How Pediatric Societies Are Reframing the Immunization Service Experience

At the recent World Vaccine Congress in Washington, D.C., hundreds of renowned global experts came together to network and share groundbreaking information dedicated to the science of vaccines.

In this exclusive MedPage Today video, Janna Patterson, MD, MPH, senior vice president of global child health and life support at the American Academy of Pediatrics (AAP), discusses her session on the AAP's global work on pediatric societies and the immunization experience.

Following is a transcript of her remarks:

It's a pleasure to talk to you a little bit today about the role of pediatric societies in reframing immunization experience. We don't have a ton of evidence about what actually works to build demand for immunizations, but we know that families and communities trust pediatric providers even if they don't accept all immunizations. And we believe that pediatricians are uniquely positioned to advocate for the needs of children as they're inherently seen as experts.

They're a trusted voice by almost all and are viewed as independent from government or other decision-making groups, so they kind of have a special niche or role. National pediatric societies as a collection of pediatricians benefit from similar perceptions.

The AAP has been working with national pediatric societies on immunization systems strengthening for nearly a decade, and we know that now more than ever, it's important to engage pediatricians and other child health providers as advocates and peers rather than as end users or learners or pieces of a system that need to be fixed.

So as we expand the definition of service delivery to a more holistic definition of service experience, pediatric societies can leverage this trust that we know people have and their providers to impact quality service delivery, provide accessible and accurate population messages, and information, of course, for families and caregivers and communities.

So along with our network of 13 pediatric societies we have been working to strengthen these national pediatric societies at national and regional levels. We do this through designing activities to build provider confidence and understand the power that they have with their patients and also in communities, and also coordinating and implementing evidence-based, but regionally specific information and messages to help immunizers combat all that misinformation and rumors that are out there. And then finally, really working with pediatric providers to confidently engage with families and build their skills so that they can support decisions by families around immunization.

When you look at who's giving immunizations around the world, there's a shocking number of private sector providers that are offering immunizations. That's true in the United States, but it's also true in other countries.

In 2021, in the midst of the pandemic, there were 18 million zero-dose children, and most of them live in low- and middle-income countries, with India, Nigeria, Indonesia, Ethiopia, and the Philippines really having some of the highest numbers. So of these six countries, five have 25% or greater of children that receive routine care in the private sector. So that's 18 million children that are getting their vaccines in the private sector.

And we know that while these are averages for the country, there's a wide variability within a country. So in some places it's much higher than the numbers that you see here. And we know that we can't maintain and increase immunization rates if we don't pay attention to this private sector and give them the tools that they need to build demand and deliver high-quality immunization services.

So when you go to look at the difference between the public and private sector, you can see that many of those in the private sector are just not getting the training that they need to keep their knowledge updated and fresh. Many of them haven't had any training in the last 12 months. You can see 50% of private providers in Indonesia and 30% of private providers in Nigeria just haven't gotten any training in the last 12 months on immunizations.

So we also saw through a qualitative assessment in Uganda that we did in partnership with the Uganda Pediatric Association, focusing in on Wakiso district, a peri-urban district outside of Kampala, that there were more private than public immunization providers. So it just gives you a snapshot of how important these private sector providers are out there in the world.

One of the ways that we've tried to leverage this voice of pediatric societies is by supporting regional learning collaboratives. The Africa Regional Learning Collaborative is a peer-to-peer exchange made up of national pediatric societies from Africa, as well as the unifying African organization on pediatric societies called UNAPSA [Union of National African Paediatric Societies and Associations]. This Africa Regional Learning Collaborative was established in 2019 with support from the AAP, and they've continued to meet monthly to address gaps in immunization service delivery, and support joint regional advocacy campaigns.

One example of what they did was to create this joint COVID vaccine campaign focused on healthcare workers. There was a time when vaccine uptake, even among healthcare workers, was really quite low in the region, so they knew they needed to create messages that were coordinated and consistent and evidence-based to really get out there to pediatric providers around the continent.

So how do we come back to this private sector and conversations around improving vaccine confidence? We've found that a lot of the immunizers have really been given practice or tools on how to talk about immunizations. You know how to give a vaccine; you know what the antigens are for and which diseases they prevent, but you don't really have the practice in that communication skills.

In order to increase the confidence in having these conversations among private sector immunizers, we worked in Indonesia, Kenya, and Uganda, to adapt and pilot a focused version of the UNICEF curriculum called Interpersonal Communication for Immunization. And that curriculum was developed specifically for public sector providers, but then we adapted it for the private sector and also to incorporate nurses and health assistants, who are often the people delivering immunizations in other countries. And we've seen an increase in confidence and self-reported communication skills across the board.

So we think more deeply about vaccine hesitancy. We know that simulation can be a great tool to address this. In order to continue finding ways to build confidence of providers, we developed the simulation training to introduce evidence-based approaches to these immunization conversations and support simulated practice and mastery of these skills in Japan and the Philippines.

It starts to make this cultural shift that's somewhat new in Japan and the Philippines to the presumptive approach and using motivational interviewing skills, which have been incorporated into many pediatric practices in the U.S. but it's quite new in these countries.

The curriculum is based on simulated patients. So rather than having a live simulated patient for scale and sustainability, we developed video-based cases that allow facilitators to take learners through a vaccine conversation, and then they adjust the parent-caregiver response video based on the how the pediatrician is responding and then using the communication skills that they've taught.

So we're just beginning these pilots. I had the opportunity to go to Japan in February for the first session on this, and it was just really fun to see how invigorated people were by practicing with these recorded patient videos that was sort of a "Choose Your Own Adventure," if you will. And the facilitator would activate a different video response depending on how the pediatrician was communicating.

So again, just beginning the pilots, we're seeing that increase in confidence. And then over the next year, we hope to really measure that difference in patient outcomes.

That will be the next phase of the work, really looking again at knowledge, attitudes, and practice, but also are we really making a difference where it matters in immunization rates among children.

Thanks for letting me share a little bit about our work.

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