Indian vaccine decision-makers’ conceptualization and fostering of ‘community engagement’: A qualitative analysis of elite interviews


 Background: Vaccination literature highlights programmatic and ethical pertinence of ‘community engagement’ in ensuring efficacious vaccines becoming effective vaccinations. However, lack of consensual definition of community engagement, recurring evidence of community backlashes especially during vaccine introductions, and paucity of literature on community engagement’s effectiveness in achieving vaccination outcomes is problematic because assuming a shared understanding of community engagement will only lead to erroneous assumptions about its value, or lack thereof. This study examines conceptualization of community engagement by vaccine decisionmakers in India and efforts to foster it during the Decade of Vaccines.Methods: Elite interviews were carried out (December 2017 to February 2018) with 25 national-level vaccine decisionmakers in India. Study participants included policymakers, immunization program heads, and vaccine technical committee leads representing Government, international non-profits, and donors. Using Schutz’ Social Phenomenological theory, an a priori framework guided coding decisionmakers’ conceptualizations of ‘communities’, ‘community engagement’, and fostering the same. NVivo12 was used for data analysis placing exemplar community engagement interventions on a low to high spectrum. Findings were validated in a one-day member check-in meeting with study participants and teams. Results: Barring themselves, decisionmakers defined ‘communities’ as vaccine-eligible children, their parents, frontline healthcare workers, and vaccination influencers namely- religious leaders, and members of local youth clubs and non-profits. ‘Community engagement’ was variously defined as vaccine outreach, capacity-building of healthcare workers, and information dissemination to guardians of vaccine-eligible children. There was no explicit policy guideline defining community engagement, and no metrics assessing its effectiveness in vaccination uptake. Participants agreed that ‘community engagement’ though evolving is a complex and under-researched area. Community engagement spectrum exemplified seven intersecting layers, with ‘low’ as ‘vaccine impositions’, and ‘high’ as ‘community’s vaccination decision-making’. Participants in the member check-in meeting proposed an operational definition of community engagement and discussed gaps/concerns related to defining/implementing it.Conclusions: It is critical to build-in the operational definition of community engagement in vaccine guidelines, develop its performance and outcome indicators, and advocate their incorporation in immunization surveillance instruments in India. Acknowledging relational gains of community engagement is pertinent to improve vaccination outcomes in India and is relevant for consideration by other countries too.


Introduction
Community engagement (CE) is increasingly recognized by public health decision-makers for its assertion that research and interventions with people without their input is unethical, and for its methodological gains in invigorating translation of research ndings [1] and fostering positive public perceptions of public health interventions [2], while decreasing the likelihood of therapeutic misconception [3]. Some scholars have referred to this political will to embed CE in biomedical policies and programs as 'governmentalization of CE' [4].
During the last few years, the Government of India (GoI) has introduced several vaccines in its immunization program, which calls for 'governmentalization of CE' [5,6]. This is critical in order to address delays inhibiting vaccines' timely uptake. For example, the cervical cancer-preventing human papilloma virus (HPV) vaccine was suspended by the Supreme Court of India in 2010, and later the country's right-wing groups wrote to the Prime Minister expressing concerns about pharmaco-governance and asserting that foreign companies were pushing the vaccine onto an unsuspecting public. Thus, it is likely that lack of appropriate CE procedures contributed to delays in its rollout, and till date the vaccine has been sporadically rolled out in only three states (Sikkim, Punjab and Delhi) out of 36 states and Union Territories of the country [7].
Communities' skepticism about vaccines has a long history in India, evidenced by covert and overt vaccine resistance, ranging from people closing their doors and windows when they heard vaccinators approaching their houses, to vaccine backlash such as physical strife between vaccinators and communities [8]. Recently, in 2017, there was decreased uptake of measles-rubella (M-R) vaccination in certain Indian states amidst community uproar following social media rumors of political conspiracy and unsafe vaccinations [9].
