Introduction

COVID-19 was declared a “pandemic” by the World Health Organization (WHO) on March 11, 2020 (WHO, 2020). According to WHO, “availability of safe and effective vaccine for COVID-19 is well-recognized as an additional tool to contribute to the control of the pandemic”, apart from other precautionary measures (Rochwulaningsih et al., 2023; Tan and Idris, 2023; Yeung, 2023). To curb the spread of COVID-19 infection, several precautionary measures have been adopted across India, including masks, social distancing, and restrictions on people’s movements and social gatherings. In addition, after the approval of the emergency use of the Covishield and Covaxin vaccines by the Government of India, a COVID-19 vaccination campaign was launched on January 16, 2021, initially for healthcare workers (HCW) and frontline workers (FLW). In the subsequent phases, people above the ages of 60, 45, and 18 years, successively, were eligible for vaccination. Vaccination for those aged 45 years and above was launched from March 1, 2021, while that for the age group 18-44 years old was launched from May 1, 2021. Subsequently, COVID-19 vaccine precaution doses were started since January 10, 2022.

During the crisis, the need to radically surmount challenges arises, therefore, it is critical to abandon traditional approaches to finding new solutions by combining existing knowledge with crisis-driven knowledge (Das et al., 2022; Lyng et al., 2021). Both technological and non-technological innovations have played pivotal roles in improving the vaccination processes (Pagliusi et al., 2018). Various innovations and activities have been initiated in the area of community mobilization to increase the uptake of vaccinations. For instance, Nasiru et al. (2012) have studied the role of community mobilization interventions for the uptake of polio vaccination in Nigeria. Similarly, other studies have been conducted in the context of cholera vaccination in Haiti (Rouzier et al., 2013), polio vaccination in India (Choudhary et al., 2021), hepatitis B vaccination in Vietnam (Zhou et al., 2003), and child vaccination in India (Pérez et al., 2020), to name a few.

Community mobilization is an important approach for developing nutrition and health-related knowledge in local communities (Singh et al., 2018). It focuses on changing peoples’ health-seeking behavior for the prevention and management of any disease. It aims to bring together civil society organizations, local government bodies, religious organizations, and local community members (Asale et al., 2019). Despite technological advancements, in-person interaction with community members is an essential channel for achieving favorable change in behavior. In an attempt to provide healthcare services at the community level and to remote areas, the role of community mobilization activities becomes crucial (WHO, 2021). In Nepal, a female community health volunteer system led to an increase in access to health services (Singh et al., 2018). Such volunteers are responsible for providing health-related counseling to females and other community members. In India, community mobilization activities for the prevention of malaria included NGOs, local-community-based groups, and female self-help groups to convey messages using different tools that included posters, leaflets, and platforms such as street plays and community-based meetings (Das et al., 2014).

Globally, governments have adopted various policies to increase the uptake of COVID-19 vaccination. Numerous studies have focused on vaccination intention and acceptance in different countries (Sherman et al., 2021; Dodd et al., 2021). Despite many published studies, little attention has been paid to how innovations and initiatives related to community mobilization have influenced COVID-19 vaccination coverage. The research gap identified in this study pertains to the insufficient exploration of how community mobilization initiatives specifically influence COVID-19 vaccination coverage (Nnaji et al., 2021). While numerous studies have examined vaccination intentions and acceptance globally, there has been little focus on how the strategies of community mobilization, such as engaging civil society, local governments, and grassroots organizations, directly impact the uptake of COVID-19 vaccinations (Kerrigan et al., 2023; Marquez et al., 2021). This gap is particularly noted in the context of localized efforts and the integration of public participation within these initiatives. The study aims to fill this gap by assessing the effect of community mobilization on vaccination attitudes and coverage in specific districts of Madhya Pradesh, India, providing insights that could inform future public health strategies and vaccination campaigns.

India has been selected for this study due to its significant and diverse population, providing an exemplary setting for examining public health interventions such as the COVID-19 vaccination campaign (Tan et al., 2023). The country’s vast and varied demographic landscape offers a valuable context for evaluating how community mobilization impacts different communities across a wide range of socioeconomic, cultural, and geographical settings (Kumar and Shobana, 2024). This diversity allows for an in-depth exploration of the unique opportunities to study the effects of community-driven health initiatives in adapting and responding to local needs and challenges.

