Community-led Strategies to Aid Vaccine Acceptance: Five Case Studies from the Global South

"The series of missteps fueling COVID-19 vaccine hesitancy, refusals, and mistrust in health systems has unfortunately spilled over to degrade the progress of previously successful routine immunizations (RI)."

The complexity of the behavioural dynamics driving vaccine acceptance has inspired calls for social science perspectives to understand and address the challenges of vaccination anxieties, avoidance, and refusal. To that end, Sabin Vaccine Institute's Social and Behavioral Research Grants Program was launched in 2019 to support a global network of interdisciplinary researchers and partners to investigate the social and behavioural drivers behind vaccine acceptance in low- and middle-income countries (LMICs). Multidisciplinary teams from five countries were awarded funding to explore the social drivers of COVID-19 misinformation and its impact on both routine immunisation (RI) acceptance and the acceptance of a COVID-19 vaccine. By describing and culling common themes from this work, this report may serve as a primer for decision-makers - informing action and investment to create more vaccine-confident communities worldwide.

The case studies in the report explain how research teams and communities designed interventions employing a range of strategies, including participatory research to equip and empower community health workers (CHWs) and community influencers to dispel rumours and strengthen trust between patients and providers, as well as digital and social media messaging to increase vaccine literacy. The case studies demonstrate the value of community-centric approaches for generating localised solutions, which Sabin has found to be an essential strategy for addressing the complex social factors of vaccine acceptance. These early learnings highlight that one size does not fit all, and resources should focus on understanding effective approaches to design context-appropriate messaging and policy.

The case studies include:

1. Equipping Community Health Workers with Social Science Training: Invaluable Liaisons to Support Vaccine Access and Acceptance - Kambia District, Sierra Leone [London School of Hygiene & Tropical Medicine, University of Bath, and the Kambia District Health Management Team] - CHWs were equipped to engage their communities around vaccine confidence and as advocates for equitable vaccine access. Organisers collected observations and translation of findings into co-designed operational recommendations for vaccine deployment and community engagement around vaccination. They then capacitated and collaborated with civil society activists in the District by conducting trainings on: (i) key methods to track and respond to rumors and concerns and how to devise evidence-driven community engagement strategies and (ii) recommendations from CHW-led research. The programme then directly supported the implementation of District-level community engagement strategies, connecting vaccine confidence and access programming to wider health system strengthening efforts, as trust in vaccines is closely related to broader structural challenges.
2. Community Health Worker-Led Intervention for Vaccine Information and Confidence - Mewat District, India [Johns Hopkins Maternal and Child Health Center India and Bal Umang Drishya Sanstha - BUDS] - Community members from the rural village of Ghasera co-developed and implemented a 4-step intervention to motivate vaccine acceptance and uptake of routine childhood and COVID-19 vaccination, as follows: (i) developed a community accountability board (CAB) comprised of identified community influencers; (ii) conducted human-centred design workshops with CHWs and CAB members to establish a multi-level understanding of the barriers faced in accessing vaccines and implemented a baseline survey with caregivers of children to assess their knowledge, attitudes and practices (KAP) around vaccines; (iii) co-designed, implement and evaluate an intervention pathway with CHWs and CAB members; and (iv) ensured long-term sustainability through monthly CAB meetings. Effective health communication strategies were found to be targeted health promotional videos and simple pamphlets with local community influencers shareable via digital platforms (e.g., WhatsApp).
3. Value of Community Co-Design for Vaccine Confidence Interventions - Karachi, Pakistan [Dow University of Health Science, Karachi, and Aga Khan University] - A community-driven approach to improve vaccine literacy and strengthen participants' capacity for vaccination decision-making was implemented with the objective of improving vaccine uptake among an under-served urban population residing in Muslim Abad Colony, Landhi Town. This was an inherently vaccine-hesitant population, with hardcore refusal of polio vaccination. Household surveys and focus group discussions (FGDs) were conducted to explore misinformation, rumours, misconceptions, and fear regarding the COVID-19 pandemic and vaccination among residents of informal settlements. Insights established key areas for an intervention designed with and for the community. The process involved five stages of the Design Thinking Model. Engagement and empowerment of women was found to be crucial in driving change, especially in Muslim settings, but attention needs to be given to their local values, traditions, and cultural practices.
4. Interrupted Time Series Study of Adult Perceptions Regarding COVID-19 and COVID-19 - Trans-Nzoia County, Kenya [University of Nairobi, the AMUA Sikhendu Medical Center, Kitale County Hospital, and GrainBank and VaccineLink LTD] - An interrupted time series analysis was conducted to investigate the following amongst the adult population in Kiminini sub-county rural smallholdings of Trans-Nzoia County, Kenya: (i) COVID-19 misinformation in trusted social networks to better understand the public's risk perception about COVID-19 and willingness to vaccinate for COVID-19 and (ii) testing and evaluation of a community-led virtual intervention that organically amplifies accurate COVID-19 messaging to debunk misinformation and increase acceptance of a COVID-19 vaccine. One insight to emerge: Strategies to boost social confidence in COVID-19 vaccination should centre around the promotion of the safety, efficacy, and importance of COVID-19 vaccines.
5. mHealth and Social Media-Based Interventions to Improve Childhood Immunization Coverage & COVID-19 Vaccine Hesitancy - Sindh Province, Pakistan [Aga Khan University and Yale Institute for Global Health] - Exploratory research using a purposive sampling approach was implemented to conduct semi-structured (60) in-depth interviews with parents/caregivers and 7 FGDs amongst HCWs across three sites to: (i) investigate the knowledge and awareness of parents/caregivers and HCWs regarding childhood RI and COVID-19 vaccines, and (ii) understand the suitability of mHealth and social media interventions to improve vaccination coverage during the COVID-19 pandemic in the Pakistani context. Based on the findings, HCWs were trained on the use of digital health tools to create and sustain vaccine awareness and advocacy and increase science literacy, especially within rural and peri-urban settings. Lady health workers and home RI vaccinators learned to effectively communicate about vaccines and vaccination and engage interpersonally with vaccine refusers. They then conducted home vaccination drives and employed targeted informational outreach with community members and heads of household influencing vaccination decision-making behaviour.

Another grantee whose work is not summarised in this report: Using Community Influencers to Address COVID-19 Misinformation and Vaccine Hesitancy: A Quasi Experimental Study - Buikewe, Uganda.

Common themes emerged from the evidence that can inform policy, programme, and practice aimed at increasing opportunities to build vaccine confidence and improve vaccination uptake within specific communities. These themes are described in Table 3 on page 7 of the report. For example:

• With regard to policy, one recommendation is to integrate insights curated from context-specific, in-depth social science research in community experiences of vaccination, including an exploration of access and confidence issues, into routine and emergency vaccination programmes as they are being planned and conducted.
• At the programme level, Sabin recommends, for example, that CHWs be equipped to become advocates for vaccine confidence and equitable, expansive vaccine access in their communities. The case studies also point to the value of earning the trust of faith leaders and empowering them with knowledge on vaccine benefits so they may become vaccine champions.
• One suggestion at the practice level: Improve upon health, vaccine, and vaccination messaging by translating it into local languages, considering local vernaculars, and disseminating it through locally acceptable pathways, including low-cost digital health solutions: pamphlets, video clips and messaging via social media platforms, automated audio ring tunes, Friday prayer, etc.