Despite recent progress, vaccine decisionmakers in India are increasingly concerned with low vaccination uptake, as only 62% of vaccine-eligible children (12-23 months) receive all basic vaccinations, compared to the 90% target set under GoI's Universal Immunization Program (UIP), to be achieved by the Decade of Vaccines in 2020 [10]. Vaccine decisionmakers also suggest that broadening the understanding of CE will establish how concerted and strategic CE can facilitate building transparent vaccine communication between communities and decisionmakers; this may be especially useful in overcoming communities' myths and fears regarding the new vaccines, which are often considerably more expensive than existing ones, and target relatively 'hidden' diseases. [6,7].
In addition to the growing sensitization of CE among Indian vaccine decision-makers, the Supreme Court advisory recommends meaningful dialogue with the communities to accelerate vaccination uptake [11]. However, CE evidence is limited to a few systematic examinations focusing on community counselling and vaccination campaigns, often in pockets of high vaccine resistance and low vaccination coverage [12], focusing on public opposition rather than involvement, and with no evidence demonstrating if and how communities are engaged beyond individual decisions to vaccinate themselves and their children [9,11]. Wider academic literature attributes this dearth of CE related studies to the variously premised and sometimes con icting de nitions and rationale of CE [13] and absence of CE metrics [14]. Other studies mention that evaluating engagement is challenging, as such activities often occur in the context of ongoing work and adopting more collaborative engagement approaches [15,16].
This study examined Indian vaccine decision-makers' perspectives about CE, the circumstances in which CE was implemented, and how they fostered CE for effective vaccination amid a variety of constraints. It is our intention that typifying an understanding of CE will lead to contextual and ethical application of CE within a complex system of relationships among researchers, policymakers, implementation scientists, and vaccine users, and will prevent erroneous assumptions about its value and utility, or lack thereof. Study ndings will also inform research and data needs related to CE, which may trigger a policy dialogue for robust measures to assess what works, how it works, and, over time, if CE efforts have improved vaccination rates, then considering it for replication in diverse country and community settings.

Methods
Schutz's Social Phenomenology Theory was used as an underlying approach because it is consistent with the belief that 'conceptualizations' are socially constructed and appropriated to explore participatory action [17]. This theory also helped direct attention toward considering the dynamic contexts in which CE was conceived and operationalized [18,19]. Social Phenomenology further helped to treat CE conceptualization and its fostering as intersubjective, integral to institutions and systems, all embedded in history, time, and space [18]. This study included nation-level vaccine decision-makers who were policy-makers, program heads and/or associates in the government, private sector, non-governmental organizations, and country-o ces of international donor and UN agencies -because by virtue of their knowledge and position they could give a big-picture perspective [18] about CE strategizing and implementation during the Decade of Vaccines (2010-2020). In keeping with the assumptions and beliefs of social phenomenology, a two-step participatory approach for data collection was used: (1) semi-structured 'elite interviews' followed by (2) member check-in meeting [19].
The interviews were conducted among 25 purposefully selected vaccine decision-makers in India during December 2017 to February 2018. Data also included eld-notes written within 24 hours of each interview. The interview topics drew from earlier studies focusing on community engagement as a strategic tool for vaccine research and rollout [19,20]. Accordingly, the inquiries explored participants': (1) conceptualization of community and CE, (2) evolution of CE, (3) fostering support for CE, (4) resources available for CE, (5) partnerships for CE, (6) enablers to CE, and (7) barriers to actualize CE.
Participants were recruited using snowball sampling method, beginning from the professional network of the principal investigator (TD). Recruitment emails were sent in December 2017, followed up with phone calls to identify interest and availability for an in-person interview. Each interview lasted for 50 to 90 minutes, were carried out in English, and in the country-o ces of the respective agencies/institutions/organizations located in or around New Delhi, the capital city of India. Interviews were audio recorded and transcribed verbatim. All personalized information was anonymized.