This paper aims to analyze the implementation of the COVID-19 Vaccination Campaign in India with special emphasis on the aspects of community mobilization and public participation. The study will highlight the challenges encountered during the COVID-19 campaign and solutions designed, and stakeholders’ experiences of the vaccination drive. Additionally, the impact of community mobilization on people’s attitudes toward vaccination is being assessed. For the study, four districts in the state of Madhya Pradesh are identified based on the parameters of vaccination coverage, geography, demography, and socio-economic factors.

While existing studies have acknowledged the importance of community mobilization in increasing vaccination uptake, this study introduces several novel aspects to the existing body of knowledge (Enria et al., 2021). The study focuses specifically on the COVID-19 vaccination campaign in the diverse and complex socio-economic landscape of Madhya Pradesh, India, providing insights into how varied community engagement strategies affect outcomes in a high-stakes public health crisis. This study also examines the roles of local community-based groups and civil society in vaccine dissemination, which have been less emphasized in previous research. Additionally, it employs a comprehensive case study approach that not only assesses the effectiveness of these strategies but also captures the nuanced challenges and solutions from stakeholders’ perspectives, offering a more detailed and practical understanding of the dynamics at play. This approach allows for the development of a tailored framework that could guide future vaccination campaigns, ensuring they are more community-specific and culturally sensitive. The lessons from the vaccination process in Madhya Pradesh will be helpful to policymakers and practitioners in devising strategies for increasing vaccination coverage of existing vaccines and introducing new vaccines. The study started with an analysis of the existing literature on the impact of community mobilization in public health programs globally. Based on the findings from existing studies, the methodology was formulated to suit Madhya Pradesh’s context. Primary interviews in the form of open-ended qualitative interviews were conducted. A case study approach was followed to analyze the findings which have been discussed thoroughly in the section “Discussion”. Finally, a framework was formulated, and thematic analysis to understand the impact of community mobilization on COVID-19 Vaccination in Madhya Pradesh.

Materials and methods

Brief overview of healthcare research and selection of research method

This section briefly discusses the case study methodology adopted for this study. The literature evidences a wide acceptance of the case study methodology in healthcare research. Data collection methodologies in such studies include semi-structured interviews, observations, surveys, and focus group discussions (Balta et al., 2021; Chaudhuri et al., 2021; Coccia, 2022; Harding et al., 2021; Lyng et al., 2021; Moncatar et al., 2021; Oderanti et al., 2021).

This study utilizes the narrative descriptive approach for case studies and community mobilization thematic analysis. The narrative case studies focus on a district-level community mobilization process since the unit of analysis is the district. The study enumerates the challenges encountered and initiatives adopted by each district and seeks to understand different stakeholders’ perspectives. Furthermore, the approach of the study facilitates the analysis of multiple variables, which should lead to generalized results.

The case studies are developed based on the measures taken by the government and focus on real-life case examples in four districts of Madhya Pradesh. The key themes generated will help in establishing the latent challenges and innovative ways that may influence future vaccination processes and health-seeking behavior. Madhya Pradesh was specifically chosen for its significant geographic and demographic diversity as the second-largest state by area and the fifth-largest by population in India (Badkul et al., 2022). This diversity offers a unique setting to examine how community mobilization strategies affect COVID-19 vaccination uptake across various environmental and population contexts. The state’s variability in vaccination coverage and its mix of tribal and rural populations with often limited healthcare access provides a distinctive opportunity to study the impact of community-driven efforts on improving health services. Additionally, Madhya Pradesh’s well-established public health infrastructure and network of community health volunteers are crucial for implementing and assessing health campaigns, making it an ideal model for understanding community mobilization’s effects on health initiatives and informing broader national and global strategies.

District selection

The literature provides many methodologies for district selection criteria. For instance, vaccine uptake (high and low) (LaMontagne et al., 2022; Baker et al., 2013), coverage greater than the national average (Gallagher et al., 2017), urban/rural representation (Shanawaz and Sundar, 2014), and vaccination coverage (Martineau et al., 2018; Haji et al., 2016; Shanawaz and Sundar, 2014; Worrell and Mathieu, 2012).

