Factors Influencing the Prioritization of Vaccines by Policymakers in Low- and Middle-Income Countries: A Scoping Review

"Communication efforts and sociocultural considerations pertaining to vaccines may have a more relevant role in the decision-making process in LMICs."

Vaccination decision making in low- and middle-income countries (LMICs) has become increasingly complex, particularly in the context of numerous competing health challenges. This scoping review reviewed the factors that influence decision-making among policymakers for the introduction of new vaccines - that is, those that have been approved by the World Health Organization (WHO) but that have not yet been integrated into national immunisation programmes - in LMICs.

A comprehensive database search of relevant literature published from 2001 to 2021 led to identification of 843 articles, 34 of which were retained after abstract screening, full-text screening, and grading with the mixed-methods appraisal tool (MMAT). Articles in the study represented a diverse range of perspectives and methodologies.

The majority of included studies (n = 29) reported on the key actors at the sub-national, national, and global levels who played an active role in vaccine decision-making and introduction. Careful collaboration and planning across stakeholders, including epidemiologists, clinicians, health workers, vaccine scientists, economists, behavioural scientists, advocates, policy analysts, communication specialists, government officials, international agencies, and donors, was a key requirement in facilitating new vaccine introduction. Academics were found to be a key group for governments to notify of new vaccine introduction to enhance community acceptance. In addition, representatives from professional associations such as women's health organisations were found to be active in advocating for vaccine introduction. On that note, political prioritisation and political commitment towards vaccination were found to be highly influential in over half of the included studies.

The formulation of new vaccine policy and vaccine introduction required that the disease in question was deemed important enough to be addressed. Perceptions of importance were found to be influenced by several cues to action, which included media attention, disease outbreaks, and advocacy and social mobilisation efforts. Studies that described the role of media as being a cue to action detailed how media framing can result in the politicisation of vaccines, which may significantly affect policymakers' decisions for introduction. The highly visible nature of dengue, for instance, garnered considerable public attention and placed pressure on policymakers and politicians to develop solutions to control the disease.

Other factors identified in the articles included programmatic and economic considerations, vaccine impact, and vaccine equity, ethics, and accessibility. Furthermore, 9 articles stressed that developing communication strategies and advocacy was critical prior to introduction and was a noteworthy consideration during the decision-making process. Without a carefully formulated strategy to communicate research to policymakers, decision-making for vaccine introduction was found to be especially challenging. Studies also reported the importance of considering communication efforts to reach communities-at-large during the decision-making process to heighten awareness and promote acceptability of vaccines. The need to consider vaccine acceptability in the decision-making process was deemed to be important in countries in which anti-vaccine campaigns were prevalent, with experts identifying the need for data on community knowledge, attitudes, and practices relevant to vaccines before introduction. One study noted the importance of sensitising health workers to improve motivation and mitigate anti-vaccine negativity projected on them from the community.

Seven studies (5 of which were published from 2012-2021) discussed how policymakers considered social and cultural aspects of vaccine introduction in the decision-making process. Brooks and Ba-Nguz (2012) reported that country experts identified a need for data pertaining to community knowledge, attitudes, and practices prior to introducing malaria vaccines. Similar findings were also noted for human papillomavirus (HPV) vaccines, in which policymakers were found to be very specific in mentioning concerns related to how communities would perceive these vaccines.

One of the topics covered in the scoping review's discussion section is the central role communication played in influencing decision-making for vaccine introduction in a number of studies, particularly for vaccines meant for non-traditional age groups (e.g., adolescents). Communication may have higher pertinence as newer vaccines are increasingly meant for older age cohorts, with vaccine hesitancy amongst adults increasing substantially over the past several years, particularly in light of the COVID-19 pandemic. For instance, there is evidence that communication efforts coupled with advocacy and social mobilisation may heighten demand for HPV vaccines and can serve as a critical cue to action for decision makers.

As highlighted in this review, decision-making amongst policymakers transcends a simple yes/no dictating whether a vaccine should be introduced or not. Input from global and national-level key actors is important throughout all phases of the decision-making process; however, undue influence or bias should be avoided. It is also important to highlight that key actors are dynamic and may frequently shift during the decision-making process due to organisational changes and turnover of government officials. After the decision-point is reached, key actors may also be highly influential in subsequent processes involving policy formulation, policy adaptation and policy implementation.

The researchers offer suggestions for future studies, such as investigations of levels of influence and power dynamics between stakeholders, particularly comparing global and national stakeholders. These dynamics may significantly influence decision-making processes, as stakeholders may hold differing levels of influence and may harbour discordant agendas that support or hinder vaccine introduction, particularly as increased focus has been centred on country ownership and transparency in decision making.

In conclusion: "This review provides insights that can be used to guide the development of resources to support informed decision-making for vaccine introduction amongst policymakers and stakeholders."