Once a preliminary analysis of the interview data was achieved, TD presented the ndings in a one-day member-checking meeting among the study participants and their teams (who held second-line leadership positions) in January 2018. Study participants and their team members who participated in the member check-in meeting were knowledgeable of the issue, and were comfortable to validate, and candidly critique the topline ndings. This meeting ensured that interpretations from the interview ndings made sense to the vaccine decisionmakers and their teams in India. The study was deemed exempt by Indiana University's Institutional Review Board.

Data Analysis
First, all data were transcribed verbatim and entered in N-Vivo12 (QSR International, Melbourne, Australia) for qualitative data management. Accordingly, an a priori coding structure was used to categorize individual participant's conceptualization of CE, how their interests in CE for vaccination evolved by overcoming barriers and optimizing facilitators, while integrating 'policy push for vaccine uptake' and 'generating vaccination demand pull' approaches for different vaccines under the UIP. To reach intercoderreliability (>90%), two coders joined TD, iteratively reviewed, and re-reviewed data for existing and emerging themes and/or patterns, and ultimately crystallized a holistic interpretation through multiple coding conferences [70][71][72]. Thereafter the three coders independently coded ve interviews to test, reject, accept, or re ne the codes [19]. The nal coding structure contained 7 multi-dimensional CE themes with 42 nodes. Exemplar interview excerpts illustrate the ndings, although the analysis drew from the entire dataset.
Based on the interpretive analysis used in social phenomenology, rst-level broad construction of CE was done, followed by the second-level typical constructs, deliberated through critical events or performance of CE 'duties' and 'responsibilities' throughout the tenure of the decision-makers [19,38]. Fostering of CE was elucidated using exemplar quotes, with 'Low CE ' highlighting vaccination imposition among communities and 'High CE' as communities' empowered vaccination decision making.

Results
All study participants held national and regional leadership roles in vaccine policymaking, nancing, and/or program planning and management across vaccine research, development, and roll-out stages for at least ten years in India. In addition to their role in India, ve participants reported managing programs in multiple countries of Asia, Africa and Latin America. Table 1 describes the study participants.

Conceptualization of Community
Most participants de ned communities as 'bene ciaries of the UIP,' with a notion of transactional exchange of vaccine related information between the providers and the communities, always with the aim for vaccination uptake. In these cases, communities consisted of the following categories of people : (1) vaccine-eligible children, vaccine-eligible young adults, and their parents and guardians who make vaccination-decisions for the former; (2) frontline healthcare providers who deliver vaccines and sensitize vaccine-eligible populations and their guardians for improved vaccination rates and herd immunity; (3) local-level stakeholders who disseminate information to encourage vaccination uptake; (4) gatekeepers, who resist a particular vaccine or vaccination per se, and; (5) implementers, a group that includes what is known in India as the 3A's: Auxiliary Nurse Midwifes (ANM), the Multipurpose Workers (MPWs) responsible for administering vaccines among < 5000 people, Accredited Social Health Activists (ASHA), and Anganwadi Workers (AWW), who are workers who live with and are responsible for promoting maternal and child health, including interpersonal communication for full immunization coverage, among <1000 priority populations.
Few participants taking the 'whole community approach' mentioned: "…Communities are in relation to HIV vaccine trials such as the commercial sex workers. It is the whole communities in which those individuals were living." [Participant from a vaccine clinical trial organization] Most of the participants acknowledged their distance from the community, mentioning "if I went to the community nobody will accept me," while comparing the sense of community with local organizations because they "help raise community demand for routine immunization." These organizations included grassroots Non-pro t Organizations (NPOs), community-based organizations (CBOs) like women's selfhelp groups (SHGs), local-level representatives of occupational groups like brick-kiln workers and barbers, and the local-chapters of technical and youth organizations such as the Indian Association of Pediatricians (IAP), Indian Medical Association (IMA); Rotary Club, Lion's Club, National Cadet Corps, National Service Scheme, and Nehru Yuva Kendras. Several NGO heads identi ed themselves as communities for their people-centric approach though, in most of these expressions, fractious relationships and issues of incompatibility between decisionmakers [mostly government or donors] and NPOs were evident.