A diverse set of districts was proposed in terms of coverage, geography, and demography. The districts were assessed based on the following parameters: vaccination coverage, standard deviation of the vaccine stock utilization, and demography. The district selection analysis was performed in three stages:

Stage 1

Districts with a first dose coverage higher than the state average were selected.

Stage 2

Consistency of vaccine consumption against vaccine stock available was the key criterion for coverage performance. The standard deviation of the vaccine stock utilization for seven months, from March to September 2021, was considered to measure the consistency of coverage performance against stock availability. Districts with the lowest standard deviation have the highest consistency, while those with the highest standard deviation have the lowest consistency. Thus, one district that showed the highest standard deviation, with a positive trend (indicating vaccine uptake intake increased over the period) from March to September 2021, was selected. Two districts with low standard deviation, i.e., showing consistency in the coverage were selected.

Stage 3

Demographic indicators, such as population composition, geographic indicators, and forest cover, were considered in selecting the districts.

Therefore, the selection of the districts focused on coverage performance, utilization of vaccines, rural/urban/tribal composition, and vaccination coverage. Thus, four districts were selected based on the following rationale:

  • Indore district was selected because it had the highest COVID-19 first-dose coverage Another reason was that Indore had the highest urban composition.

  • Dindori district was selected as it showed consistent COVID-19 coverage performance throughout the vaccination program based on the vaccination trends. Dindori has a high tribal population signifying the presence of different sets of social and cultural norms.

  • Harda district was selected as it transformed over a period and showed the highest improvement in COVID-19 vaccination coverage among other districts. It has a high forest cover.

  • Datia district was selected for its consistent COVID-19 performance throughout the vaccination program. Furthermore, the district is primarily a rural district.

Table 1 provides the basic demographics and vaccination statistics for the four districts, which help in understanding the profiles of these districts. Annexure I depicts the trends in COVID-19 vaccinations in these four districts.

Table 1 Demographics and vaccination statistics for the districts.
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Sample size and data collection

Overall, 34 semi-structured interviews were conducted with purposefully sampled multiple stakeholders, with 6–9 interviews per district. These stakeholders, representing the officials with roles and responsibilities related to community engagement in the COVID-19 vaccination campaign in Madhya Pradesh, are listed in Table 2.

Table 2 Stakeholders’ roles, responsibilities, and interview details.
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The interviews were conducted online, given the pandemic situation, and lasted from 30 to 60 min. The semi-structured interviews facilitated in-depth, open-ended responses from the interviewees through the standard participatory research method. The broad questions asked during the semi-structured interviews were related to resources, challenges, innovation, vaccination coverage, and knowledge sharing.

Results

In the following subsections, the analysis is provided based on the interviews conducted and secondary data. The study illustrates four different districts and their innovative community mobilization campaigns to attain the health-seeking behavior that led to increased vaccination coverage. In the following subsections, the steps taken for vaccine service delivery and planning as well as community mobilization are individually discussed for each of the four districts.

Indore district

Indore, with a population exceeding one million people, reported that it had vaccinated 100 percent of its eligible (adult) population with the first dose of the COVID-19 vaccine. The district also reported the highest first-dose coverage in the state. The effective coordination and implementation of community efforts in the form of crisis management groups, community leaders, and the private sector enhanced vaccination coverage. The district administration brought all the departments together which led to seamless planning and implementation.

Inter-departmental coordination

Meetings of members from different government departments in the form of district taskforce and block taskforce committees were held for preparation and planning purposes. Teams of the health departments, municipal corporations, and district administration were formed. Inter-departmental support through school teachers, PRI members, and revenue staff was garnered for the mobilization of the community.

Involvement of the private sector

Private hospitals and associations were involved in spreading awareness and infrastructure provision for vaccination. Vaccination centers and sites were established, while mobile vans were utilized to vaccinate people in remote areas and those with high footfall. All the district areas were strategically covered by microplanning related to vaccination sites. “Drive-in” facility sites were also organized where people could be vaccinated sitting in their four- or two-wheelers.

Involvement of community

The information was disseminated through community mobilizers such as ASHAs and Anganwadi workers, printed banners at vaccination sites, etc.

