title: Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India.
abstract: BACKGROUND
  Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. In one of the Indian states, Kerala, after routine immunization had reached high coverage in the late 1990s, it started to decline in some of the districts. This paper describes an application of complex adaptive systems theory and methods to understand and explain the phenomena underlying unexpected changes in vaccination coverage.
  
  
  METHODS
  We used qualitative methods to explore the factors underlying changes in vaccination coverage in two districts in Kerala, one with high and one with low coverage. Content analysis was guided by features inherent to complex adaptive systems such as phase transitions, feedback, path dependence, and self-organization. Causal loop diagrams were developed to depict the interactions among actors and critical events that influenced the changes in vaccination coverage.
  
  
  RESULTS
  We identified various complex adaptive system phenomena that influenced the change in vaccination coverage levels in the two districts. Phase transition describes how initial acceptability to vaccination is replaced by a resistance in northern Kerala, which involved new actors; actors attempting to regain acceptability and others who countered it created several feedback loops. We also describe how the authorities have responded to declining immunization coverage and its impact on vaccine acceptability in the context of certain highly connected actors playing disproportionate influence over household vaccination decisions.Theoretical exposition of our findings reveals the important role of trust in health workers and institutions that shape the interactions of actors leading to complex adaptive system phenomena.
  
  
  CONCLUSIONS
  As illustrated in this study, a complex adaptive system lens helps to uncover the 'real' drivers for change. This approach assists researchers and decision makers to systematically explore the driving forces and factors in each setting and develop appropriate and timely strategies to address them. The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts.
authors.affiliation: Centre for Chronic Disease Control and Governance Hub, Public Health Foundation of India, Delhi NCR, Plot No, 47, Sector 44, Gurgaon 122002, India. vakkan2000@gmail.com.
authors.forename: Joe
authors.initials: J
authors.lastname: Varghese
authors.forename: V Raman
authors.initials: VR
authors.lastname: Kutty
authors.forename: Ligia
authors.initials: L
authors.lastname: Paina
authors.forename: Taghreed
authors.initials: T
authors.lastname: Adam
mesh_terms: D005191:Family Characteristics; D006296:Health Services; D006801:Humans; D007114:Immunization; D007194:India; D010342:Patient Acceptance of Health Care; D011634:Public Health; D036301:Qualitative Research; D035502:Trust; D014611:Vaccination