"….they [Government or donors] want to clip our wings. This is very sad because we [NPOs] bring up issues [local issues of the communities], which you [Government or donors because of being at the national-level] might never know." Some participants identi ed vaccine-gatekeepers, people who were suspicious that vaccination is a political agenda against minority groups, as communities. Interventions targeting their positive vaccination decisions increasingly came across as an area of CE.
"… in Mallapuram the mother generally said 'no' to vaccination because their husband lived in the Middle East [who were proxy decision-makers for their child's vaccination]. We [decisionmakers] then realized that we have to nd a way to tap the men [fathers] who are in uencing immunization acceptance back home." Finally, although the media was not de nitively identi ed as 'community' in this section, whether the media was part of the community or a driver of community's vaccination decision outcomes was unclear.
Most participants had the perception that media spread misinformation and promulgated negative sentiments among vaccine priority populations about vaccines, and thus expressed the need "to stop negative media so that they [media] do not "blindly publish", or "over-sensationalize when it is not an Adverse Event Following Immunization (AEFI)."

Conceptualization of CE
The participants perceived CE both as a strategy and tool in implementation terms, and variously de ned CE as segments of processes comprising of: (1) vaccine policy and program formulation; (2) capacitybuilding of frontline stakeholders; (3) vaccine information dissemination among communities to promote vaccination uptake, and; (4) targeted community-level interventions to curtail the recurring incidents of vaccine-related community backlash. There was evidence of relational goals of CE, like "longer-term trust building" [between the vaccine decision-makers and the communities], driven to "….understand what is going on in people's minds [regarding vaccinations]".
Intuitively, all the participants proposed ongoing and early CE for better vaccination outcomes: "The moment you leave the village, it will be the same thing.
[Communities] will say, 'Are you mad that you listened to them [vaccine decisionmakers] and got your child vaccinated?" Exemplifying need for ongoing community engagement.
"We have never faced any challenges with the introduction of and expanded the program in other districts in 2017. We could reach almost 98% of our targets [for HPV vaccinations]. We always go to the communities earlier and have media campaigns, and interpersonal communications to sensitize people on what [vaccine] we would give to their children." Highlighting effectiveness of early-on engagement with communities.
However, several participants critiqued that CE interventions came in waves, mostly during vaccine introductions, before and during vaccine trials, and in case of a disease outbreaks, and that there were no tools or metrics to measure its impact. This they opined could be because: "The Immunization Technical Unit was not built with a CE model [CE frame] for immunization. Like, you [Government] compensate ASHAs for fully immunizing children and trainings attended, but not for CE." Participants expressed a top-down and decentralized vaccine governance structure where vaccine policy formulation and vaccine introduction were made at the Ministry, considering disease burden, vaccine cost, cold-chain, and supply chain issues, and was completely funded by the MoHFW and the international donors.
"….[CE is like] a chandelier, the Ministry (MoHFW) is the hook. The different lights are the different partners, they are held at right distances in the right manner; meaning in immunization, the roles are wellde ned and there are very clear partnerships and no duty-shedding." The development of the vaccine policy and vaccine operational guidelines in English and Hindi (the o cial language of India which is understood, spoken, and read by more people than English is) by the technical bodies of MoHFW, such as the Immunization Technical Support Unit (ITSU), and the Mission Steering Group, was conceptualized as CE too. Participants mentioned that the "state translated and modi ed [these documents] if they think that something is to be added or deleted," though there were no examples of any such revisions incorporated based on communities' recommendations.