“We conducted multiple surveys and educated people about the importance of vaccination. Our primary tools for community awareness included TV news, door-to-door visits, social media, and digital media. We also discussed multiple communication strategies, including training meetings for teachers and local leaders.”—Vaccination Team

Crisis management committees were made at the ward and block levels. Assistance was sought from community leaders, political parties, businesspersons, and representatives from every section of society for mobilization purposes. Support from community leaders led to increased vaccination in different community groups. Various vaccination sites were introduced in religious places. For instance, a vaccination center was introduced in Gurudwaras, while facilities such as food, water, sitting space, vaccination registration, and certificate printing were provided at the center. Announcements were frequently made from religious places and municipal corporation vans. The COVID-19 vaccination team initially encountered various challenges, including limited vaccination sites, vaccine hesitancy, and limited knowledge about the side effects of the vaccine. Special jingles related to COVID-19 vaccination were created and played to mobilize community members for COVID-19 vaccination.

Social media

Technology plays an important role in the dissemination of information on various social media platforms, such as WhatsApp and Facebook. Lists of vaccination centers were provided through the Indore Nagar Nigam (Municipal Corporation) app.

“We utilized different mediums like radio, newspapers, mobiles, and WhatsApp to spread awareness about need, importance and availability of vaccines. Social media was the most popular and effective tool for disseminating information. We also faced multiple challenges during the administration of vaccines, some of which required us to conduct behavioral training to increase the awareness and acceptance of the vaccines. Overall, we are very thankful for the careful administration of the vaccination drive, which also helped pregnant women to get vaccinated.”—Vaccination Team

“We used to send vaccination photos of the known and respected people of the community on the WhatsApp group to motivate others”—Vaccination Team

Equitable access

To ensure equitable access, “Nari Tikakaran Kendra” (women’s vaccination centers) for females was planned.

“Observing and identifying the community challenges was essential. In many areas, especially some Muslim dominant areas females were particularly hesitant in participating in the vaccination drives, we understood the sensitivity and established special women vaccination centers.”—Community Mobilizers

For daily wage earners, special vaccination sessions were planned, where food was also provided. Senior citizens or those suffering from ill health could not reach vaccination sites. Hence, various religious places and other government premises were utilized to increase the number of vaccination sites.

“We had arranged the entire setup for the vaccination drive, in the main hall with facilities for breakfast, tea, snacks and rest. We promoted the vaccination drive primarily through our WhatsApp groups, and mouth reference. There were some challenges, such as some people were unable to book a slot. To overcome that we had set up a registration desk and appointed a team to help in this. We got amazing response from everyone, there were days when we vaccinated around 700 people, in a single day.”—Vaccination Team

AEFI management

Vaccinators were provided training related to COVID-19 protocols and, importantly, the management of adverse events following immunization (AEFI) cases to encourage people to vaccinate. For post-COVID-19 vaccination monitoring and potential AEFI cases, each of the vaccinated individuals was issued with an additional vaccination card that included the vaccination site in-charge number, doctor’s number, and other necessary information. A control room was established to receive calls from the public related to the COVID-19 vaccination process and for regular follow-up post-COVID-19 vaccination.

Harda district

Approximately 79% of the population of Harda district resides in rural areas. Persuading the Harda district locals to vaccinate, especially in the tribal and rural areas, was a difficult task. Moreover, Harda did not show the expected coverage performance during the initial stages; however, it started to perform the following measures that were taken to resolve the challenges. Effective communication by localizing the IEC materials and communication strategies led to increased COVID-19 vaccination coverage in the Harda district. “Jan Bhaagidari,” i.e., the people’s participation model in the form of collective efforts by the district leadership, administration, vaccination teams, community leadership, and volunteers, led to the success of COVID-19 vaccination in Harda.

Election booth approach

The electoral list for the 18+ age group was used as a basis to identify the eligible population for vaccination; these lists were distributed among community mobilizers for them to approach eligible people.

Mobile team approach

In far-flung areas with limited reach, mobile vaccination teams were created to vaccinate people. In the initial phases, vaccine supply was limited and uncertain. However, in later stages when the supply of vaccines was increased, COVID-19 vaccination centers and mobile teams were also increased to cater to the increased demand for vaccination.

Equity in vaccination

Most of the tribal and rural population depended on agriculture for their livelihood and the population was engaged in farming activities in the daytime, the people did not turn up for vaccination. To address this challenge, evening camps were specially scheduled for agricultural workers.

