Community-Based Approaches to Increase COVID-19 Vaccine Uptake and Demand: Lessons Learned from Four UNICEF-Supported Interventions

"...calls for multidisciplinary health system strengthening approaches that render vaccination easy and convenient and promote pro-equity, gender-sensitive, evidence-based tailored strategies to reach the most vulnerable."

Three years into the COVID-19 pandemic, uptake of COVID-19 vaccines remained highly variable as a result of persistent inequities in vaccine access, prevalence in dis/misinformation around vaccines in general and, in some situations, reduced trust in health services. The United Nations Children's Fund (UNICEF) contends that community-driven interventions are key to developing solutions that are evidence-based, context-specific, and culturally appropriate to drive impactful, sustainable change around vaccination. People-centred approaches are also critical to collectively diagnose uptake barriers and co-design solutions with communities. This article shares lessons learned from 4 UNICEF interventions that supported governments to generate acceptance and demand for COVID-19 vaccines in Zambia, Iraq, Ghana, and India. Together, the case studies show that social and behaviour change (SBC) interventions are powerful approaches for influencing drivers of change and supporting local action toward healthier societies.

Four key approaches rooted in social and behavioural sciences were deployed:

Zambia: utilising community rapid assessment for real-time insights into COVID-19 knowledge, behaviour, and demand for vaccines - UNICEF employs social and behavioural evidence and inclusive, participatory approaches to work with communities to understand what drives decision-making, and design interventions that create meaningful, sustainable change in the health sector. Central to this approach is recognising that populations are heterogeneous and that people have different attitudes, motivations and practices around topics such as vaccination. Community rapid assessment provides a way to gather key data from the community and design tailored community-informed solutions.

Specifically, UNICEF, in collaboration with Zambia's Ministry of Health, employed the behavioural and social drivers (BeSD) of vaccination framework, established by the World Health Organization (WHO) to measure 4 domains influencing vaccine uptake: what people think and feel about vaccines; social processes that drive or inhibit vaccination; individual motivations (or hesitancy) to seek vaccination; and practical factors involved in seeking and receiving vaccination. The findings were subsequently used to identify population-wide personas that similarly represent the vaccination-related constructs of "thinking and feeling", "social norms", and "levels of motivation". A mobile survey via interactive voice response (IVR) was developed to establish ongoing evidence on key behaviours around COVID-19 prevention and insights into demand for COVID-19 vaccines. The survey was designed and executed by Viamo, a global social enterprise specialising in mobile engagement and information and communication technology for development. A rapid assessment was implemented over two rounds, between March 30 and April 25 2022 (Round 1) and from October 8-16 2022 (Round 2). The findings informed: (i) the development of tailored strategies to improve vaccine acceptance and demand for the different personas, and (ii) the revision of the national Advocacy Communication Social Mobilization strategy.

Selected recommendations based on lessons learned in Zambia:

• Share timely, fact-based information about vaccine safety and efficacy through trusted sources, which should be maximised using interactive/dialogue-based multimedia and partnering with health professional associations to positively shift vaccination perceptions within the health worker community and the public.
• Invest in qualitative SBC data collection to understand reasons behind declines in trust.
• Prioritise trust building interventions, such as engaging religious leaders and key influencers as champions and engaging social networks of vulnerable groups.
• Increase tailored messages and interventions to address safety concerns and the information gap existing amongst women and key vulnerable groups and within urban locations.
• Ensure greater representation of women in subsequent surveys to understand specific gender-related barriers.
• Facilitate access to vaccination for those who are willing to get the vaccine but find it hard for various reasons (e.g., providing simplified registration process and implementing education and outreach, including information on vaccination accessibility).

Iraq: 3iS (intensification of integrated immunisation) outreach to improve COVID-19 vaccination and routine immunisation - COVID-19 vaccination coverage remains suboptimal in the country, and major efforts - beyond campaigns and supplementary immunisation activities (SIAs) - are required to catch children up on missed doses of routine immunisations, like measles and polio, due to the disruptions in health services from the COVID-19 pandemic. Launched in February 2022 and continuing (quarterly, as of April 2023), the 3iS approach aimed to accelerate control of COVID-19 by improving vaccine uptake, particularly amongst hard-to-reach and vaccine-hesitant groups, and by raising public awareness about COVID-19. 3iS uses direct community engagement to deliver health messages and encourage service uptake. As part of the process, community mobilisers and other team members were trained in interpersonal communication and drew on their familiarity with the communities to involve local leaders.

The strategy resulted in over 4.4 million doses of COVID-19 and routine immunisation vaccines delivered between February and November 2022 across 155 districts in 19 provinces. The enhancements to service delivery and intensive demand-creation efforts contributed to diphtheria, tetanus, and pertussis (DTP3) coverage for 2022 reported as 93% and measles at 88% by October 2022, which are the highest coverage rates since 1987 and 1999, respectively. In 2022, every province of Iraq had over 80% DTP3 coverage for the first time in at least 8 years.

