Grounding evaluation design in the socio-ecological model of health: a logic framework for the assessment of a national routine immunization communication initiative in Kyrgyzstan.

Childhood routine immunization (RI) is a highly effective public health intervention for the prevention of infectious diseases. Despite high immunization rates, a 2018 Knowledge, Attitudes, and Practices (KAP) study by the United Nations Children's Fund (UNICEF) noted a growing practice of vaccine refusal among parents and primary caregivers as well as clusters of significantly lower immunization coverage in some provinces. Moreover, a 2018 Joint Appraisal report by GAVI (Global Vaccine Alliance) has highlighted a decrease in immunization rates among children under 1 year of age from 96.1% to 92% for some vaccines. As a result, UNICEF is spearheading a national communication initiative to increase the rates of RI in Kyrgyzstan. This initiative includes strengthening interpersonal communication skills of local healthcare workers, improving the quality and accuracy of media coverage via a tailored outreach to the Kyrgyz media, as well as fostering community engagement to give voice to local champions and engage hesitant parents and vaccine refuters. UNICEF has also partnered with a research team for the design phase of a suitable evaluation framework. Grounded in the socio-ecological model (SEM) of health, the framework recognizes the interconnection of behavioral, social, and policy change, and includes not only activity-specific indicators (process indicators) but also progress, outcome, and impact indicators to document results among key groups and stakeholders at different levels of the SEM, and, ultimately, on immunization rates in Kyrgyzstan. The framework reflects the importance of an integrated and multilevel approach to intervention and communication design, and integrates the SEM with a logic model that connects different components of the initiative. This paper introduces this evaluation framework, including implications for the evaluation of child health programs, and other public health, communication, and international development interventions.