“One of the major challenges was to reach remote areas which had very low network coverage and further motivating such agricultural communities as they were initially focused only on their farming activities.”—Health professional

“Registration process was particularly challenging in rural areas, forest regions and among the tribal population due to lack of awareness and proper infrastructure”—District Administration

Convincing the remote forest area and the rural population to vaccination, the local administration translated the IEC (Information, Education, and Communication) materials orally into local dialects. The local administration deployed mobilizers and local volunteers who were familiar with the local dialect to mobilize the community. Forest staff, Anganwadi workers, ASHAs, and government teachers were involved in the awareness campaigns.

Localized strategy

The community mobilizers, including ASHAs and Anganwadi workers, visited individual households to mobilize people. These community mobilizers explained the benefits of vaccination and used themselves as examples of vaccinated individuals to motivate the people. The community mobilizers resolved misinformation and hesitancy, including common apprehensions that vaccines caused death and severe illnesses.

“A large section of the community was apprehensive of the after effects of the vaccination. They had multiple misconceptions, which we cleared by citing examples of community leaders who already got vaccinated”—Vaccination Team

“We encountered the Misinformation spread through social media by translating messages into local languages and involving religious leaders. We even prepared AFI Kits for those who came for vaccination, but no adverse effects were reported after vaccination”—Health professional

Additionally, the traditional custom of “peele chawal” (turmeric-smeared rice or yellow rice) was followed. The community mobilizers invited the local population to the vaccination camp by offering them yellow rice. This custom is related to the marriage invitation where anyone who accepts yellow rice is obligated to go to the marriage function. Additionally, “Chaupal” (village public space) meetings were conducted to raise people’s awareness about the COVID-19 vaccination and encourage them to be vaccinated. Thus, these initiatives helped to mobilize the community to develop health-seeking behavior towards vaccinations. Support from gram panchayat “mukhiya” or “pradhaan” (chief village administration) and community leaders was sought in mobilizing the people. “Nimantran Patras” (invitation cards) were circulated among the population, inviting them to accept the COVID-19 vaccination.

Dindori district

Dindori district has approximately 95.4% of the total population residing in rural areas. Approximately 64.7% of the total population belongs to scheduled tribe categories. The population in the Dindori district was vaccine-hesitant in the initial phase of vaccination. There was misinformation that only COVID-19-affected people should be vaccinated. Additionally, people were skeptical about the side effects of vaccination. Dindori overcame the challenges with innovations and community involvement. The effective implementation and localization of initiatives led to community mobilization and improved vaccination coverage in the Dindori district. Localized techniques using traditional customs and community-led campaigns made Dindori’s vaccination coverage consistent with a focus on equity and measures to reach one and all.

Door-to-door vaccination approach

Regarding the planning of the sessions, vaccination was performed at the planned vaccination centers during the first half of the day, while in the second half, the vaccination team went to vaccinate people door-to-door and in the crop fields.

“People had multiple misconceptions and were skeptical to get vaccinated. Community engagement, leading through examples, door-to-door visits were some of the ways we employed to increase their trust level.”—Vaccination Team

Election campaign approach

Eligible people were mapped to the nearest vaccination center using the voter list data to track the performance at a micro level. In addition, pick-and-drop facilities from home to vaccination centers were provided in certain areas. Facilities for additional checkups such as blood pressure and sugar level were also provided at the COVID-19 vaccination centers.

Mass-mobilization

Various initiatives were adopted to mobilize the people, including announcements at places with high footfall and crossroads, neighborhood meetings, the use of banners and posters, city cable advertisements, and the use of the local language for interpersonal communication with the people.

Involvement of community

The community mobilizers included different stakeholders, such as ASHA, Anganwadi workers, local administrators at block and district levels, NGOs, community leaders, political leaders, youth volunteers, and local community members. Furthermore, members of “Jan Abhiyan Parishad” (public campaign council), and the “women and child development department” were actively engaged in the process of mobilizing people.

“We invited teachers, ASHA workers, local leaders, political representatives, frontline workers to get vaccinated publically in front of local people to spread awareness about benefits of Vaccination.”—Vaccination Team

Localized mobilization

As in the Harda district, the vaccination team in Dindori distributed “peele chawal” (turmeric-smeared rice) among rural households as an initiative to mobilize people to vaccinate. “Nukkad nataks” (street shows) were performed to generate awareness; vaccination sites were also planned in the same area.