Except the Vaccine Policy (2011), which recommended enhancing communities' vaccination acceptance and con dence, and vaccine-speci c Operational Guidelines, which recommended community-facing strategies, participants did not indicate any sub-population based, exclusive CE speci c policy. Almost half of the participants cited the Communication Strategy for Polio Eradication, (UNICEF and USAID CORE Group), detailing intensive outreach for polio vaccination as nearest to any CE guideline. Three participants, considering India's diversity where "every mile the language changes, the culture changes" suggested having "village-level communication strategy." Participants noted strategic programs like Mission Indradhanush (MI) and Intensi ed Mission Indradhanush (IMI) to achieve 90% immunization "to the last child" as CE.
The heads of organizations and technical bodies often criticized chasms in this one-way, top-down approach as "working in silos" and "not real CE," and feared that it would ultimately "hinder an integrated approach." A few participants identi ed spaces like the Village Nutrition and Sanitation Days (VHND), organized monthly at the AWC/ rural child care center, where communities could clarify or question about the vaccines and vaccination strategy. However, these participants were doubtful if communities possessed any emancipated voice beyond seeking or resisting vaccines.

Capacity Building of Frontline Stakeholders
Some participants mentioned cascade Training of Trainers (ToT) for the 3As and local Master Trainers to motivate communities for full immunization as CE. Notably, the CE roles of the 3As and other local stakeholders were different. The ANM and AWWs were salaried staff for vaccine administration among communities, the ASHAs received honoraria for counselling and escorting the communities for vaccinations, whereas the local NPOs and CBOs were instrumental in carrying out community-based activities to motivate community's vaccination decisions, and, in the case of vaccine trial conducting organizations, were conduits between researchers and vaccine clinical trial participants.
Participants conceptualized the 3-day Boosting Routine Immunization Demand Generation (BRIDGE) course for the 3As, and vaccination sensitization trainings for the local-level vaccine-champions (CABs, local religious leaders, barbers, and CBO members), as CE. In these it appeared that some interpersonal tactics were imparted to frontline stakeholders, which was later delegated by them. However, a few participants questioned the 'quality CE outcomes' from these trainings: "So, you [Government] piggy back everything on that the Community Healthcare Worker, who talks to communities about everything immunization, family planning, maternal health, school health, adolescent health, non-communicable diseases, and cancer…[but] you are not actually engaging or doing CE."

Vaccine-Related Information Dissémination
Most respondents mentioned "bilateral information transfer [interpersonal and behavior change communication] sent down to communities" as CE. In the same vein, most participants denoted the Communications O cer as the CE human resource. In fact, one participant said, "The role of communication, I mean CE, sorry using the wrong word again." "We [vaccine providers and decisionmakers] sat with communities and asked if they wanted to talk. We would ask, why the children were not getting immunized. Then they [communities] asked what the harm is if children did not get immunized?" "…we could reach almost 98% [vaccination] targets. We use all sorts of communication channels to make people understand what we are going to give their children and why." Some participants highlighted the need to be creative and explore web-based media considering its easier usage, cost-effectiveness, and penetration to interior locations: "Nobody is interested to read your mobile texts. So, use GIF messaging." Vaccine-champion-engagement and celebrity-engagement to motivate communities' vaccination decisions came across as another form of CE, though there were mixed reactions regarding this strategy.
"The Deputy Collector used to vaccinate his child in the [community], and then the parents [with vaccineeligible children] believed. We explained that vaccines do not differentiate between a Hindu and a Muslim child." Quote highlighting champion engagement as an effective strategy for CE "Our communication campaigns are pathetic. What is the point in having [a lm star in his 70s] there? We have no way of measuring that. Does he convey safety of the product? To sell a toothpaste or a phone we spend hundreds of millions of dollars. How much is going into selling something far more important as vaccines?" Quote highlighting ambiguity about celebrity engagement's effectiveness for CE Targeted Community Interventions Some participants perceived CE as a [right of the communities], "communities want the leadership to come to them. …just sit with them [communities], work with them and that is CE. The leader needs to go to the community …. at least once or twice. It really increases the communities' motivation and trust." Others suggested more emancipatory understanding of CE: "[Vaccine] demand generation is another thing. It means that you [government/vaccine providers] are giving we [vaccine-eligible community] are accepting. Policy in uencing is that where the [empowered] community thinks that certain things needs to be changed. Like, if the community thinks that oral vaccines are easier than the others, are they in uencing the government to change?" Intervention programs re ected a range, between vaccine imposition and respectful engagement with community stakeholders, where participants' responses re ected balanced trade-offs between CE's time and resource investments and feasibility, emphasizing that it is a "marathon, and not a sprint," "an expensive process" and "took 20 years to learn about community and how to do CE." "In XXXX district community was very resistant and started beating the vaccination team. Then we had to contact a local muscleman, briefed him that this [carrying on with the vaccination drive] is important, and then told him to make an announcement that vaccination is not a bad thing." Quote implying vaccine imposition on populations.
