The WHO Tailoring Immunization Programmes (TIP) Approach: Review of Implementation to Date

"TIP research can be a means to two ends: building in-depth understanding on the side of health authorities, researchers and service providers; and building trust and helping to break barriers of misunderstanding on the side of community. Ideally, TIP involves an extended commitment to community engagement..."

The World Health Organization (WHO)'s Tailoring Immunization Programmes (TIP) approach offers countries a process through which to diagnose barriers and motivators to vaccination and to design tailored interventions. This article presents a review of the approach as implemented in the European Region, finding that some of the most commonly cited strengths of the TIP approach were its interdisciplinary nature and focus on community engagement, as well as its ability to enhance the ability of programmes to listen and learn - thereby gaining an understanding of community and individual perspectives. (See Related Summaries, below, for access to more on TIP.)

In the Region, sub-optimal vaccination coverage, often in specific population pockets, poses a continuous threat of outbreaks of preventable disease and death and jeopardises further progress towards disease elimination. Prompted by the European Technical Advisory Group of Experts on Immunization, in 2012, the WHO Regional Office for Europe developed TIP, which is a step-wise model and theoretical framework for country processes, guided by principles of broad stakeholder and beneficiary engagement and listening. Drawing on behavioural science, social marketing, and qualitative and quantitative research, TIP is designed to facilitate: (i) identification and characterisation of clearly defined population groups with low uptake; (ii) diagnosis of vaccination behaviour barriers and motivators and segment priority groups to reach based on this; and (iii) development of interventions that tailor not only how services are promoted but how they are delivered to overcome barriers and increase vaccination coverage. The intention with TIP was to inspire the traditionally more supply-oriented immunisation programmes to apply a more people-centred and comprehensive approach, built on listening to the intended beneficiaries and taking into account the complexity and the wide range of factors influencing vaccination uptake. These include not only individual motivation, attitudes, and beliefs, but also social, community, cultural, legislative, institutional, and structural factors.

Between 2012 and 2016, the TIP approach was applied and tested in 4 countries in the Region, and was also adapted for seasonal influenza and antimicrobial resistance programmes, with additional projects in 4 countries. Conducted during June to December 2016, the review was based on: visits to Bulgaria, Lithuania, Sweden, and the United Kingdom (UK) that had conducted a TIP project; a review of national and regional TIP documents; and an online survey of the Member States in the WHO European Region that had not conducted a TIP project to assess their views on challenges related to vaccination uptake, need for and experience with behavioural insights and behaviour change interventions in their country, plans for and capacity and resources available to conduct such work, and their perceptions of the TIP itself.

Table 1 on page 1511 of the article briefly summarises the TIP projects that were evaluated. A key takeaway: "Understanding the perspectives of susceptible and low-coverage populations is crucial to improving immunization programmes. TIP provides a framework that facilitated this in [the] four countries." As illustrated in Table 2 on page 1512, many participants perceived value in the TIP process and cited a number of positive if indirect outcomes, including new insights gained, relationships established, and the value of questioning assumptions.

"One common theme across countries was a strong focus on community engagement and consideration of the wide range of behavioural determinants affecting vaccine uptake, including those related to ability, motivation and opportunity. According to participants, this made the approach suitable for working with communities and individuals with complex and multifactorial challenges. In each case the key innovation of the TIP approach involved openness to tailoring service delivery to the needs of communities. Examples include the Charedi community in the United Kingdom, Roma communities in Bulgaria and Somali communities in Sweden. Applications of TIP there seem to have been productive at yielding socially acceptable and appropriate intervention ideas."

Participants in the review also cited the critical importance of TIP leadership; the engagement of WHO was generally highly valued and appreciated. Although stakeholder engagement was recognised as critical, many participants also emphasised their surprise at the amount of time and technical skill involved in the process. "For the future, a clearer description of the steps of the TIP process will be needed."

In summary, the web-based survey, with participation from more than two-thirds of the Member States in the Region, suggested that the large majority recognise the problems of low vaccination uptake, and there is demand for and in some cases concrete plans for behavioural insights research and behaviour change interventions (see Figure 1 on page 1513).

In reflecting on the findings of the review, the authors observe that the current TIP guide emphasises its role as a diagnostic tool, but experience from the first round of TIP in countries shows that implementation - i.e., changing immunisation systems and service delivery culture - is a long and difficult process. They recommend that new TIP projects should clearly emphasise intervention as the ultimate goal, and design methods to incentivise the move to piloting or scaling up ways to tailor services. Several strategies were discussed to encourage this shift in emphasis, such as truncating the initial diagnostic phase by using rapid review methods, fostering community engagement through the process of implementation itself. Qualitative methods can also form part of the intervention optimisation phase and later the evaluation, where it can be refined and deeper insights into remaining barriers gathered.

As next steps, WHO is advised to incorporate the conclusions and recommendations presented in the article as a revised version of the TIP guidance document. "A continuous process of adjustment and improvement based on cumulative evidence will be needed to realize the full potential and optimal conditions for the application of this approach." Emphasis should be placed on monitoring and evaluating outcomes and impact; a mix of indicators should be developed and monitored to demonstrate both the direct and indirect gains of the work conducted, including indicators related to equity and other measures as outlined by respondents.