Equity in vaccination

The vaccination team made an extra effort to mobilize people. For instance, it reached distant places in the Dindori district by boat. In addition, because the local population was reluctant to vaccinate during the harvesting seasons, farm workers were vaccinated in the fields themselves. Additionally, workers under MNEREGAFootnote 1 schemes were granted paid half-day leave for vaccination.

“We identified areas where the vaccination percentage was the lowest. After that we found out the data of people who had their first/second dose pending. Our team made their best efforts in spreading awareness among these people, motivating them to get vaccinated and facilitating them to the vaccination centers”—Community Mobilizers

Datia district

Approximately 70.4% of the total population of Datia district reside in rural areas. The district comprises both urban and rural populations. Therefore, the challenges encountered in mobilizing the urban and rural communities were different. In rural areas population density is low, making it difficult to vaccinate a greater number of beneficiaries within the stipulated time. Hence, local solutions were devised to plan sessions and mobilize beneficiaries. Technology also played a major role in communicating with the beneficiaries. District administration focused on generating trust in the government health system.

Localized planning

The mobilization activities for the rural areas were performed at the village level. In a day, session sites for a village were planned and the village administrative unit was notified in advance. For the urban population, larger units of the urban area were broken into smaller units: wards, streets, and colonies. Furthermore, the in-charge officer for each of the identified units was assigned the responsibility for community mobilization for the uptake of vaccination. Consistent efforts were made to vaccinate the targeted number of people per day based on the population (density). In the initial phases, appropriate camps were established for vaccination. Afternoon sessions were planned in areas where the vaccination coverage was relatively low in the mornings. Later, door-to-door vaccination was introduced in addition to these camps. COVID-19 “Maha Abhiyan” (mega vaccine drives) at state and district levels, as well as several mini “Maha Abhiyaans” at local levels, were organized weekly by the district authority. The tasks were divided among the teams and for each village/ward/street/colony; one person was appointed to be in charge for each of these. Since Maha Abhiyan required a larger workforce, private nursing college students were approached. Appropriate training was provided to these students for the roles of vaccinator and verifier.

Furthermore, when very few people approached the vaccination centers, a call center was established and provided with a list of those people who were older than 18 years. From the overall list of people due for vaccination, an active list was prepared of those who currently resided in the Datia district. The people on the active list and their family members were then approached for COVID-19 vaccination.

Focus on capacity building

Regular training sessions were conducted to update the vaccination teams. For instance, ASHA, Anganwadi workers, and ANMs (vaccinators) were regularly provided with updated IEC material for generating awareness.

Dynamic mobilization strategy

At the beginning of the vaccination process, people were reluctant to be vaccinated. During the second wave of the COVID-19 pandemic, various myths prevailed among the people. However, as information gradually filtered through, and with the involvement of people from different sectors and communities, as well as the adoption of local initiatives, the hesitancy started to decrease. The community mobilizers and administrative staff adopted a transition approach in which people were not directly approached to vaccinate; instead, people were first made aware of the benefits of vaccination and inspired to vaccinate. Only thereafter were they directly approached to vaccinate.

Use of technology

For people who were infected with the COVID-19 virus, various other approaches were adopted. For hospitalized patients, video calling was scheduled with their family members. Additionally, the patients’ medical bulletins were shared with the family members via WhatsApp. These types of initiatives helped to generate trust in the initiatives adopted by the district administration.

“We utilized the facility of video calling for feedback mechanisms on managing the vaccination process”—District Administration

Discussion

This study underscores the pivotal role of community mobilization in fostering healthcare-seeking behaviors, drawing on the control of malaria, dengue, and the improvement of neonatal and maternal health outcomes as core examples (Vanlerberghe et al., 2009; Ingabire et al., 2014; Gai Tobe et al., 2019). In line with Asale et al. (2019), our findings support the structured involvement of diverse stakeholder groups including influential community members, youth organizations, and village administrators in mobilization initiatives. These groups undergo initial training and subsequently take on the mantle of responsibility to engage their respective communities.

