Maintaining trust in immunisation has reached a tipping point in the COVID-19 pandemic, with the growing spread of misinformation and disruptions to immunisation challenging confidence in health services globally. Last month, community health workers, immunisation champions and experts in social behaviour and communications strategies convened virtually, sharing first-hand testimonies on the issue of vaccine hesitancy. Facilitated by Sheetal Sharma, Safari Doctors, Kenya and Vice Chair of the Gavi Civil Society Steering Committee, the discussion emphasised the need for a greater understanding of community perceptions of vaccination and offered recommendations to overcome new and old obstacles.
Detailing the knock-on impact of the COVID-19 pandemic on routine immunisation services, Nazish Mujhgan Karim, a Provincial Master Trainer with a UNICEF funded immunisation project in Pakistan, described how COVID-19 had further damaged already declining confidence in health systems. With many governments now unable to ensure patient safety, fear of contracting COVID-19 is reducing the number of people accessing local facilities resulting in an unprecedented crisis in confidence in the health system. These challenges are compounded by misinformation filtering down to communities. Rina Dey, Communications Director CORE Group Polio Project India described the stigmatization faced by community health workers, accused of spreading the disease whilst conducting door to door visits. This breach of trust leads to the inability of delivering essential and basic health services to the populations.
Dr Joseph Seriki, a Senior Technical Health Specialist with Save the Children in Somalia, described how fear and misinformation were not the only factors contributing to ‘trust built over years being eroded’. Dr Seriki highlighted how in Somalia, COVID-19 related logistical hurdles like supply chain shortages and travel restrictions had made it difficult for people to access vaccines. Additionally, the severe economic impact of the pandemic has led to many people prioritising feeding their families over accessing routine immunisation services.
Understanding and actively listening to community perceptions first
Edmund Duodu, a registered community nurse and Director of the Divine Mother and Child Foundation in Ghana, reminded us that the choices we make with respect to sustaining routine immunisation services will set the precedent for our ability to deliver on the 2030 Sustainable Development agenda. Highlighting the importance of understanding the perceptions and concerns of communities to increase vaccine uptake, Edmund added that much is still unknown about the beliefs leading to vaccine hesitancy. These considerations must extend to an understanding of cultural, religious and traditional beliefs.
Speaking first-hand from her experiences of addressing mistrust in vaccinations in India, Rina Dey, detailed the success of campaigns to improve confidence in routine immunisation and polio services in the states of Uttar Pradesh and Haryana. Rina highlighted how the first step towards addressing mistrust was developing an understanding of social science and interpersonal relationships within communities, describing how interactions in small focus groups were integral in understanding doubts about immunisation. She emphasized how the lessons learnt in polio eradication are being utilised to address similar issues concerning mistrust during COVID-19.
Engaging the right people in the right way
Addressing this lack of knowledge through meaningful, personalised communication requires close collaboration with grassroots organisations. Empowering and developing the capacity of local health workers and civil society will be critical for effective social mobilisation and communication strategies needed to address vaccine hesitancy. These sentiments were echoed by Nazish who highlighted the need to include religious and political leaders whilst working with CSOs and local NGOs to identify marginalised populations. In Pakistan and Afghanistan, between July and August 2020, approximately 50 million children were left unimmunised due to COVID-19.
BBC Media Action’s Global Creative Advisor Radharani Mitra highlighted that communities require targeted and tailored communications strategies to address the issue of trust in health systems. She warned that relaying scientific information and facts will not suffice in changing beliefs and attitudes concerning vaccination, instead “communications solutions aimed at building trust have to be able to capture people’s imaginations and have a powerful emotional connect.” Radharani further explained her “5 mantras to keep trust in immunisation”.
What does this mean for a COVID-19 vaccine?
As we look to the rollout of COVID-19 vaccines, building community confidence in vaccination becomes more important than ever. Radharani highlighted the urgent need to ‘get ahead of the challenge’ so that there is vibrant demand for COVID-19 vaccines once they become available. Meanwhile, Edmund encouraged a focus on innovative and personal engagement with communities noting that generating trust in COVID-19 vaccines will require the ability to “communicate in meaningful, relevant and personal terms to crowd out misinformation.”
There are, as Dr Joseph highlighted, practical considerations that extend beyond understanding community behaviour that will be equally critical for generating confidence. Trust in COVID-19 vaccine programs will also depend on the effectiveness of systems designed to deliver them – ensuring the health systems are functioning with adequate supply and crucial cold chain equipment in addition to ensuring COVID-19 vaccines are safe, widely available with community health workers supported sufficiently to administer them.
Maintaining trust in immunisation amid a global pandemic represents an unprecedented challenge. An understanding of community perceptions, considering the different contexts, background and socio-cultural factors, will serve as a foundation for restoring eroded trust and building confidence in essential health services. At this crucial moment for immunisation, considering community perceptions of vaccination has never been more important.
Authors: Neil Raw (RESULTS UK), Yanira Garcia (ACTION Secretariat), Elo Otobo (Save the Children), Diane Le Corvec (Gavi CSO), Thiago Luchesi (Gavi)
