# Methodological review: Prioritizing a future research agenda for overcoming immunization implementation barriers in Pakistan

## TL;DR

This paper reviews a workshop method used to prioritize research for improving immunization in Pakistan, emphasizing structured and inclusive processes.

## Contribution

The study introduces a novel methodological approach combining Dot Voting, Impact Feasibility Matrix, and Delphi techniques to prioritize immunization research in Pakistan.

## Key findings

- Twenty-three research questions were prioritized and grouped into four themes, including data systems and workforce capacity.
- The methodological triangulation highlighted underemphasized areas like cost-effectiveness and operational feasibility.
- The success of such processes depends on inclusivity, reflection, and stakeholder engagement.

## Abstract

Research prioritization plays a critical role in aligning health research agendas with the urgent system-level challenges, especially in resource-constrained settings. This study aims to analyse the methodology of priority setting workshop, conducted to prioritize a future research agenda for overcoming immunization implementation barriers in Pakistan.

A methodological review, a subtype of observational study designs.

In June 2024, an immunization priority setting workshop was convened by the National Institute of Health (NIH) and Aga Khan University (AKU), and WHO-Alliance for Health Policy and Systems Research. Our review analyses the design, and implementation of the workshop methodology which integrated Dot Voting and Impact Feasibility Matrix and post-workshop Delphi-informed thematic categorization process. The prioritized research questions were via consensus among 26 subject matter experts from government, academia, and frontline program implementers.

The Dot Voting method surfaced both technical (e.g., data systems, serosurveys) and contextual (e.g., workforce motivation, coverage gaps) research questions, fostering layered domains. Impact Feasibility Matrix confirmed these priorities while surfacing underemphasized areas (e.g., cost-effectiveness and operational feasibility), thus enhancing methodological triangulation. Subsequent Delphi-informed process synthesized 23 highest-ranked questions synthesized into four themes: (1) Strengthening immunization program through improved data system, (2) Innovative digital health approaches to strengthen immunization system and data quality, (3) Enhancing workforce capacity and well-being in immunization program, (4) Ensuring fair access and distribution of vaccination services.

This methodological review highlights the value of structured and participatory processes in identifying priority research areas for immunization implementation. However, their success depends not on just the process itself but also on being reflective, inclusive and able to manage complex challenges. Future, efforts in Pakistan and similar settings should balance real-world limitation with strategies to ensure equity and stakeholder engagement. This case adds to the global conversation on strengthening methods for setting health research priorities in low-middle-income countries.