In contexts like Bangladesh, community mobilization has been strategically utilized to enhance awareness and demand for healthcare services, significantly impacting neonatal and maternal health metrics (Gai Tobe et al., 2019). Similar strategies are relevant in rural and tribal areas where health-seeking behaviors are deeply intertwined with socio-cultural norms (Arakelyan et al., 2021). Trust in community mobilizers emerges as a critical factor, influencing the acceptance and subsequent adoption of recommended health practices. The development and maintenance of this trust are crucial for the successful implementation of health interventions, as evidenced by reduced malaria mortality when appropriate health-seeking behaviors are adopted (Nwaneri and Sadoh, 2020).

Further analysis within this study focused on the COVID-19 vaccination campaigns in the districts of Indore, Dindori, Harda, and Datia. Our observations reveal that community mobilization, led by key influencers and thematic activities, is essential, especially in times when public fear of the virus diminishes and the perceived urgency for vaccination wanes. The fluctuation in community willingness to engage with health interventions underscores the necessity for ongoing, effective communication strategies that deliver accurate health information and maintain public engagement (Chandani et al., 2021).

Our findings indicate that the success of health campaigns, such as those for COVID-19 vaccination, hinges on continuous community support and the adept handling of communication initiatives. The role of community mobilization extends beyond immediate health crises, providing a framework for sustained health improvement across different settings. Thus, reinforcing community mobilization not only addresses immediate health challenges but also fosters a long-term culture of health consciousness and resilience against future health threats.

A cross-case analysis (Table 3) was also performed to identify the common and distinguishing factors among the four districts. The cross-case analysis outcome was primarily based on the overall responses received from the interviewees during the semi-structured interviews in which they were asked to rankFootnote 2 the impact of key factors in the three categories of “high,” “medium,” and “low.” These factors though exhaustive emerged as the most important factors that impacted vaccination in the four districts.

Table 3 Cross-district analysis of COVID-19 vaccination coverage.
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Based on this cross-case analysis of the districts, an overall framework was proposed (Fig. 1) to understand the role of the key components that influenced community mobilization in these four districts.

Fig. 1: Framework for Community Mobilization.
figure 1

Proposed framework to understand the role of the key components that influenced community mobilization.

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Influencers and community-mobilization activities

The community mobilization activities were supported by the district administration, various government departments, and the community. The eligible population list was prepared based on the electoral list. Subsequently, beneficiaries were contacted and persuaded to accept the COVID-19 vaccine wherever required. Regular follow-ups were undertaken by community mobilizers such as ASHAs, AWWs, etc. to ensure that people had been vaccinated. Although various media (print, TV, social media, etc.) of communication were utilized in the vaccination campaign, the impact of “in-person communication” was acknowledged and appreciated by most of the interviewees. This proves that human relationships still play an important role in influencing people.

Administration activities included crisis management groups to deal with hesitancy issues at district, block, village, and ward levels. Government administrative officers and elected representatives participated in these meetings. Government inter-departmental support included participation by all the government departments, including the education, revenue, Panchayati Raj, and police departments. Employees from these departments supported the health department in community mobilization and in organizing vaccination sessions.

Community influencers included a long list of groups within the common people who actively contributed to the campaign. The groups included youth volunteers, religious groups, self-help groups, livelihood groups, NGOs, and civil-society organizations. These groups organized innovative activities such as street plays, the distribution of turmeric-smeared rice (yellow rice), mobile vans, and invitation cards. Local communities played a key role in persuading people to vaccinate because of the trust that the local influencers could generate.

Key communication themes

The key communication themes related to providing correct knowledge and updates about not only the COVID-19 vaccination but also the pandemic. Reducing hesitancy towards COVID-19 vaccination was the main objective of community mobilization, primarily in the initial days, which was followed up by informing people about the where, when, how, and why of vaccination. Last, information was provided about the second dose in the latter half of the campaign. Communication themes included the need for COVID-19 vaccination, dispelling myths and misinformation, communicating correct and updated information about COVID-19 and its vaccine, communication-related to vaccination sites and the timing of vaccination, special sessions planned for vaccination, motivating people to be vaccinated, and sharing examples of local influential locals who were vaccinated. In rural and tribal areas, communication was localized to suit the language and customs of the population. Local jingles, songs, and punchlines were designed to mobilize people. Both written and oral communication played a key role; however, oral and in-person communication was more effective. It was also observed that a message delivered by a known person (with credibility in the community) was more effective in convincing the community. Within the vaccination teams, the key communication themes related to training, vaccine session details, vaccine availability, and any problems that were encountered during vaccination sessions.