"We engaged with the staff of Aligarh Muslim University, Jamia Milia Islamia and Jamia Hamdard [institutions of higher education that were created to manifest indigenous ethos and spirit of plurality and diversity in India], who went to the eld. That helped to address the issue of vaccine hesitancy among religious leaders [Muslim religious leaders]." Quote elucidating participatory stakeholder engagement.
Later, in the member check-in meeting, participants reiterated that effective CE conceptualization and conduct will require devising CE performance and outcome indicators and advocating their incorporation in immunization surveillance instruments in India. Herein, all the participants emphasized the need to document CE effectiveness and its relational gains: "… as a country, I will not be ashamed …., very poor in documentation. You will hardly see any papers from the learnings of polio eradication. This is so because the people who are doing CE do not have the time to document."

Fostering of CE
Though a strict categorization of responses by organizations would not be accurate, a spectrum with seven different expressions and patterns of CE fostering roles by participants was deciphered. These examples helped see tangible ways in which CE goals were realized. Exemplar quotes in Table 2 explain the full repertoire of different engagement strategies to foster CE.
All participants acknowledged "decision-makers' good intention for CE but they were not matched with recipes of successful CE models." Again, most of the CE interventions reported were during the National Polio Surveillance Program (a campaign of the WHO and MoHFW initiated in 1995 to ensure polio eradication through house-to-house poliovirus vaccine delivery), with minimal evidence of institutionalization, replication or scale-up of these during introduction of other vaccines. Examples of such interventions were: "…approaching the brick-kiln owners, getting the list of all the children, and sending it to the Government o cials [vaccine decisionmakers] requisitioning vaccination" or the "Communication O cer giving vaccine IEC materials to the barbers and training the barbers' associations' who in turn sensitized the men [customers] on vaccination." Evolution and Transformation of CE All participants indicated that CE was still a "very poorly understood space," "complex," and there were "several gaps to understand this puzzle." Three participants from NPOs critiqued that it is "offhand," "adhoc practices to douse the re," " re ght," or "control big chaos and help put things back to normal" and recommended "real community engagement" and a "scienti c approach to CE." Recollecting CE's evolution, participants noted that the earlier paternalistic prevention impositions has built a negative community memory, and jeopardized communities' trust on vaccine authorities: "..the vaccine fear was connected to the family planning program, when women were forcibly sterilized." Quote exemplifying that the 'face of decisionmakers' continues to be same for 'communities', and the negative experiences of mandatory sterilizations carried out in the 80s and 90s have a bearing on the immunization drives and campaigns even now.
There were some evidence of pragmatic pressures by external provider/donor organizations "GAVI funding went partly for community mobilization." that reinforced renewed systems-thinking and inclusive bottom-up-models, like: "We were not really very serious and formed a small community group. (Initially, the community group) they came, had some snacks and went off. CE really didn't go beyond that. But by then the NIH and USAID wanted Community Advisory Boards or CABs …and then we learnt how necessary it was." Consequently, several participants indicated recent and direct interactions between vaccine decisionmakers and communities while referring to "The Prime Minister's O ce invites suggestion from the public" and "Health Minister issues letters to each ASHA and ANM encouraging them to vaccinate every child." In the member check-in meeting, participants came up with a robust de nition of CE, which can be summarized as: "CE is an upstream policy imperative rather than downstream interventions to build trustworthy relationships between vaccine decision-makers and communities. It involves demystifying vaccine science and transparent communication for empowered community agency. This would enable communities to critically analyze vaccine related myths and misinformation and enable knowledge coproduction in building community sensitive vaccine policies and programs.
