mobilizers, leadership) and contextual differences (social media effectiveness in urban vs. rural/tribal areas). Overall, community mobilization provided not only immediate gains in vaccination coverage but also a transferable framework to reinforce long-term health consciousness and resilience for future public health initiatives.

Community mobilization—via local leadership at multiple administrative levels, frontline workers (ASHA, AWW, ANM), culturally localized strategies and materials, in-person communication, and engagement of influential community heads—was central to achieving high COVID-19 vaccination coverage in Indore, Harda, Dindori, and Datia. Urban successes leveraged leadership, business and community support, and social media; rural/tribal gains relied on community volunteers and localized communication. The collaborative, people-participation approach and localized strategies are replicable for routine immunization and other social programs. The study contributes by documenting district-level planning processes, stakeholder coordination, and challenges during the campaign, and by proposing a framework for community-specific, culturally sensitive mobilization. Future work should adapt these lessons to other vaccines and settings and evaluate long-term integration into routine health systems.

- Generalizability: Analysis limited to four districts within one state; findings may not generalize across Madhya Pradesh or India. - Study design: Qualitative case studies inform theory but limit generalizability; sustainability of identified initiatives was not assessed. - Unexamined factors: Training/capacity building depth and mobilizers’ working conditions, terrain challenges, and incentives were not analyzed; these warrant further research to understand motivation and performance. - Future research: Empirical testing of how social, geographic, and demographic factors impact mobilization effectiveness; evaluation of sustainability and scalability of initiatives.