Selected lessons learned in Iraq:

• The flexibility and locally rooted design of the 3iS campaign enabled community mobilisers to be versatile and engage communities on locally relevant topics, such as cholera prevention activities.
• Interventions are sometimes affected by on-the-ground realities and challenges. For example, some communities were difficult to reach or inaccessible, particularly in areas formerly claimed by ISIS, and teams did not have access to some disputed areas. Instead, local health workers from tribal societies, who have experience working on the national polio and measles campaigns, led campaigns in some of the affected areas.
• The 3iS approach incurs costs of around US$1 million for outreach services per month of implementation, which is far less than the societal costs incurred for disease outbreaks. Similar approaches can be used in the future to promote universal health coverage of a wide range of preventative, promotive, and curative health services across the life cycle.

Ghana: applying human-centred design (HCD) to improve COVID-19 vaccination uptake - In early 2022, a large disparity existed between COVID-19 vaccine supply and coverage in Ghana. In line with UNICEF's work to find inclusive and person-centred solutions, over a 3-day period, regional- and national-level stakeholders from Ghana Health Services, UNICEF staff, implementing partners, and civil society organisations received theoretical and practical HCD training through activities facilitated by UNICEF and Common Thread Communications. These activities involved an initial introduction to behavioural design, a rapid enquiry in 3 locations, and an intervention co-design workshop informed by the rapid enquiry findings. This process revealed that most Ghanaians in the region were willing to get vaccinated if the opportunity arose (e.g., if vaccination was available at work, or at the market).

These findings informed prototyping and iterating of wayfinding materials to direct people to convenient vaccination sites. Prior to the intervention, very few mobile or static vaccination sites had any signs, posters, murals, or other visual indications that vaccines were available. Most community members relied on radio announcements or word of mouth to learn about vaccine availability, and within vaccination sites, the public relied on instructions from health workers to guide them through the vaccination process. Prototyping and feedback allowed for ideas from the HCD process to be tailored and improved by testing them with the community and frontline health workers.

India: facilitating community-led vaccination linkages for marginalised communities through risk communication & community engagement (RCCE) - In public health emergencies, RCCE is a key participatory approach to meaningfully engage communities to ensure that they have accurate, timely information, advice, and solutions delivered through trusted sources and channels. A new initiative known as COLLECT (Community-Led Local Entitlements & Claims Tracker) was created as a research and advocacy platform to fulfill the need for local evidence by creating a flow of information between those at the margins of society and authorities. In November 2021, the COLLECT-RCCE (C-RCCE) initiative began a 6-month intervention across 11 states focused on building community-level awareness on COVID-19 appropriate behaviour across India, addressing myths related to vaccines, and boosting vaccination rates amongst vulnerable groups. The C-RCCE was a community-led initiative, supported by UNICEF India and implemented by the Praxis Institute for Participatory Practices, a development support organisation aimed at democratising development processes to make them more inclusive, relevant, and responsive for marginalised communities. As part of C-RCCE, a system was established to share information between households in the community and the local administration for prompt response and action, inclusive of community mobilisation and interpersonal communication.

The programme deployed 560 community-level fellows to gather information and insights on vaccination status, access to schemes and healthcare, and disseminate information to communities. Thirty-nine district-level coordination agencies and 31 district-level fellows were deployed to work with 8 fellows, each. UNICEF and Praxis provided technical support for the engagement and worked with the district-level agencies. Messaging strategies took the form of intensive interpersonal communication and community meetings, educational and communications-based trainings with doctors, engagement of local panchayats and key influencers as trusted health messengers, and the mapping and addressing of myths through regular follow-ups in community meetings. Door-to-door interactions with community members were also deployed to tackle the myths and rumours. As many parents/child caregivers were hesitant to get their children vaccinated, special awareness meetings and door-to-door awareness visits from health workers were organised with parents to provide correct information and reassurance around vaccination. To encourage vaccination among pregnant women, another key group, the team individually met husbands and other family members to explain the importance, efficacy, and safety of COVID-19 vaccination.

The initiative reached half a million people over 6 months, translating into a 25% increase in vaccination rates. Overall, collaboration with the community was critical to the success of the intervention, as was the use of a flexible, multi-pronged messaging medium to disseminate information through local networks, combined with flexibility in how this was deployed at the local level.

Reflecting on all 4 case studies, the authors note that, although different approaches were deployed across the country interventions, all were rooted in an SBC approach aimed at understanding the needs of the community and collaboration at the community level to remove barriers impeding uptake and to inform and develop solutions. UNICEF recognises that the interconnected nature of social norms, behaviour, community systems, and health systems requires multidimensional tools to both diagnose root causes and intervene with a system of solutions. These interventions also demonstrate the importance of applying tailored approaches that rely on behavioural evidence and demographic segmentation to understand and address the specific concerns of different groups. Collaborative, multidisciplinary research, often with community members themselves, led to greater awareness of the wider social and political context of the setting. Together, the case studies also highlight the value of multi-pronged approaches to tackle the complex, often interconnected factors affecting vaccine uptake.

In conclusion: "Going forward, UNICEF's work on SBC for immunization will continue to focus on promoting pro-equity, gender transformative, people-centered, and evidence-based tailored strategies to encourage demand and uptake of all vaccines, including COVID-19, as part of essential health services, while maintaining public trust in health systems and vaccines. Capitalizing on COVID-19 investments will be important to integrate COVID-19 vaccination demand into routine immunization and strengthen primary health care and community-based systems. Broader use of the tools and approaches shared here can be deployed to improve COVID-19 vaccination coverage, close gaps in routine immunization and strengthen pandemic preparedness efforts."