Community-level COVID-19 vaccination promotion capacity and its association with vaccination dose per capita in China: an entropy-weighted TOPSIS and multilevel analysis

OBJECTIVE: To develop an evaluation framework for community-level capacity to promote coronavirus disease 2019 (COVID-19) vaccination and to quantify vaccination promotion capacity across primary care communities in different regions of China. We further examined the association between promotion capacity and COVID-19 vaccination dose per capita to inform optimization of primary immunization services in the post-pandemic era. METHODS: A multicenter cross-sectional study was conducted across 94 primary care communities from 10 provinces. Indicators of vaccination mobilization and service delivery from 2020 to 2022 were collected via questionnaire across four domains: health education, mass vaccination, incentives, and monitoring/reminders. External and internal covariates were collected simultaneously, including policy, ecological and socioeconomic environments. The entropy weight method and the technique for order preference by similarity to ideal solution were used to calculate a composite score index, and communities were categorized using the rank-sum ratio (RSR) method. After covariate selection via Lasso regression, multilevel mixed-effects linear regression models assessed associations between promotion capacity and dose per capita. RESULTS: Marked provincial differences were observed in overall vaccination promotion capacity. Provinces such as Anhui, Henan and Zhejiang had a higher proportion of high-capacity communities (25%), whereas provinces/municipalities such as Hubei, Guizhou, Shanghai, Guangxi, Shandong, Fujian and Xinjiang had a larger share of medium- and low-capacity communities. In multilevel mixed-effects linear regression models, the RSR ranking of overall vaccination promotion capacity was significantly and negatively associated with community COVID-19 vaccination dose per capita (exp[β] = 0.79, 95% CI: 0.69-0.92), indicating that communities with better (lower RSR ranking scores) capacity achieved higher dose per capita. RSR rankings of all four primary domains were negatively associated with vaccination dose per capita: health education capacity (exp[β] = 0.76, 95% CI: 0.65-0.88), mass vaccination capacity (exp[β] = 0.74, 95% CI: 0.63-0.87), vaccination incentive capacity (exp[β] = 0.77, 95% CI: 0.65-0.91), and monitoring/reminders (exp[β] = 0.93, 95% CI: 0.88-0.98). The number of policy documents issued by municipal-level authorities and studied by local staff, as well as the post-training assessment pass rate among vaccination staff, were consistently and positively associated with dose per capita in most models. CONCLUSION: In conclusion, the composite evaluation framework effectively captured regional differences in community vaccination promotion capacity. Higher overall capacity and better performance in all four domains were linked to higher COVID-19 vaccination dose per capita. Strengthening policy dissemination and implementation, enhancing the quality of training and assessment for vaccination staff may help build an efficient community-based vaccination promotion system, mitigate vaccine hesitancy, and increase vaccine coverage.