The study highlights four different case studies to explore the role of community mobilization on health-seeking behavior during COVID-19 vaccination. Moreover, the goal was to convince people to adopt such behavioral changes related to health awareness for the long term. Therefore, the role of community mobilizers and the initiatives adopted to develop health-seeking behavior should be continued. It was also found that most of the initiatives and innovations adopted for community mobilization were similar but localized. For instance, the traditional custom of “peele chawal” was followed in various areas, the announcement through municipal vans, involvement of local influential people or community leaders, government departments, social media, in-person communication, “Maha Abhiyaans”, posters, banners, etc. were among common practices that were followed across all the four districts.Footnote 3

Conclusion

The widespread impact of COVID-19 and hesitancy among people about vaccination have posed challenges in achieving immunization coverage. The challenges were different based on social, cultural, and geographic factors. Overall, the impact of the local leadership (at district, block, and village levels), support of frontline workers ASHA, AWWs, ANMs, etc., the role of in-person communication, involvement of influential community heads, localized strategies, and communication materials were key factors in achieving the present status of COVID-19 vaccination coverage in Indore, Harda, Dindori, and Datia districts.

The study highlights the importance of the collaborative approach adopted by the local administrators, people participation, and the localization of strategies in achieving high vaccination coverage in these four districts of Madhya Pradesh. In the urban areas, factors such as local leadership, support of businesspersons, and community leaders, and use of social media facilitated the COVID-19 vaccination process. Furthermore, in tribal and rural areas, support from local community members, community volunteers, and the localization of communication strategies were key factors that contributed significantly to the community mobilization for COVID-19 vaccination.

The lessons from the localized communication strategies, building trust in communities, and the holistic systems approach could be replicated for other social programs, such as routine immunization.

Implications

This study makes a three-fold contribution to the existing literature of Health and Medical Humanities, Health Policy and Services, and Social Sciences. First, the study describes the process of planning the COVID-19 vaccination campaign adopted in four different districts of Madhya Pradesh in different contexts, including urban, tribal-rural, and urban-rural populations. The study highlights the different approaches adopted by the districts that led to increased overall COVID-19 vaccination coverage. Second, the study illustrates the role and co-ordination of different stakeholders in the process of community mobilization. The study identifies the roles of local leadership, community leaders, political leaders, vaccination teams, youth volunteers, teachers, local community members, NGOs, ASHA, Anganwadi workers, different departments, and other members as crucial for community mobilizing. Third, the study illustrates the challenges encountered by the community mobilizers and district planning teams in increasing COVID-19 vaccination coverage.

A more significant implication of the study is in the domain of social and public health programs and behavioral change in communities. The study highlights how different factors influence the behavior of people and how community mobilization can influence this behavior.

Limitations and future research

The study has a few limitations. First, the study was conducted on four select districts of a state. Although this study considered the different geographical variations and compositions, it may not be generalizable to all the districts of Madhya Pradesh or other states of India. However, given the similarity of the approach adopted for increasing COVID-19 vaccination coverage, similar steps can be adopted to test the validity of these approaches in further research. The second limitation is due to the qualitative nature of the study. The study cannot be generalized; rather, it can be used to inform theory. Various initiatives were identified in this study; however, the sustainability of these initiatives was not evaluated. Therefore, researchers can examine the sustainability of the various initiatives that were adopted for community mobilization to increase COVID-19 vaccination coverage. Third, training and capacity building, as well as mobilizers’ working conditions, were not considered in the study. Therefore, the roles of difficult terrain, working conditions, and incentives for extra work are promising areas for research on understanding the motivation level of the mobilizers involved. Fourth, the study highlights different levels of challenges, such as vaccine hesitancy and lack of awareness among people of four select districts, encountered during the COVID-19 vaccination campaign and the localized community mobilization initiatives of stakeholders to improve the uptake of vaccination. However, due to the qualitative nature of the study, there is scope for future research where insights on how social, geographic, and demographic factors impacted community mobilization can be empirically tested.