[CE] is incumbent to sustained political-will and resources to ensure evidence-informed, tailored, vaccine policies and programs, providing equitable, quality, and tangible vaccination and capacity building bene ts to community members." Meeting participants also suggested the need to recognize the relational gains of CE and carry out interventions in ways such that trustworthy relationships between communities and decision makers is established. There were comments re ecting realizations like "If we [decisionmakers] close the doors once again to the community, we might lose their trust, and not get the communities back, ever again." They also recommended creating more opportunities for relationship-building and group discussions between community HCWs and vaccine decisionmakers.

Discussion
To the best of knowledge, this is the rst study to conduct 'elite interviews' of national-level vaccine decision-makers to examine ethical, political, relational, and public health imperatives of CE for vaccine acceptability and uptake in India. While much of the research output highlighted decisionmakers' humanistic and utilitarian understanding of 'communities' and 'CE,' re ning professional craftsmanship, including evaluation and documentation, in order to 'do effective CE' came out as an important consideration among vaccine decision-makers and implementation researchers.
Notably, being an Indian from an American university gave TD the identity of an 'informed outsider,' which allowed for considerable interpretive latitude and probing opportunities during interviews and member check-in meetings [20,21]. Studies on 'elite interviewing' mention that such conditions are rare, both due to re exivity issues, and because such people are hard to reach, surrounded by gatekeepers, and have power and ability to protect themselves from intrusion and criticism [20]. The uniqueness of the study also lies in the fact that none of the CE strategies/interventions were ranked as 'best practice' over another by institutional mission or leadership a liation, unlike the traditional ranking of engagement models in Holland Matrix (1997) [22], or Arnestein's Ladder [23]. This helped reduce social desirability issues among the participants.
Low CE and high vaccination resistance was particularly marked where vaccine decision-makers continued to operate in an older paradigm of a paternalistic system, wherein social distances between communities and decision-makers were large, only a section of the public was perceived as 'community', and ensuring full immunization to communities under UIP was considered the most important CE goal.
These ndings complement other literature [11,14,24] highlighting leadership's reductionist approach to conceptualizing communities, which may inhibit formation of trusted collaborations with the communities, ultimately compromising the creation of communities' agency [25]. Some authors have described this as 'conservative corporatism [25,26], which, contrary to the 'whole community approach' [24], can lead to fragmented health governance, introduce barriers to building a comprehensive peoplecentered vaccine policy reform [15,26], and risk de ning communities as internally homogenous entities, which is surely awed given the diversities prevalent in India [27], and might mean undermining the need of tailored CE strategies for particular sub-populations, especially among whom vaccine hesitancies are high, and/or vaccination uptake is low [26,28].
While ndings supported CE's substantive and salutary contribution to vaccine demand generation and disease eradication, such 'passive demand' did not quite match the more 'active demand' recommendations, which includes 'individual demand' of seeking vaccines and 'community demand' re ecting social support for vaccination as a norm [29]. Head's research even attributes such utilitarian CE to health inequities [30], while Gopichandran's work are one of the few ones which look into the relational gains of CE and posits development of trust between vaccine decisionmakers and communities as a result of shared CE goals integrated to the vaccination targets [31]. Accordingly, doing 'real' CE may require a paradigm-shift to perceive communities as integral part of the policy and delivery systems, incorporate CE metrics in vaccine surveillance, and create new role with a focused responsibility to coordinate CE. All of these might demand more research and resources to understand CE's effectiveness against the ability and keenness of the vaccine decisionmakers to push for a CE strategy and implement it.
Incumbent to meeting the ambitious vaccination targets under the MI and IMI, CE came as an equilibrating reaction (to appease community outrage by using control or by counselling communities) rather than an integral approach, essentially to ful l donor mandates. Adhikari et. al. has de ned such CE as 'short-hand' [32], often resulting in wasted resources, with the potential to create mistrust rather than enhance bene ts, create legitimacy, or share responsibility [31,33]. Other authors have envisaged that such CE in the longer run can give rise to communities as agents of the government, and CE becoming an 'involvement industry' 'procured from external organizations' [30,34]. To alleviate this, Folayan et. al.
(2019) have recommended memoranda signed between the government and local partner organizations at the study design stages [35].
That said, Webber's article doubts whether national government-based public health initiatives might ever be able to stray too far from a top-down approach, postulated as the 'two-community thesis' [34]. Other authors suggest that deviation from this will require transformative leadership, which is di cult to achieve in the public service sector with the prevailing traditional organizational thinking, policies, and management techniques [36,37].
While the frontline local stakeholders played role as a two-way conduit between the decisionmakers and the community, more studies are recommended to examine the complex issues like internal chasms and accountability mechanisms between the 3As, and motivational erosion when CE work is not recompensed. Similarly, Ramsbottom's et al.'s study shows that although social-media messaging is a cost-effective mechanism for vaccine information dissemination, it might not be the best for India, and could leave out social media illiterate populations, those in erratic and sporadic internet connectivity, or where vaccine communication needs translating it to local dialects [26].
Ensuring open discussion of the vaccine decisionmakers and their team members on an apparently 'downstream' topic like 'community engagement' took time to convince the potential participants alongside challenges to access study participants because of the ongoing community uproars around M-R and HPV vaccines which were playing out in real time in the country, then [38,39]. Despite these structural impediments theoretical saturation was ensured, and the best quality data was achieved utilizing TD's familiarity with some of the study participants, sensitive mix of knowledge and intercultural humility, exibility to re-schedule appointments after o ce hours or on national holidays, and use appropriately persuasive multiple communication channels like Facebook Messenger, or WhatsApp [19], in addition to emails and phone calls. The study ndings were limited by the inherent limitations of a qualitative study design. However, the unanimous intention of participants to enhance vaccination through effective CE, and to devise vaccination-speci c CE process and outcome indicators inevitably invigorates research and implementation optimism, given that existing literature demonstrates that intentions are moderately good predictors of future behavior [40, 41].

Conclusion
The implementation and policy utility of this study is time sensitive, given that it has synthesized narratives of CE in the vaccine policy and praxis space, and can be both used to understand past CE challenges and successes retrospectively and prospectively plan community-led, tailored CE initiatives for better vaccination outcomes. While the growing impetus for CE by vaccine decisionmakers is noticed, more investments are required in embedding and operationalizing the CE de nition to vaccine guideline documents in the country. It is also critical to devise CE process and outcome indicators, and advocate to incorporate them in vaccination surveillance datasets. Deeper analysis of the relational outcomes of CE by sub-population and its incorporation in policies is being proposed. Promoting CE without interrogating power-relations, such as the heavy reliance on Northern donors, and decisionmakers' stereotypical outlook of CE can be counter-productive, unintentionally reinforcing potentially harmful social structures and mistrust between communities and decisionmakers.

Declarations
Ethics approval and consent to participate: This manuscript is one of the papers from my doctoral dissertation and was deemed 'exempt' by the Indiana University's Institutional Review Board. This study undertook elite interviews of 25 national-level vaccine decisionmakers in India. Consent to participate was sought from all study participants via email. https://www. rstpost.com/india/wont-take-modi-rss-vaccine-myths-quacks-derail-malappuramvaccination-drive-putting-lakhs-of-children-at-risk-4236543.html.